Embargoed until ISSUE REPORT Ready or Not? 10:00 am ET on Tuesday, December 19 2017 PROTECTING THE PUBLIC’S HEALTH FROM DISEASES, DISASTERS AND BIOTERRORISM DECEMBER 2017 Acknowledgements Trust for America’s Health is a non-profit, non-partisan This report is supported by grants from the Robert Wood Johnson organization dedicated to saving lives by protecting the health Foundation. TFAH thanks the foundation for its generous support. of every community and working to make disease prevention a The opinions in this report are those of the authors and do not national priority. necessarily reflect the views of the supporters. TFAH BOARD OF DIRECTORS Gail C. Christopher, DN David Fleming, MD Karen Remley, MD, MBA, MPH, FAAP President of the Board, TFAH Vice President CEO/Executive Vice President?  PATH American Academy of Pediatrics Cynthia M. Harris, PhD, DABT Vice President of the Board, TFAH Stephanie Mayfield Gibson, MD Eduardo Sanchez, MD, MPH Director and Professor Senior Physician Adviser and Population Health Chief Medical Officer for Prevention Institute of Public Health, Florida A&M University Consultant American Heart Association Private Contractor Robert T. Harris, MD Umair Shah, MD, MPH Treasurer of the Board, TFAH David Lakey, MD Executive Director and Local Health Authority Medical Director Chief Medical Officer and Associate Vice Harris County Public Health  North Carolina Medicaid Support Services Chancellor for Population Health Vince Ventimiglia, JD CSC, Inc. The University of Texas System Chairman  Theodore Spencer Octavio N. Martinez, Jr., MD, MPH, MBA, FAPA Vice Chairman of Leavitt Partners Board of Secretary of the Board, TFAH Executive Director Directors Senior Advocate, Climate Center Hogg Foundation for Mental Health at the Leavitt Partners Board of Managers Natural Resources Defense Council University of Texas at Austin REPORT AUTHORS PEER REVIEWERS Laura M. Segal, MA TFAH thanks the following individuals and organizations for their time, expertise and in- Vice President of Public Affairs sights in the reviewing all or portions of the report. The opinions in the report do not neces- Trust for America’s Health sarily represent the views of these individuals or their organizations. Dara Lieberman, MPP Senior Government Relations Manager James S. Blumenstock Nicolette A. Louissaint, PhD Trust for America’s Health Chief Program Officer for Health Security Executive Director Kendra May, MPH Association of State and Territorial Health Healthcare Ready Consultant Officials Octavio N. Martinez, Jr., MD, MPH, MBA, FAPA Molly Warren, SM Sarah Despres, JD Executive Director Health Policy Research Manager Director, Government Relations, Health Programs Hogg Foundation for Mental Health at the Trust for America’s Health The Pew Charitable Trusts University of Texas at Austin Sandra Eskin, JD Vicki Shabo CONTRIBUTOR Director, Food Safety Vice President for Workplace Policies and Strategies Chris N. Mangal, MPH The Pew Charitable Trusts National Partnership for Women & Families Director of Public Health Preparedness and Jonathan Fielding, MD, MPH, MA, MBA Kathy Talkington, MPA Response Professor-in-Residence Project Director, Antibiotic Resistance Project Association of Public Health Laboratories UCLA Fielding School of Public Health  The Pew Charitable Trusts David Fleming, MD Eric Toner, MD Vice President Senior Associate PATH Johns Hopkins Center for Health Security 2 TFAH • healthyamericans.org Ready or Not? TABLE OF CONTENTS Table of Contents INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Protecting the SECTION 1: STATE-BY-STATE HEALTH SECURITY INDICATORS . . . . . . . . . . . 15 Indicator Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Public’s Health Indicator 1: Public Health Funding Commitment – State Public Health Budgets . . . . . 20 from Diseases, Indicator 2: National Health Security Preparedness Index . . . . . . . . . . . . . . . . . . . . 22 Disasters and Indicator 3: Public Health Department Accreditation . . . . . . . . . . . . . . . . . . . . . . . . 25 Indicator 4: Antibiotic Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Bioterrorism Indicator 5: Flu Vaccination Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Indicator 6: Enhanced Nurse Licensure Compact . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Indicator 7: United States Climate Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Indicators 8 and 9: Public Health Laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Indicator 10: Paid Sick Leave Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 SECTION 2: NATIONAL HEALTH SECURITY ISSUES AND RECOMMENDATIONS 43 A. Reforming Baseline Abilities to Diagnose, Detect and Control Health Crises: Foundational Capabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 B. Supporting Stable, Sufficient Funding for Ongoing Emergency Preparedness and Funding a Permanent Public Health Emergency Fund for Immediate and “Surge” Needs During an Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 C. Supporting Global Health Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 D. Improving Federal Leadership Before, During and After Disasters . . . . . . . . . . . . . 58 E. Innovating and Modernizing Infrastructure, Including Wide Implementation of Faster Diagnostics, Biosurveillance and Medical Countermeasures . . . . . . . . . . . . . . . . 59 F. Maintaining a Robust, Well-Trained Public Health Workforce . . . . . . . . . . . . . . . . . 66 G. Rebooting and Developing a New Strategy for Hospital and Healthcare Emergency Preparedness – Including Surge Capacity for Major Emergencies . . . . . . . . . . . . . 69 H. Readying for Climate Change and Weather-Related Threats . . . . . . . . . . . . . . . . . 76 I. Supporting Community Resilience -- for Communities to Better Cope and Recover from Emergencies -- With Better Behavioral Health Infrastructure and Capacity . . . 87 DECEMBER 2017 J. Stopping Superbugs and Antibiotic Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . 92 K. Improving Vaccination Rates -- for Children and Adults; and . . . . . . . . . . . . . . . . . 95 L. Protecting Food and Water Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 APPENDIX A: STATE PUBLIC HEALTH BUDGET METHODOLOGY . . . . . . . . . . 102 I NT RO D UC TION Ready or Not? INTRODUCTION Ready or Not? Protecting the PROTECTING THE PUBLIC’S HEALTH FROM DISEASES, Public’s Health DISASTERS AND BIOTERRORISM In the 16 years since the 9/11 and anthrax tragedies, the country from Diseases, has had countless reminders demonstrating the need for a Disasters and sufficient response to the public’s health needs during major incidents—be they caused by extreme weather events, disease Bioterrorism outbreaks or a contaminated food supply. The 2017 Atlantic Hurricane Season or major disasters is also essential to was particularly historic. After respond to ongoing health threats. The Hurricane Harvey made landfall in bad news is that the accomplishments Texas, it hovered over Houston for achieved to improve public health and days—dropping several feet of rain that preparedness for all hazards are being caused unprecedented flooding and undermined due to severe budget cuts sank the Earth’s crust around Houston and lack of prioritization. two centimeters.1 Harvey was followed Instead, the nation is in a continued by two Category 5 storms–Hurricanes state of reacting inefficiently with a series Irma and Maria, which had a profound of federal emergency supplemental impact on many Caribbean nations, funding packages each time a disaster Puerto Rico, the Florida Keys and other strikes. The country does not invest areas in the region. Out West, rain was enough to maintain strong, basic core scarce as communities were ravaged by capabilities for health security readiness one of the worst wildfire seasons ever. and there is often a need for additional The fast-moving blaze in California’s funds — emergency surge dollars in the wine country killed 43 people, scorched form of a standing Health Emergency 250,000 square miles and destroyed Fund that can be used when major 8,900 structures.2 events happen. Rather, funding to Despite the frequency of health threats, support the base level of preparedness often the country is not adequately has been cut — by more than half since prepared to address them, even with all 2002 — eroding advancements that the prior lessons about what is needed had been achieved and the country’s for an effective response. Emergencies standing capabilities have been reduced. are a matter of when, not if; there is This leaves our country unprepared no reason to continue to be caught off to respond effectively, and scrambling guard when a new threat arises. to divert funds from other ongoing priorities when health emergencies, DECEMBER 2017 The good news is that considerable inevitably, happen. This leads to a progress has been made to effectively situation of being reliant on emergency prepare for and respond to public funding to try to backfill basic gaps while health emergencies of all types and sizes, also trying to address the new surge and much of what it takes to prepare problems created by any given crisis. for bioterrorism, major disease threats l M any improvements made after 9/11, Departments to Support National Zika the anthrax tragedies and Hurricane Response and found that of jurisdictions Hospital Emergency Preparedness Katrina have eroded. The primary responding to a survey, more than Funds Have Been Cut in Half source for state and local preparedness 88 percent noted that ongoing Since 2003 for health emergencies has been cut readiness activities (e.g. planning by about one-third (from $940 million activities, trainings, exercises, volunteer in fiscal year (FY) 2002 to $667 million recruitment, coalition participation, etc) in FY 2017) and hospital emergency would be affected; more than 72 percent preparedness funds have been cut in responded that functional preparedness $514 million half ($514 million in FY 2003 to $254 areas (e.g. surveillance, epidemiology, million in FY 2017).3 The one time vector control, clinical services, lab $254 million supplemental funding in FY 2016 for services, etc.) would be affected; and the ongoing public health threat of a majority reported that supplies and Zika means that states may have to staffing levels would be affected;4 and FY 2003 FY 2017 redirect other funds in FY 2018 to l U nstable funding leads to a cycle of address this continuing threat; hiring and firing of trained specialists l F urther cuts to preparedness programs — which often means the experts at the Centers for Disease Control and needed to respond are not on-staff or Prevention (CDC) would disrupt key available when new crises hit. critical infrastructure — the nation’s Investments in improving preparedness disease command and control centers — also bolster health departments and the including the Emergency Management healthcare system overall — so they can Program, Emergency Operations better deal with ongoing needs like the Centers (federal and in states), opioid epidemic, foodborne diseases, Laboratory Response Network, Strategic water and lead safety, and other National Stockpile and management of challenges communities regularly face. select biological agents and toxins; l L ack of available emergency funds has led to redirection of money from HEALTH SECURITY MATTERS5, 6 other priorities when a crisis hits. For l A s of 2016, in the course of one United States and around the world in example, delays in funding for the year, CDC’s Emergency Management the prior two years alone. 2016 Zika response led to redirecting Program conducted 585 global money from the Ebola response and l T here have been more than 16 activities, including 65 Emergency from core state and local preparedness known terror plots in just New York Operations Center activations for grants. This left most states with a weaker City since 9/11. outbreaks in the United States and preparedness infrastructure that was 27 other counties, and 135 exercises. l F or the past 30 years, there is an not easily backfilled when emergency In 2016, for the first time, there were average of one brand new contagious money was finally available. In May 2016, four simultaneous CDC Emergency disease emerging each year. Infectious the Association of State and Territorial Operations Centers responses: Zika, diseases regularly cost the country a Health Officials, National Association Ebola, the Flint water crisis and polio. minimum of $170 billion year, and major of County and City Health Officials, new pandemics have the potential to Association of Public Health Laboratories l C DC’s Emergency Operations Center disrupt the global economy. A severe and Council of State and Territorial was activated more than 90 percent new flu pandemic could cost the country Epidemiologists examined the Impact of the time in the past 7 years. CDC more than $680 billion — 5.5 percent of the Redirection of Public Health scientists have responded to more of the Gross Domestic Product.7 Emergency Preparedness Funding than 750 health emergencies in the (PHEP) from State and Local Health TFAH • healthyamericans.org 5 In 2003, TFAH first issued the Ready or Not? report to examine the nation’s readiness to respond to public health emergencies. Over time, the report has tracked significant progress that has been achieved, but also remaining vulnerabilities and the backsliding of some advances, as budgets have been cut. public health personnel; improvements in medical surge capacity, development of the National Disaster Medical System, Medical Reserve Corps, the HHS Operations Center, and emergency support function leadership in the Office of the Assistant Secretary for Preparedness and Response; and the Center for Medicaid and Medicare Service’s release of Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. l ome major ongoing gaps include: S Coordinated, interoperable, near Modern and stable health security there are core basic capabilities that real-time biosurveillance, including requires refocusing public health experts agree could be maintained to a sustained investment to maintain departments, healthcare and resources to better protect the public from the range surveillance systems to more more effectively use workforce, existing of possible concerns. In the past 15 years: rapidly identify emerging threats; infrastructure, emerging technology and l ome major advancements include: S sufficient funding for the entire strategies to achieve better outcomes and Integrated public health emergency medical countermeasure strategy, results — and better protect Americans operations planning and coordination; including funding to continue from new and ongoing threats. A strategic upgraded public health laboratories; research, development, purchase modern biodefense also yields strong more advanced development and and distribution of vaccines, antiviral returns — investing in prevention and manufacturing for vaccines and other medications, diagnostics and effective standing response capabilities medical countermeasures (MCMs); antibiotics; chemical and radiation helps avoid the costs in dollars and lives. development of the Strategic National laboratory services; surge capacity Ready or Not? includes a review of state Stockpile, a federal repository of within the healthcare system for a and federal public health preparedness. medical countermeasures, as well as an mass influx of patients, along with The report is intended to help inform improved system to develop medical standards of care and in-place tiered policymakers, partners and the public countermeasures more quickly; systems of care for a range of threats; about the status of preparedness. It improved plans, resources and tactical standing surge capacity abilities within provides a snapshot of a number of capacity to rapidly deploy MCMs to the the public health system to respond important indicators of preparedness community; enhanced surveillance, to multiple emergencies at the same and reviews key national policies epidemiologic investigations, situational time, particularly if multiple states are and priorities. It provides greater awareness and information sharing experiencing multiple emergencies transparency for programs; encourages mechanisms and communications; simultaneously and one state cannot increased accountability for spending of enacted legal and liability protections; rely on out-of-state assistance; preparedness funds; and recommends advances in foodborne illness detection; ongoing reductions in the public ways to help the nation move toward a animal health surveillance; increasing health workforce; and the ability to more strategic capabilities system that and upgrading public health staffing help communities — and especially is able to effectively respond to health trained to prevent and respond to their most vulnerable populations — threats. While it is impossible to be 100 emergencies; improving systems for become more resilient to cope with and percent prepared for all emergencies, deployment of emergency medical and recover from emergencies. 6 TFAH • healthyamericans.org In the 2017 Ready or Not? report: l E nsuring stable, sufficient health of transforming the nation’s ability Section 1 features 10 indicators of key emergency preparedness funding to promptly detect and contain areas in each state that together provide to maintain a standing set of core disease outbreaks and respond to a snapshot of areas of health security. capabilities so they are ready when other health emergencies. For Reflecting a broad definition of all- they are needed. In addition, a example, continuing investments hazards preparedness, they assess the complementary Public Health in the modernization of near real- ability to respond to a wide range of Emergency Fund is needed to time, interoperable surveillance, crises, from infectious disease outbreaks provide immediate surge funding for such as syndromic surveillance; to natural disasters to man-made attacks. specific action for major emerging developing the next generation of threats. The current process of medical countermeasures, including l T he scores in the report are not insufficient funding means there are antivirals, vaccines and rapid intended to serve as a reflection on long-standing gaps in the baseline diagnostic tests; and adopting wider performance of specific state or local system. Emergency supplemental use of advances in genomics to detect health departments, since they reflect budgets take time, cause delayed and contain outbreaks. a much broader context including responses and cannot be used to resources, policy environments, l R ecruiting and training a next backfill ongoing vulnerabilities in the healthcare systems and availability generation public health workforce response system. and health status of communities, with expert scientific abilities to including many factors beyond the l S trengthening and maintaining harness and use technological direct control of health departments. consistent support for global health advances along with critical thinking The report is intended to help identify security as an effective strategy for and management skills to serve where sufficient action has been taken preventing and controlling health as Chief Health Strategist for a to support adequate public health crises. Germs know no borders as community. The workforce should preparedness, and where and how was recently seen with the Zika and be able to lead health investigations; federal and state governments can Ebola outbreaks. build plans to address problems; improve or overcome obstacles to bring partners and resources l Improving federal leadership better readiness. together across the health sector before, during and after disasters and other affected sectors for — including senior leadership and Section 2 is an examination of national increased collective impact; support coordination for a government- policy issues and recommendations community engagement; and wide approach to health security, from health and security experts for communicate and effectively educate preparedness, response and recovery how to improve the nation’s ability to the public on how to reduce risk efforts. Clear federal leadership ensure stronger baseline capabilities are and better protect themselves, their and an agreed upon framework of in place and the system is more flexible families and their neighborhoods. responsibilities — including fully and able to respond efficiently and utilizing authorities in existing law l Reconsidering health system effectively when new emergencies arise. — can clarify roles, particularly in preparedness for new threats and Key priorities include: health emergency responses that cross mass outbreaks. Develop stronger l R equiring strong, consistent baseline federal agencies and involve domestic coalitions and partnerships among public health abilities in regions, states and international actions. providers, hospitals and healthcare and communities around the country. facilities, insurance providers, l nnovating and modernizing I Communities should maintain a key pharmaceutical and health equipment infrastructure needs — including set of foundational capabilities and businesses, emergency management a more focused investment strategy focus on performance outcomes in and public health agencies. More to support science and technology exchange for increased flexibility and integrated approaches help leverage upgrades that leverage recent reduced bureaucracy. the strengths and coordinate activities breakthroughs and hold the promise TFAH • healthyamericans.org 7 across the public and private sectors, support regionalized health models and incentivize and speed the use of new technologies into practice. Engage all of the partners to invest in building a broader community response strategy since all partners in a community are at risk and stand to benefit from more effective preparedness and response abilities. l P reventing the negative health consequences of weather-related threats. As climate changes, the likelihood of unusual weather patterns and extreme weather events increase, water rises to unsafe levels and the insects and animals that spread disease move into new geographic locations. It is essential to work to mitigate the impact of climate, weather and michelmond / Shutterstock.com natural disasters on health problems, in addition to building the capacity often at disproportionate risk. This tools against many infectious diseases. to anticipate, plan for and respond to must also include support for local In spite of effective vaccines to such possible events. organizations and small businesses — prevent disease, there are significant which are essential and inherent parts sections of the population who are l Supporting a culture of resilience so of communities — to prepare for and unprotected leading to a number of all communities are better prepared to respond to emergencies. recent outbreaks of such preventable to cope with and recover from illnesses as measles and meningitis. emergencies, particularly focusing l P rioritizing efforts to address one of the on those who are most vulnerable. most serious threats to human health l F ocusing on fixing the food safety Sometimes the aftermath of an by expanding efforts to stop superbugs system to better match and address the emergency situation may be more and antibiotic resistance. Outbreaks of potential risks in modern agricultural harmful than the initial event. new and/or difficult to treat infectious and food processing, sales and Loss and suffering of loved ones, illnesses require a range of capacities distribution approaches. State and local dislocation associated with housing from sophisticated and timely governments need the capacity to detect damage, continuing environmental laboratory testing to epidemiologists and contain foodborne outbreaks, using risks and post-traumatic stress to track potential exposures to modern technology as well as traditional have occurred in many recent immunizations and treatment. tools and personnel for both prevention emergencies. Certain populations and rapid response. l I mproving rates of vaccinations for such as older adults, people with children and adults — which are one disabilities, pregnant women, infants of the most effective public health and those with limited resources are 8 TFAH • healthyamericans.org U.S. NATURAL DISASTERS IN 2017 Multiple natural disasters wreaked havoc on the nation in 2017 — from record hurricanes in the Atlantic to drought, floods, and fires in the West. According to the National Oceanic and Atmospheric Administration (NOAA), as of October 6, there have been 15 separate weather and climate disaster events, each with losses exceeding $1 billion across the United States.8 This number does not include the California fires that killed over 40 people and destroyed nearly 9,000 structures in mid-October. Three Category 4 and 5 hurricanes (Harvey, Irma and Maria) made landfall in the U.S. and its territories, a record for a single year.9 Source: NOAA due to extreme rainfall. According to l H urricane Maria made landfall l C alifornia Floods. In February, NOAA, more than 30 inches of rainfall in southeast Puerto Rico after extreme rainfall across northern and fell on 6.9 million people, while 1.25 striking the U.S. Virgin Island of central California created substantial million experienced over 45 inches St. Croix. Up to three feet of rain property and infrastructure damage and 11,000 had over 50 inches. The caused widespread flooding and from flooding, landslides and erosion. massive flooding displaced over 30,000 mudslides across the island and Severe damage to the Oroville people and damaged or destroyed its transportation, agriculture, Dam spillway caused a multi-day over 200,000 homes and businesses. communication and energy evacuation of 188,000 residents Harvey caused 84 deaths. 12 infrastructure were severely damaged. downstream, and San Jose’s Coyote Maria tied Hurricane Wilma (2005) Creek overflowed its banks, flooding l H urricane Irma made landfall at Cudjoe for the most rapid intensification, neighborhoods and forcing 14,000 Key, Florida after devastating the U.S. strengthening from tropical depression residents to evacuate.10 Virgin Islands at its full category 5 to a category 5 storm in 54 hours.14 storm strength. Twenty-five percent of l E xtreme Drought in North Dakota, South buildings in the Keys were destroyed l C alifornia Wine Country Wildfires in Dakota and Montana severely disrupted while 65 percent were significantly October killed 43 people, scorched agriculture—damaging field crops and damaged, and the Florida and South over 245,000 acres and destroyed forcing ranchers to sell off livestock due Carolina coasts experience significant over 8,900 structures. The rapidly to lack of feed for cattle. The drought storm surge damage. Irma maintained moving fire forced approximately also set the stage for devastating a maximum sustained wind of 185 100,000 people to evacuate, some wildfires later in the season.11 mph for a record 37 hours, and it was at a moment’s notice. This was the l H urricane Harvey made landfall near also a category 5 storm for longer than deadliest wildfire in California history Rockport, Texas. It ultimately produced all other Atlantic hurricanes except Ivan and preliminary damage estimates historic flooding in the Houston area in 2004. Irma killed 95 people.13 exceed $3 billion.15,16 TFAH • healthyamericans.org 9 EXAMPLES OF KEY EMERGING AND EMERGENCY HEALTH THREATS l Z ika: Primarily transmitted by the bite of There have only been two MERS-CoV an infected Aedes aegypti mosquito, Zika cases in the United States (in 2014), can be passed from a pregnant woman and those individuals were traveling to her fetus and can result in severe birth from other locations. defects including microcephaly. Scientists l F oodborne Illness: An estimated 48 continue to study how Zika virus affects million Americans get sick, 128,000 mothers and their children to better are hospitalized and 3,000 die from understand the full range of potential contaminated food annually.28 In 2017, health problems that Zika infection during Salmonella linked to imported papayas pregnancy may cause.17 The disease sickened over 200 people, while a Listeria itself causes mild symptoms, like fever outbreak in soft raw cheese killed two and joint pain, though many of those out of the eight people it infected. Nearly infected have no symptoms at all. Zika 600 non-travel associated cases of has also been shown to be transmitted cyclosporiasis were reported in 2017, and through sex. Cases have been reported a brand of SoyNut Butter was found to be in 49 U.S. states, three U.S. territories, contaminated with Shiga toxin-producing most of South and Central America, Escherichia coli O157:H7.29 Africa, South Asia, and the Pacific Islands.18, 19 On September 29 of this l S uperbugs (Antibiotic Resistance): year, CDC deactivated its emergency More than two million Americans response for Zika to transition efforts to develop antibiotic-resistant infections normal program operations. There is 20 each year, leading to more than 23,000 currently no vaccine or medicine approved deaths and $20 billion in direct medical for Zika. 21 The cost of care for an infant costs and more than $35 billion in with severe microcephaly to adulthood is lost productivity.30 Globally, by 2050, up to $10 million, and in just one year, the superbugs could claim 10 million lives a total costs for hospital care of people with year and could cost a cumulative $100 birth defects exceeds $23 billion. 22, 23 trillion of economic output.31 As of November 28, 2017, 5,580 l H ealthcare-Associated Infections symptomatic cases of Zika have been (HAI): Around one out of every 25 reported in 49 states and the District of people who are hospitalized each year Columbia, along with cases in three U.S. contracts a healthcare-associated territories, and many areas in South and infection leading to around 75,000 Central America, Africa, South Asia and deaths a year.32 the Pacific Islands.24 l S easonal Influenza (the Flu): While l M iddle East Respiratory Syndrome the impact of the flu varies each year, Annual Impact of the Flu Coronavirus (MERS-CoV): MERS-CoV it places a substantial burden on the is a novel coronavirus that causes a Deaths: 12,000 – 56,000 health of people in the United States Hospitalzations: severe viral respiratory disease. It has each year. CDC estimates that influenza 140,000 – 710,000 infected more than 2,000 individuals, has resulted in between 9.2 million spreading from the Middle East to South and 35.6 million illnesses, between Cases: Korea through international travel, 9,200,000 – 35,600,000 140,000 and 710,000 hospitalizations causing a significant outbreak, since Source: CDC and between 12,000 and 56,000 first detected in 2012.25, 26 MERS is fatal deaths annually since 2010. 33 in more than 30 percent of cases.27 10 TFAH • healthyamericans.org l P andemic Flu: In addition to the seasonal flu, there were three pandemics last century (1918, 1957, 1968) and one so far this century (2009). Pandemics occur when a new influenza virus emerges against which people have little- to-no immunity and the virus spreads globally with sustained human-to-human transmission. Most people have little- to-no immunity to fight against these new viruses. While experts predict influenza pandemics will occur in the future, they cannot predict when the next pandemic will occur, what strain of the virus will be involved, or how severe the pandemic will be.34 Once a novel influenza virus becomes easily transmissible among humans, it can cause a worldwide pandemic in a relatively short time. A severe pandemic in 1918 resulted in 33 percent of the population becoming ill and more than 2.5 percent (675,000 Americans) of those died. The l D engue Fever: A mosquito-borne illness people in Mexico, Central America most recent H1N1 pandemic in 2009, that causes flu-like symptoms and and South America — and more than while considered less severe than previous severe joint, muscle and bone pain. A 300,000 in the United States — have pandemics, infected around 20 percent dengue vaccine is registered in more Chagas disease, the majority of whom of Americans (approximately 60 million than 10 countries, but is not currently do not know they are infected.39 Many individuals), and resulted in approximately licensed or available in the United States. U.S. healthcare professionals are not 274,000 hospitalizations and more than Around 400 million people are infected familiar with the disease, which leads to 12,000 deaths. 35 each year, leading to about 96 million under-diagnosis.40 illnesses. An estimated 500,000 people l C hikungunya: A mosquito-borne virus l P lague: Caused by the bacterium with severe dengue require hospitalization that, while rarely fatal, causes fever and Yersinia pestis, plague is a serious illness each year, and about 2.5 percent of joint pain that can be excruciating. 36 that is endemic in the western United those affected die. Dengue is endemic in There are no vaccines or treatments States and can be fatal without prompt Puerto Rico and in many popular tourist for chikungunya, but symptoms usually treatment.41 While bubonic plague is destinations in Latin America, Asia and subside in about a week. However, usually acquired through the bite of an the Pacific islands. In the United States, in some people, joint pain can persist infected flea, the pneumonic form can be several relatively small dengue outbreaks for months. In 2013, the disease first spread directly from person to person.42 have occurred in the last decade in appeared in the Americas and in the As of October 30, 2017, an outbreak in Texas, Florida and Hawaii.38 Caribbean Islands. In 2014, Puerto Rico Madagascar resulted in up to 257 cases experienced an outbreak resulting in l C hagas Disease: Caused by the of pneumonic plague.43 In mid-2017, 4,274 reported cases. Blood donor data parasite Trypanosoma cruzi and spread there were four cases of plague in Santa suggests that an estimated 25 percent by insect bites, it can lead to severe Fe, New Mexico, but no deaths.44 of adults on the island were infected. cardiac and gastrointestinal disease. It l C holera: Cholera is rare in the United In 2017, there have been 95 cases is transmitted to animals and people States, but globally cases have increased reported from 23 states in the United by insect vectors found exclusively in steadily since 2005. Cholera is an acute States as of December 5th.37 the Americas. As many as 8 million diarrheal illness caused by the bacterium TFAH • healthyamericans.org 11 Vibrio cholerae and usually transmitted mostly among young children in l A cute Flaccid Myelitis Outbreak (AFM): by contaminated water or food. There are Africa.50 The United States experiences A recent uptick in children developing an estimated 3-5 million cases and over approximately 1,700 cases of the disease severe neurological symptoms has 100,000 deaths each year around the per year, most are exposed outside the spotlighted a rare condition called acute world.45 In 2016-2017, the ongoing war country.51 Proven interventions in malaria flaccid myelitis.58 AFM is a syndrome cut millions of Yemeni people off from endemic countries can have a profound that affects the nervous system, access to healthcare and clean water, impact on malaria control which saves especially the spinal cord, and can lead resulting in an unprecedented cholera lives, reduces risk of importation in the to temporary or permanent paralysis outbreak, causing over 770,000 cases United States and advances the effort to of the limbs. The cause of AFM is and 2,132 deaths.46 eliminate malaria. unknown and there is no known way to prevent the infection or cure it. It can l W est Nile Virus: A potentially serious l V alley Fever: An infection caused by be caused by a variety of infections, illness, for which there is no vaccine, breathing in the fungus Coccidioides, including enteroviruses, adenoviruses which is spread by infected mosquitoes which is endemic to the soils of the and West Nile virus. While the disease that contract the virus from feeding on U.S. Southwest, mainly Arizona and can infect anyone, most patients in infected birds. The majority of infected California.52 Most people never recent outbreaks have been children. An individuals have no symptoms, but experience any symptoms, but some outbreak occurred in 2014 (120 reported up to 20 percent develop symptoms, patients develop flu-like symptoms, 5-10 cases) and CDC initially suspected it was including fever, headache, body aches, percent develop long-term lung problems caused by a coinciding outbreak of the nausea, vomiting, swollen lymph and 1 percent may develop meningitis or respiratory infection enterovirus D68, glands and rashes on the trunk of the die.53 Blacks, Filipinos, pregnant women but it could ultimately not find a clear body that can last several weeks, and and people with diabetes or weakened link between the two. In 2016, a total of one in 150 people infected develop immune systems are most susceptible 144 people in 37 states and DC were serious symptoms and in some cases to the severe forms of the infection. confirmed to have AFM.59 Spinal fluid permanent neurological effects.47 In More than 147,000 Valley fever cases samples have been unable to point to 2017 (as of October 10), nearly 1,300 were reported to CDC during 1998 to one pathogen causing the paralysis. cases of West Nile virus disease in the 2014. Annual rates decreased from United States have been reported to 2012–2014, but increased in 2016 to l T uberculosis (TB): More than 9,200 CDC. Of these, 840 (65 percent) were 13.7 per 100,000, with 5,372 reported cases of this airborne infectious illness classified as neuroinvasive disease cases, the highest annual number of were reported in the United States in (such as meningitis or encephalitis) and cases in California recorded to date.54 2016, with cases in all 50 states.60 455 (35 percent) were classified as Fewer than 100 Americans die from More than 10 percent had documented non-neuroinvasive disease.48 Valley fever annually.55, 56 drug resistance, the majority of whom were exposed outside the United States. l M alaria: A mosquito-borne disease, l L yme Disease: The most common And, more than 10 million people around which can also be transmitted through vector-borne disease in the United the world become sick with TB each blood contamination or childbirth, that States and among the top 10 of all year and over half a million with the drug results in fever, headache, fatigue and nationally notifiable illnesses, Lyme resistant form of the disease. Proven potentially coma and death.49 Drugs can disease is mostly concentrated in the and emerging strategies to combat TB provide effective treatment, but resistant Northeast, mid-Atlantic and upper can reduce global numbers and have a strains are emerging and spreading Midwest. From 2008–2015, a total of direct impact on the risk of importation globally. In 2015, there were 214 million 275,589 cases of Lyme disease were and spread in the United States. cases and 438,000 deaths worldwide, reported to CDC.57 12 TFAH • healthyamericans.org BIOTERRORISM THREATS There are a wide array of infectious or multi-year, multi-million dollar poisonous biological agents that can be decontamination processes. weaponized against specific individuals Public health laboratories were or large populations. Fourteen agents overwhelmed receiving samples of meet the Material Threat Determination items to test all around the country threshold, meaning the Secretary of the — testing more than 70,000 samples Department of Homeland Security (DHS) following the identification of the believes that they could be sufficient to anthrax attacks.63 Public health officials affect national security. Some noted from CDC, New Jersey and Washington, threats include anthrax; glanders; D.C. and other agencies were among melioidosis; botulism toxin; hemorrhagic the primary investigators determining fever; tularemia; MDR anthrax; typhus; the sources of the anthrax, helping to smallpox and plague. In addition, ensure it was contained and developing radiological and nuclear agents can also containment and response strategies. be a threat to human health.61 Anthrax is a potentially lethal infection, Two threats that have been of high particularly when it manifests as focus in U.S. bioterrorism preparedness inhalation anthrax. Historically, strategies include: numerous nations have experimented l A nthrax: Five people died, 22 people with anthrax as a biological weapon, were sickened and more than 30 including the U.S. offensive biological more tested positive for exposure weapons program that was disbanded during a set of anthrax attacks in 1969.64 The worst documented during September and October 2001, outbreak of inhalation anthrax in immediately following the 9/11 humans occurred in Russia in 1979, attacks.62 More than 32,000 people when anthrax spores were accidentally took antibiotics for possible exposure, released from a military biological including many Capitol Hill employees. weapons facility near the town of Sverdlovsk, killing at least 66 people.65 Anonymous letters containing anthrax were sent to news agencies in Florida l S mallpox: Although the WHO declared and New York and to then-Senate that smallpox was eradicated in 1980, Majority Leader Tom Daschle (SD) this contagious and deadly infectious and Senator Patrick Leahy (VT) in disease caused by the Variola major their offices in Washington, D.C. virus, remains high on the list of Thirty-five post offices and mailrooms possible bioterror threats. The last were contaminated along with seven naturally occurring case of smallpox building on Capitol Hill. Postal was reported in 1977.66 Currently, workers in Hamilton Township, New there is no evidence of naturally Jersey, where the letters originated occurring smallpox transmission (postmarked Trenton, New Jersey), anywhere in the world, although small and Brentwood in Washington, D.C. quantities of smallpox virus still exist were among those exposed, and the in research laboratories in Atlanta, facilities in both locations underwent Georgia and in Novosibirsk, Russia. TFAH • healthyamericans.org 13 2017 OUTBREAKS l M easles: In Spring 2017, a measles number of Salmonella infections outbreak in a Somali-American from backyard poultry, such as community in the Minneapolis/St. Paul chickens and ducks, was the highest area sickened 65 children. Vaccination ever recorded by CDC—a total rates have dropped in this community of 1,120 cases, resulting in 248 in the past several years due to hospitalizations and one death. concerns about a link to autism from l S almonella: Proper handling of the MMR vaccine—a link that has infectious materials is essential been repeatedly disproved.67 As of to preventing illness among lab November 7, there have been a total workers. Twenty-four people in 16 of 120 measles cases in the United states were infected with Salmonella States for the year of 2017.68 Measles Typhimurium, which was linked to and mumps had been considered various clinical, commercial, and virtually eliminated as of 2000, but college and university teaching have experienced some resurgence in microbiology laboratories.71 recent years. l H epatitis: As of early December, l B acterial Infections: Pets and three states have seen over 1,300 backyard animals can often be a cases of Hepatitis A—California (665 source of infection. There were cases72), Michigan (555 cases73) and multistate outbreaks of Salmonella Utah (91 cases74). The outbreak has Agbeni linked to pet turtles and been ongoing since March—868 (72 multi-drug resistant Campylobacter percent) of those infected have been linked to pet store puppies. The hospitalized and 40 have died. A turtles sickened 37 people, while shortage of Hepatitis A vaccination is 67 people became ill from exposure complicating the response efforts. to the puppies.69, 70 In addition, the 14 TFAH • healthyamericans.org SECTI O N 1 State-by-State STATE-BY-STATE HEALTH SECURITY INDICATORS State-by-State Health Security Indicators Health Security All Americans deserve to be protected during health Indicators emergencies, no matter where they live. Readiness for health emergencies is of a community. Many of the indicators a concern in every state. However, are impacted by factors beyond the direct policies and programs vary from state- control of health officials. to-state. To help assess preparedness In addition, states differ in how they across the country, the Ready or Not? structure, deliver and fund public health report examines a series of 10 indicators services. For instance, states with high- based on high-priority areas and density urban areas may function very concerns. It is not a comprehensive differently than those with populations review; but collectively, it provides spread across smaller cities or towns. a snapshot of efforts to prevent and prepare for health threats in states and However, all states should be able to within the healthcare system. meet basic preparedness goals as defined by federal health officials and leading The indicators were selected after experts. This report was developed to consulting with leading public health provide taxpayers and policymakers with and healthcare officials and reflect: information about how well-prepared l F undamental, systemic needs for public their states and communities are for health emergency readiness; and different types of health threats. The American people deserve to know how l A reas where there is consistent data prepared their states and communities available across all 50 states and are for different types of health threats. Washington, D.C. — and information is publicly available and/or is able Using some consistent and some to be verified through surveys or updated indicators allows the report to consultation with state officials. reflect a range of preparedness issues, changing expectations for preparedness Each state received a score based on and differences in data availability over these 10 indicators. States received one time. It is important to note that many point for achieving an indicator and zero states have taken action and developed points if they did not. Zero is the lowest strengths in other areas of preparedness possible score and 10 is the highest. The or may be in the process of developing scores ranged from a high of nine in capabilities that may not be reflected Massachusetts and Rhode Island to a low in this report. In addition, limited data DECEMBER 2017 of two in Alaska and Idaho. is made publicly available to measure Scores are not intended to serve as public health preparedness. The Ready or a reflection of the performance of a Not? report compiles indicators based on specific state or local health department information that is timely and publicly or the healthcare system or hospitals available or data received from surveying within a state, since they reflect a much states directly, and where information is broader context, including resources, consistently available across states. policy environments and the health status STATE INDICATORS (2) (1) (4) (5) National Health Security Public Health Funding Antibiotic Stewardship Flu Vaccination Rate: Preparedness Index: (3) Commitment: Program for Hospitals: State vaccinated at least half State increased their overall Public Health Accreditation: State increased or maintained State has 70 percent or more of their population (ages 6 preparedness scores based on State has accredited public funding for public health from of hospitals reporting meeting months and older) for the the National Health Security health department. FY 2015 to FY 2016 and FY Antibiotic Stewardship Program seasonal flu from Fall 2016 to Preparedness Index™ between 2016 to FY 2017. core elements in 2016. Spring 2017. 2015 and 2016. Alabama 3 3 Alaska 3 Arizona 3 3 3 Arkansas 3 California 3 3 3 Colorado 3 3 3 3 Connecticut 3 3 3 Delaware 3 3 3 3 D.C. 3 3 3 Florida 3 3 3 Georgia 3 3 Hawaii 3 3 3 3 Idaho 3 3 Illinois 3 3 3 3 Indiana 3 Iowa 3 Kansas 3 Kentucky 3 Louisiana 3 3 Maine 3 3 3 Maryland 3 3 3 3 Massachusetts 3 3 3 3 3 Michigan 3 Minnesota 3 3 3 3 Mississippi 3 3 Missouri 3 Montana 3 3 Nebraska 3 3 3 Nevada 3 New Hampshire 3 New Jersey 3 3 3 3 New Mexico 3 3 New York 3 3 3 3 North Carolina 3 3 3 3 North Dakota 3 3 3 Ohio 3 Oklahoma 3 Oregon 3 3 3 Pennsylvania 3 3 Rhode Island 3 3 3 3 3 South Carolina 3 3 3 South Dakota 3 3 3 Tennessee 3 3 Texas Utah 3 3 3 Vermont 3 3 Virginia 3 3 3 3 Washington 3 3 3 West Virginia 3 3 3 Wisconsin 3 Wyoming Total 19 states + D.C. 33 States 30 States + D.C. 20 States + D.C. 20 States 16 TFAH • healthyamericans.org (7) (8) United States Climate (9) Public Health Laboratories: (6) Alliance: Public Health (10) State laboratory provided Enhanced Nurse Licensure State has joined the U.S. Laboratories: Paid Sick Leave: biosafety training and/or Total Score Compact (eNLC): Climate Alliance to reduce State laboratory Has a State has paid sick leave provided information about State participates in an eNLC. greenhouse gas emissions Biosafety Professional (July law. biosafety training courses (July 1, consistent with the goals 1, 2016 to June 30, 2017). 2016 to June 30, 2017). of the Paris Agreement. Alabama 3 3 4 Alaska 3 2 Arizona 3 3 3 3 7 Arkansas 3 3 3 4 California 3 3 3 6 Colorado 3 3 3 7 Connecticut 3 3 3 3 7 Delaware 3 3 3 3 8 D.C. 3 3 3 6 Florida 3 3 3 6 Georgia 3 3 3 5 Hawaii 3 3 3 7 Idaho 3 3 3 5 Illinois 3 3 6 Indiana 3 3 3 Iowa 3 3 3 4 Kansas 3 3 3 Kentucky 3 3 3 Louisiana 3 3 4 Maine 3 3 5 Maryland 3 3 6 Massachusetts 3 3 3 3 9 Michigan 3 3 3 Minnesota 3 3 3 7 Mississippi 3 3 3 5 Missouri 3 3 3 4 Montana 3 3 3 5 Nebraska 3 3 3 6 Nevada 3 3 3 New Hampshire 3 3 3 4 New Jersey 3 3 6 New Mexico 3 3 New York 3 3 3 7 North Carolina 3 3 3 3 8 North Dakota 3 3 3 6 Ohio 3 3 3 Oklahoma 3 3 3 4 Oregon 3 3 3 3 7 Pennsylvania 3 3 4 Rhode Island 3 3 3 3 9 South Carolina 3 3 3 6 South Dakota 3 3 3 6 Tennessee 3 3 3 5 Texas 3 3 3 3 Utah 3 3 3 6 Vermont 3 3 3 3 6 Virginia 3 3 3 3 8 Washington 3 3 3 3 7 West Virginia 3 3 3 6 Wisconsin 3 3 3 Wyoming 3 3 3 3 26 States 14 States 47 States + D.C. 47 States + D.C. 8 States + D.C. 5 (average) TFAH • healthyamericans.org 17 STATE-BY-STATE INFECTIOUS DISEASE PREVENTION AND WA MT ME CONTROL INDICATORS AND ND VT OR MN KEY FINDINGS ID NH SD WI NY MA WY MI CT RI NE IA PA NJ NV OH DE UT IL IN CA MD CO WV KS MO VA DC KY NC AZ TN OK NM AR SC Scores Color MS AL GA 2 TX LA 3 4 FL 5 AK 6 HI 7 8 9 SCORES BY STATE 9 8 7 6 5 4 3 2 (2 states) (3 states) (8 states) (12 states & D.C.) (6 states) (8 states) (10 states) (1 states) Massachusetts Delaware Arizona California Georgia Alabama Indiana Alaska Rhode Island North Carolina Colorado D.C. Idaho Arkansas Kansas Virginia Connecticut Florida Maine Iowa Kentucky Hawaii Illinois Mississippi Louisiana Michigan Minnesota Maryland Montana Missouri Nevada New York Nebraska Tennessee New Hampshire New Mexico Oregon New Jersey Oklahoma Ohio Washington North Dakota Pennsylvania Texas South Carolina Wisconsin South Dakota Wyoming Utah Vermont West Virginia 18 TFAH • healthyamericans.org INDICATOR SUMMARY Indicator Finding 1. Public Health Funding Commitment 19 states and Washington, D.C. increased or maintained funding for public health from Fiscal Year 2015 to 2016 to FY 2016 to 2017. Source: publicly available state budget information; distributed to state officials for updates and verification. 2. ational Health Security N 33 states increased their overall preparedness scores based on the National Health Security Prepared- Preparedness Index ness Index™ (NHSPI™). Source: NHSPI 3. Public Health Accreditation 30 states and Washington, D.C. have accredited state health departments. Source: Public Health Accreditation Board 4. Antibiotic Resistance 20 states and Washington, D.C. have 70 percent or more of hospitals reporting they meet core elements of Antibiotic Stewardship Programs. Source: CDC 5. Flu Vaccinations 20 states vaccinated at least half of their population (ages 6 months and older) against the seasonal flu during the 2016-2017 flu season (from July 2016 to May 2017). Source: CDC 6. Health System Preparedness 26 states participate in an Enhanced Nurse Licensure Compact (eNLC). Source: National Council of State Boards of Nursing 7. Climate Readiness 14 states have joined the United States Climate Alliance — a bi-partisan coalition of states committed to reducing greenhouse gas emissions consistent with the goals of the Paris Agreement. Source: Climate Alliance 8. Public Health Laboratories 47 state laboratories and Washington, D.C.’s laboratory provided biosafety training and/or provided infor- mation about biosafety training courses for sentinel clinical labs in their jurisdiction (from July 1, 2016 to June 30, 2017). Source: Association of Public Health Laboratories 2017 annual survey 9. Public Health Laboratories 47 state laboratories and Washington, D.C.’s laboratory reported having a biosafety professional (from July 1, 2016 to June 30, 2017). Source: Association of Public Health Laboratories 2017 annual survey 10. Paid Sick Leave 34 states and D.C. do not preempt localities from legally requiring paid sick days for workers. Source: Family Values @ Work; National Partnership for Women & Families FEDERAL, STATE AND LOCAL PUBLIC HEALTH JURISDICTIONS The federal role: Includes policymaking, funding programs, laws and issue regulations to protect, preserve and promote overseeing national prevention and response efforts, the health, safety and welfare of their residents. In most collecting and disseminating health information, building states, local governments are also charged with responsibility capacity and directly managing some select services and for the health of their populations. State and local health supporting biomedical research and production capabilities. departments and first responders are the front line in Some public health emergency preparedness and response addressing health issues during emergencies. Sometimes they capabilities, such as the Strategic National Stockpile and are the lead organizations (for example, during an infectious the National Disaster Medical System, are federal assets disease outbreak) and sometimes they are in a supportive role managed by federal agencies that supplement state and local when other agencies take the lead (for example, in responding capabilities, particularly when surge capacity is needed to to fires). Other state and local departments — such as public meet overwhelming needs. safety, environmental control or general emergency response agencies — play critical roles related to the protection of the State and local roles: Under U.S. law, state governments health of the public. Certain of the indicators may involve have primary responsibility for the health of their citizens. measures of the capacities of those other agencies. Constitutional police powers give states the ability to enact TFAH • healthyamericans.org 19 INDICATOR 1: PUBLIC 19 states and Washington, D.C. increased or 31 states cut public health funding from maintained public health funding from FY 2015-2016 FY 2015-2016 to FY 2016-2017 (0 points). HEALTH FUNDING to FY 2016-2017 (1 point). COMMITMENT — STATE California South Carolina Alabama Nevada Colorado South Dakota Alaska* New Hampshire* PUBLIC HEALTH BUDGETS District of Columbia Tennessee Arizona New Jersey Florida Virginia Arkansas New Mexico* Georgia Connecticut* New York* KEY FINDING: 19 states and Hawaii Delaware* Ohio Illinois Idaho* Oklahoma* Washington, D.C. increased or Kentucky Indiana Pennsylvania maintained funding for public Louisiana Iowa* Texas* Maryland Kansas* Utah* health from FY 2015 - FY 2016 Massachusetts Maine* Vermont Minnesota Michigan Washington to FY 2016 - FY 2017. North Carolina Mississippi West Virginia* North Dakota Missouri* Wisconsin* Oregon Montana Wyoming Rhode Island Nebraska Source: Publicly available state budget information; distributed to state officials for updates and verification. Notes: New Mexico did not respond to the data check TFAH coordinated with ASTHO that was sent out October 2017 – most recent publicly available information was used for the analysis in that case. States were given until December 6, 2017 to confirm or update information for their state. *Budget decreased for second year in a row. This indicator illustrates a state’s department, or division in charge of commitment and ability to provide public health services for FY 2015 - FY funding for public health programs 2016 and FY 2016 - FY 2017, using a that support the infrastructure and definition as consistent as possible workforce needed to improve health across the analyses of the two budget in each state, including the ability to cycles, based on how each state reports detect, prevent and control disease data. TFAH defined “public health outbreaks and mitigate the health services” broadly to include all state- impacts of disasters. General public level health spending with the exception health capacity — as well as targeted of Medicaid, Medicaid/State Children’s emergency response resources — is Health Insurance Program (CHIP) or needed to insure that core tools (such comparable health coverage programs as those related to disease tracking and for low-income residents and other laboratory personnel) exist and surge health-related programs that states capacity is readily available. deem are unrelated.  Every state allocates and reports its Based on this analysis (adjusted for budget in different ways. States also inflation), 19 states and Washington, vary widely in the budget details they D.C. increased or maintained their provide. This makes comparisons public health budgets, while 31 states across states difficult. For this analysis, made cuts. The median spending in TFAH examined state budgets and FY 2017 was $38.13 per capita, which appropriations bills for the agency, is approximately the same as last year. 20 TFAH • healthyamericans.org Public health funding is discretionary STATES’ PUBLIC HEALTH BUDGETS spending in most states and, therefore, FY 2016-2017 State Public Health FY 2016-2017 Per Capita Public is at high risk for significant cuts during Budget Health Spending tight fiscal climates. States rely on Alabama $274,290,949 $56.40 Alaska $84,857,300 $114.38 a combination of federal, state and Arizona $61,023,300 $8.80 local funds to support public health Arkansas $156,264,435 $52.29 activities, including disease prevention, California $2,424,431,000 $61.77 immunization services and preparedness Colorado $278,276,006 $50.23 Connecticut $104,214,695 $29.14 activities. The overall infrastructure Delaware $39,745,800 $41.75 of public health programs supports D.C. $94,923,000 $139.35 the ability to carry out all of their Florida $387,656,410 $18.81 responsibilities, which includes chronic Georgia $219,395,730 $21.28 Hawaii $159,900,025 $111.93 and infectious disease prevention, Idaho $151,217,000 $89.84 immunization services, injury prevention Illinois $327,241,300 $25.56 and health emergency preparedness. Indiana $84,205,745 $12.69 Iowa $219,770,221 $70.11 It is important to note that several Kansas $35,179,495 $12.10 states that received points for this Kentucky $185,502,795 $41.81 Louisiana $98,660,306 $21.07 indicator may not have actually Maine $28,006,490 $21.03 increased their spending on public Maryland $243,358,946 $40.45 health programs. The ways some states Massachusetts $364,200,373 $53.47 report their budgets, for instance, by Michigan $128,282,100 $12.92 Minnesota $358,163,000 $64.89 including federal funding in the totals Mississippi $36,645,538 $12.26 or including public health dollars Missouri $34,979,581 $5.74 within healthcare spending totals, make Montana $25,246,757 $24.22 it very difficult to determine “public Nebraska $85,688,198 $44.93 Nevada $19,851,091 $6.75 health” as a separate item. New Hampshire $29,976,434 $22.46 This indicator is limited to examining New Jersey $233,629,000 $26.12 New Mexico* $80,900,400 $38.88 whether states’ public health budgets New York $1,722,043,754 $87.21 increased or decreased; it does not North Carolina $148,298,428 $14.62 assess if the funding is adequate to North Dakota $36,404,687 $48.03 cover public health needs in the states, Ohio $144,784,069 $12.47 Oklahoma $162,020,000 $41.29 and it should not be interpreted as Oregon $113,216,399 $27.66 an indicator or surrogate for a state’s Pennsylvania $161,554,000 $12.64 overall performance. Rhode Island $60,906,278 $57.65 South Carolina $119,916,820 $24.17 For additional information on the South Dakota $31,734,355 $36.67 methodology of the budget analysis, Tennessee $336,532,700 $50.60 Texas $602,084,601 $21.61 please see Appendix A: Methodology Utah $95,347,100 $31.25 for Select State Indicators. And for Vermont $35,006,938 $56.05 the federal grants to states via the Virginia $320,760,606 $38.13 Preparedness Health Emergency Washington $301,352,000 $41.35 West Virginia $104,749,777 $57.21 Preparedness cooperative agreements Wisconsin $83,930,400 $14.52 and the Hospital Preparedness Wyoming $30,894,959 $52.77 Program (HPP), see Appendix B. National $11,667,221,290 $36.11 Source: Publicly available state budget information, distributed to state officials for updates and verification; U.S. Census Bureau * State did not respond to budget verfication request TFAH • healthyamericans.org 21 INDICATOR 2: NATIONAL 33 states had increased overall preparedness scores 17 states and Washington, D.C. have overall preparedness based on the National Health Security Preparedness scores that remained the same or declined based on the HEALTH SECURITY Index between 2015 and 2016. (1 point). National Health Security Preparedness Index between 2015 and 2016. (0 points). PREPAREDNESS INDEX™ Alabama (6.2) New Jersey (6.8) Alaska (5.9) Maryland (7.5) Arizona (6.0) New York (7.4) Arkansas (6.6) Missouri (6.9) KEY FINDING: 33 states Colorado (7.1) North Carolina (7.3) California (6.7) Nevada (6.2) Connecticut (7.3) North Dakota (6.8) D.C. (7.0) New Hampshire (7.3) had increased overall Delaware (7.2) Oregon (7.2) Florida (6.8) New Mexico (6.5) Georgia (6.3) Pennsylvania (7.0) Indiana (6.5) Ohio (6.5) preparedness scores based on Hawaii (6.4) Rhode Island (7.5) Iowa (7.0) Oklahoma (6.4) the National Health Security Idaho (6.5) South Carolina (6.4) Kansas (6.5) Texas (6.6) Illinois (6.8) South Dakota (6.5) Kentucky (6.7) Wyoming (6.3) Preparedness Index™ between Louisiana (6.3) Tennessee (6.8) Maine (7.4) Utah (7.2) 2015 and 2016.75 Massachusetts (7.3) Vermont (7.8) Michigan (6.7) Virginia (7.5) Minnesota (7.3) Washington (7.1) Mississippi (6.3) West Virginia (6.7) Montana (6.5) Wisconsin (7.4) Nebraska (7.4) Source: National Health Security Preparedness Index This indicator examines whether a state including TFAH and the Robert Wood 20 more years to reach a strong health improved its National Health Security Johnson Foundation (RWJF) — and security level of at least nine out of 10.76 Preparedness Index™ (NHSPI) score was first released in 2013. In 2015, the The scores from the Index includes 134 from 2015 to 2016, which was developed National Coordinating Center for Public individual measures, aggregated into six as a new way to measure and track Health Services and Systems Research at domains and 19 subdomains. The six the nation’s progress in preparing the University of Kentucky, with support domains encompass:77 for, responding to and recovering from RWJF, took the lead for managing from disasters and other large-scale and maintaining the Index. l ealth Security Surveillance: National H emergencies. The Index showed gains score 7.9 out of 10. The ability to In 2016, the United States posted a in a total of 33 states between 2015 and collect and analyze data to identify fourth consecutive year of gains in health 2016, while it declined in four states and possible threats before they arise. security for disease outbreaks, disasters remained unchanged in 14 states. • Sub-domains include: 1) strong and other large-scale health emergencies. The NHSPI measures the health security The overall national average was a 6.8 passive and active surveillance preparedness of the nation by looking out of a possible 10 in 2016. This is a to identify, discover, locate, and collectively at existing state-level data 1.5 percent improvement from 2015, monitor threats, provide relevant from a wide variety of sources. Uses and a 6.3 percent improvement from information to stakeholders and of the Index include guiding quality 2013. State scores ranged from a low of monitor/investigate events related improvement, informing policy and 5.9 in Alaska to a high of 7.8 in Vermont. to medical countermeasures; and resource decisions, and encouraging Generally, Northeastern states scored 2) the ability of agencies to conduct shared responsibility for preparedness highest, while those in the Deep South rapid and accurate laboratory tests across a community. and Mountain West scored lowest. If to identify biological, chemical and current trends continue, the average radiological agents to address actual NHSPI was developed by the Association or potential exposure to all hazards, state will require nine more years to of State and Territorial Health Officials focusing on testing human and reach health security levels currently (ASTHO) in partnership with CDC and animal clinical specimens. found in the best-prepared states, and more than 30 development partners — 22 TFAH • healthyamericans.org l ommunity Planning and C l ealth Care Delivery: National score H Engagement: National score 5.8 5.3 out of 10. The state of health care out of 10. How communities systems during everyday life, as well as mobilize different stakeholders in emergency situations. to work together during times of • ub-domains include: 1) prehospital S crisis. Supportive relationships care provided by emergency among community stakeholders — medical services (EMS); 2) inpatient government agencies, community care defined as a minimum of organizations and individual one night in the hospital or other residents — enables communities institution; 3) long-term care in to effectively work together during a residential setting; 4) access to crises and recover faster in the medical and mental/behavioral aftermath. health services; and 5) clinical and • ubdomains include: 1) S nonclinical home care. collaboration across sectors l ountermeasure Management: C primarily responsible for providing National score 7.0 out of 10. The direct health-related services; ability to mitigate harm from biologic, 2) actions to protect at-risk chemical, or nuclear agents. populations, including children and the elderly, as well as those • ub-domains include: 1) the S with physical/mental challenges, management, distribution and limited English proficiency and dispensing of medical materiel transportation limitations; 3) before and during an incident and NATIONAL HEALTH SECURITY management and coordination the management of the research, development and procurement of PREPAREDNESS INDEX AND volunteers during an emergency; and 4) social cohesion — the medical countermeasures; 2) the READY OR NOT? degree of connection and sense of effectiveness of countermeasure The National Health Security “belongingness” among residents. utilization, including community Preparedness Index™ and the Ready This domain has improved 16.3 preparedness for usage and follow or Not? report are complementary percent since 2013. through of usage; and 3) non- efforts to help identify areas of pharmaceutical intervention to l ncident and Information I achievement and concern for the contain disease spread or exposure Management: National score 8.2 nation’s preparedness for health using community mitigation strategies. out of 10. The ability to mobilize threats — and to identify timely policy and manage resources during a l nvironmental and Occupational E concerns and recommendations for health incident. Health: National score 7.0 out of change. NHSPI is focused on serving 10. The ability to prevent health to guide quality improvement, inform • ubdomains include: 1) multi- S impacts from environmental or policy and resource decisions and agency coordination; 2) effective occupational hazards. encourage shared responsibility for communication to the public; • ub-domains include: 1) the sufficient S preparedness. Ready or Not? focuses and 3) legal and administrative availability, access, use and protection on timely issues to raise awareness capabilities and capacities of safe and clean food and water and educate policymakers, partners responsible for assisting in the resources; and 2) the monitoring of and non-traditional audiences about execution activities, systems and air, water, land/soil and plants for preparedness issues — and to provide decision-making. hazards to assess past and current recommendations for policy change. status and predict future trends. TFAH • healthyamericans.org 23 INDEX FINDS DEEP INEQUITIES EXIST IN STATES’ PREPAREDNESS FOR PUBLIC HEALTH EMERGENCIES According to the release of the resources. Federal aid helps to reduce most recent NHSPI scores, despite differences in fiscal capacity across improvements in nearly two-thirds states, but federal preparedness of states, significant inequities in funding falls far short in eliminating the preparedness exist across the nation: health security gaps that exist between a gap of 32 percent separates the affluent and poorer states. highest state (Vermont, 7.8) and the Health security is stronger among lowest state (Alaska, 5.9). Generally, states that have achieved higher rates states in the Deep South and Mountain of health insurance coverage among West regions—many of which face their residents. Hospitals, physicians, elevated risks of disasters and and other healthcare providers are contain disproportionate numbers able invest more time and resources of low-income residents—lag behind in health security activities when Northeast and Pacific Coast states. they face fewer obligations to provide “Equal protection remains an elusive free and discounted medical care for goal in health security, as rural and uninsured patients. When disasters low-resource regions have fewer and occur, health insurance—along with weaker protections in place,” said property insurance and other forms of Glen Mays, PhD, MPH, who leads a coverage — helps to spread the costs team of researchers at the University of recovery evenly across families, of Kentucky in developing the Index. businesses, and governments. By “Closing the gaps in preparedness spreading risk broadly across society, among states and regions remains a insurance coverage promotes national priority.” resiliency and helps communities bounce back faster from adversity. “Poverty and health insurance coverage Federal and state efforts to expand are strongly linked to state health health insurance coverage under the security levels as measured by the Affordable Care Act and other health index. States with higher poverty reforms have strengthened health levels have fewer public and private security significantly, but these gains resources available to invest in health have accrued unevenly across the protections, and these states also face United States.”78 many competing demands on their 24 TFAH • healthyamericans.org 30 states and Washington, D.C. public health 20 state public health department have not received INDICATOR 3: PUBLIC departments have been accredited. (1 point.) accreditation. (0 points.) Alabama Mississippi Alaska North Carolina HEALTH DEPARTMENT Arizona Missouri Georgia Pennsylvania ACCREDITATION Arkansas Montana Hawaii South Carolina California Nebraska Indiana South Dakota Colorado KEY FINDING: 30 states New Jersey Iowa Tennessee Connecticut New Mexico Kentucky Texas Delaware New York Louisiana Virginia and Washington, D.C. public D.C. North Dakota Michigan West Virginia health departments have been Florida Idaho Ohio Nevada Wisconsin Illinois Oklahoma New Hampshire Wyoming accredited.79 Kansas Oregon Maine Rhode Island Maryland Utah Massachusetts Vermont Minnesota Washington Source: Public Health Accreditation Board. This indicator examines whether a state an identification and investigation of a specified time frame by a nationally has been accredited by the Public Health health hazards, educating the public, recognized entity; and Accreditation Board (PHAB).80 PHAB maintaining a competent workforce and l T he continual development, revision and — jointly funded by CDC and RWJF serving as an expert resource. distribution of public health standards. — is a non-profit, non-governmental As of November 21, 2017, a total of 211 organization that administers the According to surveys of accredited health departments (30 state, 179 local, national public health accreditation health departments conducted for a and 1 tribal), as well as one integrated program. It aims to improve and protect recent report titled “Evaluating the local public health department system, the health of the public by advancing Impact of National Public Health have achieved five-year accreditation and ultimately transforming the quality Department Accreditation—United through the Public Health Accreditation and performance of the nation’s state, States, 2016,” in the August 12, 2016 Board81 — together covering around tribal, local and territorial public health Morbidity and Mortality Weekly 213 million people, or about 70 percent departments. The development of Report, the “overwhelming majority of of the U.S. population.  Forty-four states national public health accreditation has respondents agreed or strongly agreed and D.C. have at least one accredited involved, and is supported by, public that accreditation stimulated quality and health department. Another 158 health health leaders and practitioners from performance improvement opportunities departments are in process of obtaining the national, tribal, state, local and within the health department, allowed accreditation. territorial levels. the health department to better identify According to PHAB, aspects of public strengths and weaknesses, helped the The goal of the voluntary national health department accreditation health department document the capacity accreditation program is to improve include: to deliver the three core functions of and protect the health of the public by public health and the 10 Essential Public advancing the quality and performance l T he measurement of health Health Services, stimulated greater of tribal, state, local and territorial public department performance against a accountability and transparency within health departments. Accreditation is set of nationally recognized, practice- the health department and improved an important benchmark of a public focused and evidenced-based standards; the management processes used by health system capable of responding l T he issuance of recognition of the leadership team in the health to a range of health threats, such as achievement of accreditation within department, among other benefits.”82 TFAH • healthyamericans.org 25 INDICATOR 4: 20 states and Washington, D.C. have 70 percent 30 states have less than 70 percent of hospitals or more of hospitals reporting meeting Antibiotic reporting meeting Antibiotic Stewardship Program ANTIBIOTIC RESISTANCE Stewardship Program core elements (1 point.) core elements. (0 points.) Alaska (71%) Nevada (89%) Alabama (64%) Montana (48%) Arizona (72%) New Jersey (76%) Arkansas (63%) Nebraska (56%) Key Finding: 20 states and California (81%) New York (75%) Colorado (63%) New Hampshire (38%) Washington, D.C. have 70 D.C. (75%) North Carolina (79%) Connecticut (69%) New Mexico (62%) Delaware (75%) Rhode Island (75%) Georgia (59%) North Dakota (39%) percent or more of hospitals Florida (75%) South Carolina (70%) Idaho (59%) Ohio (66%) Hawaii (72%) Utah (77%) Iowa (38%) Oklahoma (56%) meeting core elements of the Illinois (70%) Virginia (81%) Kansas (40%) Oregon (52%) Antibiotic Stewardship Program Indiana (72%) Washington (70%) Kentucky (59%) Pennsylvania (66%) Maryland (84%) West Virginia (75%) Louisiana (50%) South Dakota (46%) (as of 2016).83 Massachusetts (72%) Maine (62%) Tennessee (67%) Michigan (59%) Texas (58%) Minnesota (41%) Vermont (33%) Mississippi (50%) Wisconsin (59%) Missouri (59%) Wyoming (41%) Source: CDC Antibiotic Patient Safety Atlas. Puerto Rico rate: 43%. Data not available for Guam and U.S. Virgin Islands. Inappropriate use of antibiotics has adverse events associated with antibiotic contributed to one of the biggest threats use. The programs help improve quality to public health: antibiotic resistant of care and can help save money. Eight pathogens or “superbugs.”84 Superbugs high-risk antibiotic resistant superbugs are turning bacterial infections are often acquired in healthcare settings, that were once easily treated — like including Clostridium difficile infections Salmonella and Klebsiella — into deadly (CDI), a potentially deadly diarrhea that diseases. More than 2 million people in causes at least 250,000 infections and the United States are annually infected 14,000 deaths each year in hospitalized by superbugs and at least 23,000 die.85 patients.89, 90 It is estimated that Superbugs cause $20 billion in annual between 20 percent and 50 percent of direct costs and an additional $35 all antibiotics prescribed in U.S. acute billion in productivity losses.86 care hospitals are either unnecessary or inappropriate.91 Reducing the use CDC and other experts have warned that of high-risk antibiotics by 30 percent without concerted and timely action, can lower CDIs by 26 percent and other superbugs are expected to continue healthcare associated infections as a to grow dramatically. One of the most short-term benefit, and in the long-term focused and effective areas of efforts to lower risk for antibiotic resistance. On reduce over and misuse of antibiotics is any given day, one in 25 people in the through hospital-based programs that hospital has an HAI, and over the course focus on responsible and informed of a year, around 75,000 people with practices.87, 88 Antibiotic Stewardship healthcare-associated infections die Programs (ASPs) are aimed at optimizing during their hospitalizations.92 the treatment of infections and reducing 26 TFAH • healthyamericans.org Starting in 2014, CDC has recommended that all acute care hospitals implement Antibiotic Stewardship Programs. This Antibiotic Stewardship in Nursing Homes indicator examines if 70 percent or more of acute hospitals in a state report meeting the core elements of Antibiotic 4.1 MILLION Stewardship Programs, which include: l L eadership Commitment: Dedicating necessary human, financial and Americans are admitted to or information technology  resources; reside in nursing homes during a year1 l A ccountability: Appointing a single leader responsible for program outcomes.  Experience with successful programs show that a physician leader is effective; UP TO 70% of nursing home residents l D rug Expertise: Appointing a single received antibiotics during a year2,3 pharmacist leader responsible for working to improve antibiotic use; l A ction: Implementing at least one recommended action, such as systemic evaluation of ongoing treatment need UP TO 75% of antibiotics are after a set period of initial treatment (i.e. prescribed incorrectly* 2,3 “antibiotic time out” after 48 hours); l T racking:  Monitoring antibiotic prescribing and resistance patterns; CDC recommends l R eporting: Regular reporting 7 CORE ELEMENTS information on antibiotic use and for antibiotic stewardship in nursing homes resistance to doctors, nurses and Leadership Commitment ● Accountability relevant staff; and Drug Expertise ● Action ● Tracking Reporting ● Education l E ducation: Educating clinicians about resistance and optimal prescribing. *incorrectly = prescribing the wrong drug, dose, duration or reason 1 AHCA Quality Report 2013. 2 Lim CJ, Kong DCM, Stuart RL. Reducing inappropriate antibiotic prescribing in the residential care setting: current perspectives. Clin Interven Aging. 2014; 9: 165-177. As of 2016, 20 states and Washington, D.C. 3 Nicolle LE, Bentley D, Garibaldi R, et al. Antimicrobial use in long-term care facilities. Infect CS256066-C Control Hosp Epidemiol 2000; 21:537–45. have had 70 percent or more of acute hospitals report meeting this objective (of Source: CDC hospitals reporting to National Healthcare Safety Network (NHSN)).93 Reporting data to NHSN is important for tracking and setting patient safety policies and for transparency. Rates range from a high of 89 percent in Nevada to a low of 33 percent in Vermont. TFAH • healthyamericans.org 27 INDICATOR 5: FLU 20 states vaccinated at least half of their population 30 states and Washington, D.C. did not vaccinate (ages 6 months and older) against the seasonal flu half of their population (ages 6 months and older) VACCINATION RATES from July 2016 to May 2017. (1 point.) against the seasonal flu from July 2016 to May 2017. (0 points.) Connecticut (52.7%) New Jersey (49.1%) Alabama (43.9%) Missouri (46.4%) KEY FINDING: 20 states Colorado (49.9%)* New Mexico (49.2%) Alaska (39.1%) Montana (42.2%) Delaware (51.2%) New York (49.8%) Arizona (41.8%) Nevada (36.1%) vaccinated at least half of Hawaii (49.2%)* North Carolina (50.8%) Arkansas (46.2%) North Dakota (46.9%) their population (ages 6 Iowa (51.3%) Pennsylvania (53.3%) California (48.0%) Ohio (46.6%) Maine (49.9%)* Rhode Island (55.4%) D.C. (48.3%) Oklahoma (47.2%) months and older) against the Maryland (53.5%) South Dakota (53.9%) Florida (43.3%) Oregon (40.0%) Massachusetts (50.3%) Virginia (50.5%) Georgia (42.8%) South Carolina (47.4%) seasonal flu from July 2016 Minnesota (51.7%) West Virginia (49.6%) Idaho (39.5%) Tennessee (43.9%) through May 2017. Nebraska (52.3%) Illinois (41.8%) Texas (43.5%) New Hampshire (50.4%) Indiana (43.6%) Utah (43.4%) Kansas (43.9%) Vermont (47.3%) Kentucky (45.0%) Washington (48.3%) Louisiana (41.6%) Wisconsin (43.7%) Michigan (44.2%) Wyoming (38.9%) Mississippi (40.1%) Source: CDC, Flu Vaccination Coverage, United States, 2016-2017 Influenza Season * States with rates of 49 percent or higher were rounded up. Vaccination is the best prevention against population (ages 6 months and older) l T he lowest vaccination coverage was the seasonal flu. CDC recommends was vaccinated against the flu during the among adults ages 18 through 49 at everyone ages 6 months and older get 2016-2017 season. The U.S. Department 33.6 percent. vaccinated annually, yet fewer than half of Health and Human Services (HHS) l 6 5.3 percent of persons 65 or older of Americans ages 6 months and older has set a goal for the nation to vaccinate were vaccinated. were vaccinated against the flu during 70 percent of adults and 70 percent of last three flu seasons (2014 to 2015, 2015 children as part of the Healthy People Vaccination is particularly important for to 2016 and 2016 to 2017).    2020 initiative.94 This indicator uses 50 people who are at high risk of more severe percent as a marker of showing progress flu-related illnesses, including young This measure provides important toward achieving this goal. children (especially those with neurologic context for a state’s preparedness for conditions and other special health care pandemics or other major disease The highest flu vaccination coverage needs), pregnant women, people with outbreaks by measuring rates of a was 55.4 percent in Rhode Island certain chronic health conditions (such vaccine that is recommended every year and the lowest was 36.1 percent in as respiratory disease, heart disease and and across the lifespan. In addition Nevada. Twenty states vaccinated cerebrovascular diseases) and people 65 to protecting Americans from the 50 percent or more of their years and older. For example, 70 percent seasonal flu, establishing a cultural norm population or higher and 47 states to 85 percent of all flu-related deaths of vaccination, building vaccination and Washington, D.C. vaccinated 40 occur in persons 65 and older.96 If all infrastructure and establishing policies percent or higher. Nationally, 46.8 seniors received the flu shot, flu cases that support vaccinations can help ensure percent of Americans ages 6 months among this vulnerable population could the country has a strong system in place to and older were vaccinated.95 drop an estimated 15 to 25 percent.97, 98 be better able to vaccinate all Americans l F lu vaccination coverage levels were quickly during a new pandemic or Each year, millions of Americans get significantly higher for children unexpected disease outbreak. the flu — ranging from around 9 to (59.0 percent) compared to adults 36 million people, depending on the This indicator examines whether at (43.3 percent). severity and strain in different years. In least half (50 percent) of a state’s 28 TFAH • healthyamericans.org No More Excuses. recent years, flu-related deaths ranged Anyone can get from a low of 12,000 (2011-2012 flu the flu, and it season) to a high of 56,000 (2013-2014 can be serious. flu season). Flu-related hospitalizations Every year, ranged from a low of 140,000 (2011-2012 protect yourself flu season) to a high of 710,000 (2014- and those around 2015 flu season).99, 100, 101 THERE ARE MANY PLACES you by getting a TO GET YOUR FLU VACCINE. flu vaccine. In addition to its health effects, flu has a serious impact in terms of healthcare and worker absenteeism costs. Seasonal flu can often result in a half day to five days of work missed, which affects both DOCTOR’S RETAIL the individual and his or her employer. OFFICE SCHOOLS PHARMACIES STORES Annually, the flu leads to approximately $87.1 billion in economic losses each year — including $10.4 billion in direct costs for hospitalizations and outpatient visits GROCERY PEDIATRICIAN’S HEALTH and $76.7 million in indirect costs.102 OFFICE DEPARTMENT WORKPLACE STORE One study projected that an increase of vaccinations by 5 percent would prevent more than 500,000 illnesses and nearly 6,000 hospitalizations.103 MEDICAL DRUG COMMUNITY According to a CDC survey of healthcare CENTER STORE CLINICS CENTER personnel, about one-fifth (21.4 percent) For more information, visit Source: CDC of healthcare workers were not vaccinated http://www.cdc.gov/flu against the flu during the 2015-2016 season.104 Healthy People 2020 has set a Seasonal flu vaccinations reduce provided by in-network providers in target of 90 percent of healthcare workers U.S. Department of Health and Human Services hospitalizations and deaths. for Disease Control and Prevention and individual non-grandfathered CDC group vaccinated each flu season.105 Among Centers estimates that the seasonal flu vaccine private health plans and for theCS226285-B Medicaid healthcare workers, vaccination coverage prevented more than 27,000 flu-associated expansion population with no co- was highest among healthcare personnel deaths in the United States during the four payments or cost sharing, but states are working in hospitals (92.3 percent) and flu seasons from 2010-2011 to 2013-2014 still able to determine coverage and cost- lowest among those working in long-term — representing a 16 percent reduction sharing for their traditional Medicaid care settings (68 percent). Flu vaccination in deaths than would have occurred in population. As of 2013, all state Medicaid coverage levels were higher among the absence of a flu vaccination during programs, with the exception of Florida, healthcare professionals whose employers that time frame. For the 2015-2016 107 incorporate some level of vaccination required vaccination (96.7 percent). In season, CDC estimates the seasonal flu coverage benefit — 36 programs settings with no employer requirement for prevented 5.1 million illnesses, 71,000 routinely covered recommended vaccines vaccination, coverage was higher where hospitalizations and about 3,000 deaths.108 for adult beneficiaries in accordance vaccination was offered on-site at no cost with ACIP recommendations, and 17 of for one day (73.8 percent) or multiple Under the Affordable Care Act (ACA), these programs (17/36) also prohibited days (80.3 percent) and lowest among all vaccines routinely recommended copayments.109 Medicare Part B covers personnel working in settings where by the Advisory Committee on annual flu vaccinations for beneficiaries vaccine was neither required, promoted, Immunization Practices (ACIP), with no co-pay. nor offered on-site (45.8 percent).106 including flu shots, are covered when TFAH • healthyamericans.org 29 INDICATOR 6: ENHANCED 26 states participate in an Enhanced Nurse Licen- 24 states and Washington, D.C. do NOT participate in an sure Compact (1 point) Enhanced Nurse Licensure Compact (0 points) NURSE LICENSURE Arizona Nebraska Alabama Minnesota COMPACT Arkansas New Hampshire Alaska Nevada Delaware North Carolina California New Jersey Florida North Dakota Colorado New Mexico KEY FINDING: 26 states Georgia Oklahoma Connecticut New York Idaho South Carolina D.C. Ohio participate in an Enhanced Nurse Iowa South Dakota Hawaii Oregon Kentucky Tennessee Illinois Pennsylvania Licensure Compact. Maine Texas Indiana Rhode Island Maryland Utah Kansas Vermont Mississippi Virginia Louisiana Washington Missouri West Virginia Massachusetts Wisconsin Montana Wyoming Michigan Source: National Council of State Boards of Nursing The Nurse Licensure Compact (NLC),110 licensure by endorsement, which will 8. Has no misdemeanor convictions launched in 2000 by the National help remove barriers that have kept other related to the practice of nursing Council of State Boards of Nursing, states from joining in the past.113 (determined on a case-by-case basis); allows a registered nurse and licensed 9. Is not currently a participant in an In order to be eligible for a multistate practical/vocational nurse to have a single alternative program; license, a nurse must meet the multistate license that permits them to following criteria:114 10. Is required to self-disclose current practice—physically, telephonically and 1. eets the requirements for licensure M participation in an alternative electronically—in all compact states. This in the home state (state of residency); program; and allows standing reciprocity across states without an emergency declaration or any 2. a. as graduated from a board- H 11. Has a valid United States Social other sort of special circumstances.111 approved education program; or Security number. In non-NLC states, nurses are considered b. as graduated from an international H This indicator examines which states covered personnel under the Emergency education program (approved by participate in the eNLC. Currently, 26 Medical Assistance Compact (EMAC), but the authorized accrediting body in states participate, allowing nurses to legally EMAC must be triggered by an emergency the applicable country and verified practice across state lines with other states declaration by a governor and a request for by an independent credentials that are part of the eNLC. The ability assistance through the EMAC Operations review agency); for nurses to be able to work across state System, at which point resources are 3. as passed an English proficiency H lines can be a tremendous benefit during agreed upon by the requesting state and examination (applies to graduates of disasters or disease outbreaks, when the assisting state(s). Responders under an international education program affected communities may experience EMAC must be deemed “employees of the not taught in English or if English is severe workforce shortages. The eNLC state” to receive immunity and licensure not the individual’s native language); benefits both nurses and states by: reciprocity and medical volunteers are not 4. as passed an NCLEX-RN® or H l A llowing nurses flexibility and mobility; covered under EMAC protections.112 NCLEX-PN® Examination or l D riving standardized licensure The Enhanced Nurse Licensing Compact predecessor exam; requirements; (eNLC) went into effect July 20, 2017 and 5. s eligible for or holds an active, I l E nabling states to act jointly and will be fully implemented on January 19, unencumbered license (i.e., without collectively; 2018. The eNLC replaces the original active discipline); l F acilitating continuity of care; and NLC and adds extra protections. It 6. Has submitted to state and l A llowing different boards of nursing requires that all member states implement federal fingerprint-based criminal to build relationships and improve criminal background checks for all background checks; processes by learning from one another. applicants upon initial licensure or 7. as no state or federal felony convictions; H 30 TFAH • healthyamericans.org 14 states* are members of the 36 states and Washington, D.C. are not members of the Climate Alliance. INDICATOR 7: UNITED Climate Alliance. (1 point.) (0 points.) California Alabama Louisiana North Dakota STATES CLIMATE ALLIANCE Colorado Alaska Maine Ohio Connecticut Arizona Maryland Oklahoma Delaware Arkansas Michigan Pennsylvania KEY FINDING: 14 states have Hawaii D.C. Mississippi South Carolina Massachusetts Florida Missouri South Dakota joined the United States Climate Minnesota Georgia Montana Tennessee Alliance — a bi-partisan New York Idaho Nebraska Texas North Carolina Illinois Nevada Utah coalition of states committed Oregon Indiana New Hampshire West Virginia Rhode Island Iowa New Jersey Wisconsin to reducing greenhouse gas Vermont Kansas New Mexico Wyoming Virginia Kentucky emissions consistent with the Washington goals of the Paris Agreement.115 *Puerto Rico is also a member. Source: U.S. Climate Alliance Extreme weather events — which have for wildfires — killing 42 people in spatiotemporal patterns of diseases major implications for health — are Northern California’s wine country. ranging from West Nile virus and Zika becoming more and more common in Montana and the Northwest also to Lyme and other tick-borne diseases the United States. Different regions of suffered greatly with blazes in 2017 — to encephalitis are expected to shift.119 the country face different health threats spewing plumes of smoke across the l C limate change may affect the timing due to climate change — including those country. These particles in the air can of birds’ migration and boost the related to sea-level rise and associated be especially dangerous for children, spread of diseases they carry. Wild flooding, prolonged drought and water people over 65, pregnant women or birds can be infected by a number of insecurity, infectious disease outbreaks, people with lung or heart conditions.118 microbes that can be transmitted to hurricanes and other severe weather and Climate and weather-related events can humans. In addition, birds migrating extreme heat events.116, 117 Pounding impact human health in a wide range across national and continental borders rains cause devastating floods, extended of ways. Factors like potential changes can become long-range carriers of any droughts threaten agriculture and massive in water quantity and quality, air quality, bacteria, virus or parasite they harbor. wildfires threaten homes and businesses. average and extreme temperatures and Birds rapidly spread West Nile virus There are an increasing number of severe insect control are all important public after it first emerged in 1999. By 2012 weather-related disasters, and 2017’s health concerns. Certain zoonotic and the virus had been reported in humans, hurricane season exceeded imagination. vector-borne diseases, as well as food mosquitoes and birds in 48 states.120 Three massive hurricanes decimated and waterborne diseases, may increase U.S. communities — Harvey in Houston, l C hanging weather patterns put people in incidence and spread as changes in Irma in Florida and U.S. Virgin Islands in different regions at increased temperature and weather patterns allow and Maria in Puerto Rico and U.S. Virgin risk for different types of diseases. pathogens to expand into different Islands, displacing families and putting For instance, coastal areas are at geographic regions. For instance: human health at risk. increased risk for flooding and the l T he presence and number of rodents, coastal Southeast is at higher risk for In addition, the U.S. has suffered mosquitoes, ticks and other insects hurricanes.121, 122 the worst wildfire season in years. and animals that can carry infectious California’s years-long drought officially l T he rise in extreme weather events diseases (disease vectors) rise in ended in 2017. While a huge relief and natural disasters also leads to warmer temperatures. As extreme for the state’s dwindling water supply, a more fertile environment for the temperatures increase in severity the resulting vegetation growth would spread of infectious diseases and and duration, the geographic and eventually become lush kindling germs. For instance, cryptosporidiosis TFAH • healthyamericans.org 31 outbreaks, which cause diarrheal disease, are associated with heavy rainfall, which can overwhelm sewage treatment plants or cause lakes, rivers and streams to become contaminated by runoff containing waste from infected animals. Experts also believe that an El Niño occurrence may have contributed to increases of cholera.123 Communities recovering from a disaster may see food or waterborne illnesses associated with power outages or flooding, as well as infectious disease transmission in emergency shelters. In response to the U.S. federal government’s decision to withdraw the United States from the Paris Agreement on climate change, Source: CDC Governors Andrew Cuomo, Jay Inslee, and Jerry Brown created the United Fourteen states and Puerto Rico have been leading the U.S. in combating States Climate Alliance. The Alliance joined the Climate Alliance, representing climate change through policies is a bi-partisan coalition of states more than 36 percent of U.S. population that encourage investment in clean committed to the goals of the Paris and accounting for more than $7 trillion energy, energy efficiency and climate Agreement — a 26 percent to 28 dollars in combined economic activity— resilience, resulting in a 15 percent percent reduction in greenhouse gas enough to be the world’s third largest reduction in greenhouse gas emissions emissions below 2005 levels by 2025.124 country. These states have already between 2005 and 2015 alone.125 THE LANCET COUNTDOWN: TRACKING PROGRESS ON HEALTH AND CLIMATE CHANGE126 The Lancet Countdown is an international, multi-disciplinary l F rom 2007 to 2016, an average of 306 weather-related research collaboration, dedicated to tracking progress on disasters were reported per year. health and climate change from 2016 to 2030. It aims to l B etween 2000 and 2016, the number of vulnerable people report annually on a series of indicators across five themes: exposed to heatwave events has increased by around 125 1. The health impacts of climate change; million, with a record 175 million more people exposed to 2. Health resilience and adaptation; heatwaves in 2015. 3. Health co-benefits of mitigation; l I n Southeast Asia, 1,900,570 people died prematurely as a result of ambient air pollution in 2015. 4. inance and economics associated with health and climate F change; and l T he vectorial capacity for the transmission of dengue fever by Aedes aegypti, has increased an estimated 9.4 percent 5. Political and broader engagement. since 1950. 2017 Report highlights: l E conomic losses resulting from climate-related events have l A nnual weather-related disasters have increased by 46% been increasing since 1990, totaling $129 billion in 2016. from 2000 to 2013. 32 TFAH • healthyamericans.org CLIMATE AND HEALTH RISKS In 2016, Climate Central and ICF developed States at Risk: America’s Preparedness Report Card — a state-level preparedness scorecard for climate- related threats.127 The five weather- related threats examined were extreme heat (48 states), drought (36 states), wildfires (24 states), inland flooding (32 states) and coastal flooding (24 states). Each state was evaluated based only on the threats it faces. Some states face fewer threats, while others, like Florida, Texas and California, are at risk from multiple weather-related disasters. Extreme heat: Despite being the most pervasive — and deadly — threat, states are the least prepared for extreme heat. The combination of However, by 2050, Colorado, Idaho, Inland flooding: Risks depend on many heat and humidity in the Southwest Montana, New Mexico, Texas, factors — precipitation (locally or far and Gulf Coast is projected to cross Michigan, Wisconsin, Minnesota and away), soil saturation, topography and into dangerous zones for human health Washington are projected to face a flood protections like levees and dams. within the next decade. By 2050, greater summer drought threat than Florida and California have the largest 11 states are projected to have an Texas does today. vulnerable populations at risk with 1.5 additional 50 or more heat wave days million and 1.3 million people living in Wildfires: The number of large wildfires per year, two will have an additional the inland FEMA 100-year floodplain, out west has doubled since the 1970s 60, and Florida is expected to have respectively. Georgia is third most at risk and in some states, the rate has an additional 80 more days (which is with 570,000 people. More than half of increased fourfold. Fighting wildfires a fifth of the year). Extreme heat has all states assessed (17 out of 32) have now accounts for more than half of killed more than 1,200 Americans in taken no action to plan for future climate the annual budget of the U.S. Forest the last 10 years, more than any other change-related inland flooding risks or Service, up from 16 percent just 20 form of extreme weather during that implemented strategies to address them. years ago. Texas, California, Arizona time. Those most vulnerable to extreme and Nevada face the greatest threat Coastal flooding: Rising sea levels put heat are people living in poverty, from wildfires. In those four states, all 24 coastal states at risk for flooding experiencing homelessness, under more than 35 million people live in the — none more than Florida and Louisiana. the age of 5 or over the age of 65 and high threat zone — the wildland-urban By 2050, 4.6 million people are those with mental illness. Alaska faces interface — which is the point where projected to be at risk (living in the 100- a unique threat from heat — permafrost nature and development converge. year coastal floodplain) in Florida and thaw — which can cause enormous Florida, North Carolina and Georgia 1.2 million in Louisiana. More states damage to buildings and infrastructure combine for another 15 million people are prepared for coastal flooding than constructed on top of it. at risk, and four southeastern states for any other threat, but despite Florida’s Summer drought: Texas is threatened — Arkansas, Alabama, Louisiana and enormous vulnerability, it is among the by summer droughts more than any Mississippi — all face above average least prepared for coastal flooding. other state by a significant margin. increases in wildfire risks by 2050. TFAH • healthyamericans.org 33 INDICATORS 8 AND 9: 47 state laboratories and Washington, D.C.’s laboratory 3 state laboratories did not provide biosafety provided biosafety training and/or information about training and/or information about biosafety PUBLIC HEALTH biosafety training courses for sentinel clinical labs in their training courses for sentinel clinical labs in LABORATORIES jurisdiction (from July 1, 2016 to June 30, 2017.) (1 point). their jurisdiction (from July 1, 2016 to June 30, 2017.) (0 points). Alabama Louisiana ^ Ohio^ California Alaska Maine Oklahoma Kentucky KEY FINDING: 47 state Arizona^ Massachusetts Oregon^ Maryland laboratories and Washington, Arkansas^ Michigan Pennsylvania Colorado Minnesota Rhode Island D.C.’s laboratory provided Connecticut Mississippi South Carolina Delaware^ Missouri^ South Dakota biosafety training and/or D.C. Montana^ Tennessee^ provided information about Florida^ Nebraska^ Texas Georgia^ Nevada Utah^ biosafety training courses for Hawaii New Hampshire Vermont Idaho^ New Jersey Virginia sentinel clinical labs in their Illinois^ New Mexico Washington jurisdiction (from July 1, 2016 Indiana New York West Virginia Iowa^ North Carolina^ Wisconsin to June 30, 2017.) Kansas^ North Dakota Wyoming Note: ^Provided both training and information. Source: Association of Public Health Laboratories 2017 survey 47 state laboratories and Washington, D.C.’s laboratory 3 state laboratories reported not having a Key Finding: 47 state reported having a biosafety professional (from July 1, 2016 biosafety professional (from July 1, 2016 to to June 30, 2017). (1 point). June 30, 2017). (0 points). laboratories and Washington, Alabama Louisiana Oklahoma Alaska D.C.’s laboratory reported having Arizona Maryland Oregon Maine Arkansas Massachusetts Pennsylvania New Mexico a biosafety professional (from California Michigan Rhode Island Colorado Minnesota South Carolina July 1, 2016 to June 30, 2017.) Connecticut Mississippi South Dakota D.C. Missouri Tennessee Delaware Montana Texas Florida Georgia Nebraska Utah Hawaii Nevada Vermont Idaho New Hampshire Virginia Illinois New Jersey Washington Indiana New York West Virginia Iowa North Carolina Wisconsin Kansas North Dakota Wyoming Kentucky Ohio Source: Association of Public Health Laboratories 2017 survey. 34 TFAH • healthyamericans.org Public health laboratories are essential and 62 percent of laboratory reports to quickly identifying and diagnosing were being received through ELR new outbreaks and tracking ongoing compared to 54 percent in 2012. char definerizatio outbreaks. act CDC’s Epidemiology and Laboratory itive n Labs require highly expert staffing, Capacity for Infectious Diseases (ELC) extensive safety measures, specialized Cooperative Agreement distributes conftesting equipment, reagents and other resources to U.S. health departments to irma biological materials to use for testing and detect, prevent and control infectious tor y enough capacity to test for a large threat disease threats. Funding awards are or multiple threats at once. They have used to strengthen epidemiological, reco e-out r ul er ongoing responsibilities, such as testing laboratory and health information gniz ref e water and environmental conditions, as systems capacity at state, local and well as responding to emergencies and territorial levels. Zika supplemental Source: CDC novel threats, such as an outbreak of awards through ELC cooperative Salmonella or a suspicious white powder l R eference laboratories are responsible agreements also supported the U.S. that could potentially be used as an act for investigation and/or referral of Zika Pregnancy Registry to monitor of bioterrorism. specimens. They are made up of more pregnant women with Zika and their than 100 state and local public health, infants and to help jurisdictions sustain Since 2001, public health labs have military, international, veterinary, Zika prevention and surveillance efforts created networks to be more efficient agriculture, food- and water-testing through the next mosquito season.130 and effective, so that every state has a laboratories; and baseline of capabilities but does not These indicators examine two important have to invest the resources required to l S entinel laboratories provide routine components of ensuring safety in maintain every type of state-of-the-art diagnostic services, rule-out and laboratories. First, according to an annual equipment or staffing expertise. For referral steps in the identification survey conducted by the Association of example, samples can be shipped to process. While these laboratories may Public Health Laboratories (APHL), for facilities with the needed expertise as not be equipped to perform the same the time period of July 1, 2016 to June quickly and safely as possible. tests as LRN Reference laboratories, 30, 2017, 47 state labs and Washington, they can test samples. D.C reported that they provided biosafety The Laboratory Response Network for training and/or information about Biological Threat Preparedness (LRN-B) Labs not only help detect and diagnose biosafety training courses for sentinel includes clinical diagnostic and research problems, the information they provide clinical labs in their jurisdiction. In labs with a hierarchy of different helps public health officials track the addition, 47 state labs and Washington, capabilities that form an integrated, emergence and spread of different D.C. reported that they have a professional supporting network capable of rapidly outbreaks and is an essential part committed to biosafety on staff. responding to an outbreak and/or of monitoring disease threats and bioterrorism attack, including:128 understanding how to control them. According to the Occupational Safety and Health Administration (OSHA), l N ational laboratories — including In 2010, CDC began funding 57 state, there are over 500,000 lab workers in those operated by CDC, U.S. Army local and territorial health departments the United States. These workers can Medical Research Institute for to encourage increased electronic be exposed to a range of chemical, Infectious Diseases (USAMRIID) and reporting of lab results to help make biological and radiological hazards. the Naval Medical Research Center reporting faster and more complete.129 While lab safety is governed by myriad (NMRC) — are responsible in their Data collected since then show various regulations at the national, state and role in the LRN-B for specialized improvements. By the end of July local level, OSHA has developed strain characterizations, bioforensics, 2013, 54 of the 57 jurisdictions were standards and published guidance over select agent activity and handling getting some laboratory reports through the years to improve safety.131 highly infectious biological agents; Electronic Laboratory Reporting (ELR), TFAH • healthyamericans.org 35 Source: CDC 36 TFAH • healthyamericans.org Many workers handle a variety personal protective equipment (PPE) — effective containment system for safe of biological hazards, including the protective gear laboratory workers manipulations of biological agents that bloodborne agents, research animals wear to keep them safe as they carry out may produce infectious aerosols.134 and federally-regulated select agents their jobs. These include respirators, It is also important to have well-trained (e.g., viruses and bacteria) and toxins goggles and disposable gloves. In laboratorians and labs that have that have the potential to pose a severe working with the infectious agents and adequate and up-to-date equipment to threat to public health and safety. Select toxins that are regulated federally, be able to respond when new threats agents and toxins — as well as other workers must use PPE and agents arise. Strong trainings help ensure infectious agents and toxins — must be must be properly stored and handled. that appropriate biosafety precautions properly stored and handled to ensure PPE is selected based on the hazard are taken. In the past several years, the safety of the worker, his or her to the worker and must be properly labs have had to respond to emerging immediate environment and the larger fitted, maintained in accordance with threats, such as Zika, Chikungunya, public as a whole. manufacturing specifications and Dengue and Ebola. It is also important properly removed and disposed of or A biosafety program requires consistent to have enough trained staff to be cleaned to avoid contaminating the use of good microbiological practices, able to test for emerging problems — worker, others or the environment.133 use of primary containment equipment including to meet surge needs when the and proper containment facility Properly maintained Biosafety Cabinets labs get an influx of samples, such as design.132 One of the primary elements (BSCs) are another key component some states were managing in response of lab safety is the correct use of of laboratory safety; they provide an to Zika. MEANINGFUL USE OF ELECTRONIC HEALTH RECORDS Meaningful Use is defined as “the use of by a task force comprised of experts demonstrate meaningful use of certified certified electronic health record (EHR) from CDC, the Council of State and EHR technology.136 The Program technology in a meaningful manner (for Territorial Epidemiologists (CSTE) and the consists of three stages with increasing example electronic prescribing); ensuring Association of Public Health Laboratories requirements for participation. that the certified EHR technology is — is that “all labs (public and private) l S tage 1 established requirements connected in a manner that provides conducting clinical testing identify for the electronic capture of clinical for the electronic exchange of health laboratory results that indicate a potential data, including providing patients with information to improve the quality of reportable condition for the jurisdictions electronic copies of health information. care; and that in using certified EHR they serve, format the information technology the provider must submit in a standard manner and transmit l S tage 2 focused on advancing clinical to the Secretary of HHS information on appropriate messages to the responsible processes and encouraged the use quality of care and other measures.” jurisdiction; all jurisdictions can and do of certified EHR technology (CEHRT) receive and utilize the data.”135 for continuous quality improvement One public health objective for meaningful at the point of care and the exchange use is electronic lab reporting, Through the Medicare and Medicaid of information in the most structured transmitting laboratory reports to public Programs Electronic Health Records format possible. health agencies on reportable conditions. Incentive Program, Centers for Medicare Its benefits include improved timeliness, and Medicaid Services (CMS) is l S tage 3 in 2017 and beyond, focuses reduction of manual data entry errors providing incentive payments to eligible on using CEHRT to improve health and reports that are more complete. hospitals, providers and critical access outcomes. The vision for ELR — as determined hospitals that adopt and successfully TFAH • healthyamericans.org 37 INDICATOR 10: PAID 8 states and Washington, D.C. have paid sick 42 states do not have paid sick leave laws and/or preempt leave laws. (1 point.) localities from legally requiring paid sick days for workers. (0 SICK LEAVE LAWS points.) Arizona Alaska Louisiana North Carolina California Alabama Maine North Dakota KEY FINDING: Eight states and Connecticut Arkansas Maryland Ohio D.C. Washington, D.C. have paid sick Massachusetts Colorado Michigan Oklahoma Delaware Minnesota Pennsylvania leave laws or do not preempt Oregon Florida Mississippi South Carolina Rhode Island* Georgia Missouri South Dakota localities from legally requiring Vermont Hawaii Montana Tennessee Washington** paid sick days for workers. 137 Indiana Nebraska Texas Iowa Nevada Utah Idaho New Hampshire Virginia Illinois New Jersey West Virginia Kansas New Mexico Wisconsin Kentucky New York Wyoming Sources: National Partnership for Women & Families. * Takes effect July 2018. ** Takes effect January 2018. Nearly one in three private-sector industries and occupations that require employees cannot earn paid sick days for frequent contact with the public are their own illness or injury or to care for an some of the least like to provide paid ill family member.  And low-wage workers sick days. For instance, more than four are much less likely to have access to paid in five restaurant workers do not have a sick leave than highly paid workers. single paid sick day, and three-fourths of personal care and service workers, Paid sick days help reduce the spread including child care workers, do not of contagious illnesses and diseases have paid sick days.139 This increases the and increase access to preventive care chance of infectious diseases spreading among workers and their families. When through contact with food, co-workers workers without paid sick time get sick, and the general public — and can they face the impossible choice of going threaten the productivity and safety of to work and potentially infecting others America’s businesses. or staying home and risking losing their jobs. Individuals without paid sick leave Paid sick days help to ensure workers were three times more likely to forgo can comply with science-based medical care for themselves and 1.6 guidance on controlling the spread times more likely to forego medical care of an outbreak. According to a 2010 for their family compared to adults with report, almost 26 million employed paid sick leave benefits.138 Americans age 18 and older may have been infected with the H1N1 influenza Employees who are sick and possibly in 2009, and nearly eight million people contagious in the workplace enable took no time off work while infected.140 the spread of illness among co-workers Another recent study found that and customers alike, and the very 38 TFAH • healthyamericans.org providing employees who have the flu cities and counties have also passed sick with one or two paid sick days to recover leave laws, including: San Francisco, could reduce workplace infections by up Santa Monica, Berkeley, Emeryville, to 40 percent141 while another estimates Oakland and San Diego in California; that seasonal flu results in $18.9 billion Seattle, Spokane and Tacoma in per year in indirect costs attributable to Washington state; New York City; Jersey lost productivity.142 City, Newark, Irvington, Passaic, East Orange, Paterson, Trenton, Montclair, Paid sick days also improve access to Bloomington, Elizabeth, Plainfield, preventive care by giving employees the Morristown and New Brunswick in New ability to take time to go to a clinician Jersey; Philadelphia and Pittsburgh in and to ensure their children get routine Pennsylvania; Chicago, Cook County in check-ups and immunizations. A 2012 Illinois, and Minneapolis and St. Paul CDC report found that workers without in Minnesota.144 paid sick time are less likely to get screened for cancer.143 There are clear Sixteen states have actually passed signs that delaying or skipping necessary “preemption laws,” which prevent local preventive care can result in poor health jurisdictions from instituting their own outcomes and more costly care for the laws or legal requirement to provide paid more than 37 million American workers sick leave to workers, including: Alabama, who lack paid sick days. Arizona, Florida, Georgia, Indiana, Kansas, Louisiana, Michigan, Mississippi, Missouri, This indicator examines if states have North Carolina, Ohio, Oklahoma, paid sick days laws — which eight plus Oregon, Tennessee and Wisconsin.145 Washington, D.C. have. A number of TFAH • healthyamericans.org 39 EXPERT COMMENTARY A Potentially Unhealthy Mix: How Workplace Practices Can Either Enhance or Exacerbate Health Preparedness Originally featured by the National By: Michael T. Childress, MA, research associate at the Center for Business Health Security Preparedness Index and Economic Research, Gatton College of Business and Economics, University project, March 31, 2017. of Kentucky; and member of program management office team for the National Health Security Preparedness Index. The National Health Security an individual has PTO, broadband at Preparedness Index measures home, or can telecommute. This analysis the nation’s health security and illustrates how the less advantaged preparedness—that is, the nation’s can be affected differently by disease ability to prepare for, respond to, and outbreaks, disasters, and large-scale recover from large-scale health threats. emergencies—and how workplace The Preparedness Index measures practices can either exacerbate or health security from a broad, multi- ameliorate health security. sectoral perspective using nearly 140 measures from more than 50 different Rationale sources. Here we examine three of Social distancing policies, such as school these measures: paid time off (PTO), closures and self-quarantine measures, telecommuting, and high-speed internet were used during the 2014 Ebola access from home, in the context of outbreak and the 2009 H1N1 influenza health security, preparedness and equity. (flu) pandemic to thwart the spread of These factors have at least three things disease. The efficacy of this approach, in common: they enhance compliance however, is largely determined by the with social distancing policies used extent to which individuals adhere to in infectious disease outbreaks; they it. The Centers for Disease Control and highlight the private-sector role in Prevention estimates that almost 18 of the nation’s health preparedness; the 26 million H1N1 infected workers in and they bring to the fore important the fall of 2009 took days off from work, equity issues. For prime working-age but the remaining 8 million workers adults between 25 and 54 years old, an did not and likely infected another 7 estimated 81 percent have broadband million co-workers.146 access at home, approximately 62 percent have some form of PTO, and Broadband access facilitates the about 30 percent can telecommute continuity of operations during when they are away from their usual emergencies that can limit the adverse workplace. However, there are economic impact of disasters. There significant differences based on income was, for instance, a citywide closure and education levels, with individuals of Boston after the 2013 Marathon at lower income and education levels bombing, but some businesses reporting lower percentages of PTO, stayed open with teleworkers and broadband access, and telecommuting. experienced limited financial Our analysis of individual-level losses. Similarly, health department U.S. Census data reveals statistically staff were able to work remotely to significant independent effects of maintain critical communications and education and income on whether surveillance activities. 40 TFAH • healthyamericans.org These three factors—PTO, TABLE 1—Estimated Gross and Net Percentage of Workers (25 To 54 Years) telecommuting, and high-speed internet With Paid Time Off, Households With Broadband, and Telecommuters access from home—can enhance the Paid Time Off Household Broadband Telecommuters likelihood individuals will adhere to social Wages & Salary Gross Net Gross Net Gross Net 1st Quartile (lowest) 25% 55% 58% 62% 12% 18% distancing and quarantine measures.147 2nd Quartile 58% 58% 76% 77% 20% 24% PTO and telecommuting are two of 17 3rd Quartile 71% 69% 88% 86% 32% 31% item measures within the Preparedness 4th Quartile (highest) 73% 67% 95% 90% 47% 41% Index domain of Countermeasure Education Management.148 PTO is an indicator of Less than High School 33% 44% 55% 61% 9% 15% preparedness and resilience, because High School 53% 56% 70% 73% 15% 18% Some College 52% 61% 83% 83% 25% 27% it enables one to shelter in place or Bachelors or Higher 70% 69% 93% 88% 44% 40% evacuate during an emergency without Race experiencing the economic hardship White (non-Hispanic) 57% 61% 83% 81% 31% 30% of lost income. Likewise, the ability to Non-White (non-Hispanic) 55% 59% 74% 77% 26% 30% telecommute and household access to Residence high-speed internet are vital because, like Non-Metro 54% 60% 76% 78% 19% 25% Metro 58% 61% 81% 81% 31% 30% PTO, if one can work at home, remain Age economically productive, and shelter Under 40 58% 58% 81% 81% 30% 31% in place, it enhances individual security Over 40 65% 64% 81% 80% 29% 29% and community resilience.149 Also, as Gender one of 13 measures in the Incident & Female 55% 58% 80% 81% 26% 26% Information Management domain,150 Male 59% 63% 81% 80% 34% 34% household broadband access reflects the degree to which one can receive factors across income and education big differences across education levels. timely and up-to-date information during levels. The “gross” numbers, explained Those with a bachelor’s degree or a public health emergency. The Pew in detail below, represent the overall higher are 1.7 times more likely to have Research Center reports that four in ten percentages for everyone in that household broadband (93 percent) than Americans often get their news online, category. We can see, for example, that those without a high school diploma (55 highlighting the reliance on the internet those without a high school diploma percent)—and are 4.9 times more likely for staying informed.151 are much less likely to have PTO (33 to telecommute (44.2 percent compared percent) than those with a bachelor’s to 9.1 percent). Factors Affecting PTO, Telecommuting, degree or higher (70 percent), and & Household Broadband Access Within each of the education and workers in the lowest income group (25 income groups described above, the Based on our analysis of prime working percent) are much less likely to have individuals and households might be age adults from 25 to 54 years old, an PTO than those in the highest income quite different from each other and estimated 62 percent of workers have group (73 percent). only share membership in the group some form of PTO,152 about 30 percent Similarly, individuals with higher income on the basis of that one factor. That is, can telecommute when away from their and education levels are more likely among those with a bachelor’s degree usual workplace,153 and an estimated 81 to have household broadband and are or higher there will be members from percent of households have broadband more likely to telecommute. Individuals, every income group, both genders, many in the home.154 However, there are for instance, in the highest income ages, and all races and ethnicities. We call significant differences based on income quartile are 1.6 times more likely to have these the “gross” percentages. However, and education levels, with individuals household broadband (95 percent) than because so many factors are correlated— at lower income and education levels those in the lowest income quartile (58 like income, education, race, gender, showing comparatively lower percentages. percent)—and are four times more likely and location of residence—the gross The numbers in Table 1 illustrate some to telecommute (46.8 percent compared differences do not reveal how much of of the significant differences in these to 11.7 percent). Likewise, there are a digital divide, for example, is due to TFAH • healthyamericans.org 41 income (because higher education is associated with higher Figure 1: Estimated Relationship Between Income and income), education (since lower income is correlated with lower Paid Time Off, Broadband at Home, & Telecommuting education), or location of residence (since individuals in metro (net effect of income, ages 25 to 54 years) 100% areas tend to have higher income and educational attainment). PTO 90% 90% 86% Broadband To better address the equity issues represented by the gross 80% Telecommute 77% 69% differences described above, it is necessary to isolate and 70% 62% 67% 60% 58% identify the “net” differences. Multiple regression analysis 55% allows us to assess the independent or net effects of these 50% 41% 40% factors.155 The net effect is an estimate of how individuals and 31% 30% households differ along a single dimension while holding all 24% 20% 18% other factors constant. For example, comparing two individuals 10% with the same education, race, age, gender, and residence— 0% but from different income groups—allows us to estimate the Lowest Quartile 2nd Quartile 3rd Quartile Highest Quartile effect of income on whether one has PTO, telecommutes, or has household broadband access. Knowing whether the root cause of the inequity is primarily due to a lack of income, Figure 2: Estimated Relationship Between Education and education, or where someone lives can suggest whether the best Paid Time Off, Broadband at Home, & Telecommuting public policy approach might be subsidizing internet access, (net effect of education, ages 25 to 54 years) launching an information campaign explaining the benefits of 100% PTO 88% broadband, or providing the last mile of wired infrastructure. 90% Broadband 83% 80% Telecommute 73% The differences in the “net” percentages across income and 70% 69% 61% 61% education groups are significant and important (see Figures 60% 56% 1 and 2). Someone with a bachelor’s degree is nearly 1.6 50% 44% times more likely to have PTO (69 percent v. 44 percent), 40% 40% more than 1.4 times more likely to have high-speed internet 30% 27% 18% at home (88 percent v. 61 percent), and about 2.6 times more 20% 15% likely to telecommute (40 percent v. 15 percent), assuming all 10% other factors ceteris paribus, compared to the lowest education 0% Less than HS HS/GED Some College Bachelors & Above category, and we see similar patterns across the income quartiles. Discussion sense suggests: the less-advantaged are affected differently by Inequality—in both opportunity and outcome—is becoming the disease outbreaks, disasters, and large-scale emergencies. defining zeitgeist of our era. We typically think about inequality in the context of income, but equity and health also go hand-in- We illustrate here how lower levels of education and hand. Alonzo Plough, PhD, MPH, chief science officer and vice income are associated with a decreased likelihood (both president of Research, Evaluation, and Learning at the Robert in terms of gross and net percentages) that one will enjoy Wood Johnson Foundation, for example, recently described the benefits of PTO, have household broadband access, how extreme weather events can have a disproportionate impact or telecommute. Understanding the root causes of these on “children, the elderly, people with chronic health conditions, differences and addressing the inequities will enhance health the economically marginalized and communities of color.”156 security, preparedness, and community resilience. However, And others have raised concerns about the disproportionate understanding the root causes is not sufficient—community vulnerability of lower-income Americans to the Zika virus.157 leaders from the private, public, and nonprofit sectors must work While there are many ways in which this relationship can together to tackle the root causes of these inequities. By doing so, manifest itself, research and analysis confirm what common the health security of the entire community will be enhanced. 42 TFAH • healthyamericans.org SECTI O N 2 National NATIONAL HEALTH SECURITY ISSUES AND RECOMMENDATIONS National Health Security Issues and Recommendations Health The nation’s health security policy needs to be built to expect Security Issues new emergencies. Health crises are not a question of if, but & when. Being prepared requires maintaining a stronger steady defense that is able to more effectively manage ongoing Recommendations public health needs while being ready to be able to respond to emerging and emergency priorities. Investments have helped significantly E. nnovating and Modernizing I improve many areas of preparedness Infrastructure, Including Wide over the past 16 years, but they have Implementation of Faster fallen short of what is needed to Diagnostics, Biosurveillance and address some major gaps and ensure a Medical Countermeasures; consistent and strong level of readiness F. aintaining a Robust, Well-Trained M across the country. In addition, budget Public Health Workforce; cuts have eroded gains, including sustaining some basic capabilities. G. ebooting and Developing a New R Strategy for Hospital and Healthcare TFAH has identified a set of concerns Emergency Preparedness — and recommendations for improving Including Surge Capacity for Major America’s preparedness for health Emergencies; emergencies, including: H. eadying for Climate Change and R A. eforming Baseline Abilities to R Weather-Related Threats; Diagnose, Detect and Control Health Crises: Foundational Capabilities; I. upporting Community Resilience S — for Communities to Better Cope B. Supporting Stable, Sufficient and Recover from Emergencies Funding for Ongoing Emergency — With Better Behavioral Health Preparedness and Funding a Infrastructure and Capacity; Permanent Public Health Emergency Fund for Immediate and “Surge” J. topping Superbugs and Antibiotic S Needs During an Emergency; Resistance; C. Supporting Global Health Security; K. Improving Vaccination Rates — for Children and Adults; and D. mproving Federal Leadership I Before, During and After Disasters; L. rotecting Food and Water Safety. P DECEMBER 2017 “ level of attentiondoesit not afford the biological threat the Simply put, the Nation same as does other threats: There is no “ world remains under-prepared to prevent, detect, and The respond to infectious disease outbreaks, whether naturally centralized leader for biodefense. There is no comprehensive occurring, accidental, or deliberately released. Distance national strategic plan for biodefense. There is no all-inclusive alone no longer provides protection from disease outbreaks. dedicated budget for biodefense. The Nation lacks a single leader Infectious disease and pathogens can move from one to control, prioritize, coordinate and hold agencies accountable point on earth to almost any other place in the world for working toward common national biodefense. This weakness within 36 hours. ” 159 precludes sufficient defense against biological threats. ” 158 — dmiral Tim Ziemer, Senior Director for Global Health A — National Blueprint for Biodefense: Leadership and Major A Security at the National Security Council, 2017. Reform Needed to Optimize Efforts, 2015. SELECT FEDERAL PUBLIC HEALTH PREPAREDNESS ACTIVITIES AND ACTIONS THE PANDEMIC AND ALL-HAZARDS PREPAREDNESS ACT (PAHPA) The Pandemic and All-Hazards l N ational Health Security Strategy (NHSS);  Programs for state and local Medical Preparedness Act — passed into law in l S ituational Awareness: Surveillance, Counter Measure stockpiles.  2006 — aims “to improve the Nation’s Credentialing, and Telehealth; and  Major program areas: public health and medical preparedness l E ducation and Training l N ational Health Security Strategy and response capabilities for emergencies, whether deliberate, accidental, or natural.” In 2013, Congress reauthorized PAHPA l A ssistant Secretary for Preparedness PAHPA amended the Public Health through the Pandemic and All-Hazards and Response Service Act to establish within HHS a new Preparedness Reauthorization Act l N ational Advisory Committee on Assistant Secretary for Preparedness and (PAHPRA) in order to build on HHS’s Children and Disasters  Response (ASPR); provide new authorities national health security work. PAHPRA l M odernization of the National Disaster for a number of programs, including the reauthorized funding for public health Medical System advanced development and acquisitions of and medical preparedness programs, medical countermeasures; and establish such as the Hospital Preparedness l T emporary reassignment of State and a quadrennial National Health Security Program and the Public Health Emergency local personnel during a public health Strategy. Preparedness Cooperative Agreement, emergency  amended the Public Health Service Act l I mproving State and local public health Major program areas: to grant state health departments greatly security  l B iomedical Advanced Research and needed flexibility in dedicating staff l H ospital preparedness and medical Development Authority (BARDA) and resources to meeting critical community surge capacity  Medical Countermeasures; needs in a disaster, authorized funding l E nhancing situational awareness and l E mergency Support Function (ESF) #8: through 2018 for buying medical biosurveillance  Public Health and Medical Response: countermeasures under the Project Domestic Programs;  BioShield Act, and increased the flexibility l E nhancing medical countermeasure review  l E mergency Support Function #8: of BioShield to support advanced l A ccelerating medical countermeasure Public Health and Medical Response: research and development of potential advanced research and development International Programs;  medical countermeasures.  PAHPRA PAHPA is up for reauthorization again in also enhance the authority of FDA to l P ublic Health Emergency Preparedness and 2018. Congress will be considering what support rapid responses to public health Hospital Preparedness Program Grants;  public health authorities need to be revised emergencies and the Shelf-Life Extension l A t-Risk Individuals;  to prepare the nation for emerging threats. 44 TFAH • healthyamericans.org CDC’S 15 PUBLIC HEALTH PREPAREDNESS CAPABILITIES160 Since 2011, CDC has focused on 15 core establishing a standardized, scalable capabilities in six domains as the basis for system of oversight, organization and state and local public health preparedness supervision consistent with jurisdictional to assist health departments in their standards and practices and with the strategic planning, including: National Incident Management System. Biosurveillance Information Management l P ublic health laboratory testing is the l E mergency public information and ability to conduct rapid and conventional warning is the ability to develop, coordinate detection, characterization, confirmatory and disseminate information, alerts, testing, data reporting, investigative warnings and notifications to the public support and laboratory networking to and incident management responders. address actual or potential exposure to all hazards, including chemical, l I nformation sharing is the ability to radiological and biological agents in conduct multijurisdictional, multidisciplinary clinical, food and environmental samples. exchange of health-related information and situational awareness data among all l P ublic health surveillance and levels of government and the private sector epidemiological investigation is the in preparation for and in response to public ability to create, maintain, support and health incidents. strengthen routine surveillance and detection systems and epidemiological Surge Management investigation processes, as well as to l F atality management is the ability to expand these systems and processes in coordinate with other organizations to response to public health emergencies. ensure the proper recovery, handling, identification, transportation, tracking, Community Resilience storage and disposal of human remains l C ommunity preparedness is the ability of and personal effects; certify cause of communities to prepare for, withstand and death; and facilitate access to mental/ recover from public health incidents in the behavioral health services to the family short and long term, through engagement members, responders and survivors. and coordination with emergency management, health care organizations l M ass care is the ability to coordinate with and providers, community and faith-based partner agencies to address the public partners, and state and local governments. health, medical and mental/behavioral health needs of those affected by an l C ommunity recovery is the ability to incident and gathered together. This collaborate with community partners capability includes ongoing surveillance following an incident to plan and advocate and assessment as the incident evolves. for the rebuilding of public health, medical and mental/behavioral health systems to l M edical surge is the ability to provide ad- a functioning level or better. equate medical evaluation and care during events that exceed the limits of the normal Incident Management medical infrastructure, and to survive a l E mergency operations coordination hazard impact and maintain or rapidly re- is the ability to direct and support a cover operations that were compromised. public health or medical incident by TFAH • healthyamericans.org 45 l V olunteer management is the ability l N on-pharmaceutical interventions is the l R esponder safety and health is the ability to coordinate the identification, ability to take actions (other than vaccines to protect public health agency staff recruitment, registration, credential or medications) that people and communi- responding to an incident and support the verification, training and engagement of ties can use to slow the spread of disease. health and safety needs of hospital and volunteers to support the public health medical facility personnel, if requested. l C ommunity mitigation is the ability to agency’s response. slow the spread of disease through the In 2017, CDC began a process to refine implementation of non-pharmaceutical the 15 capabilities, with input from Countermeasures and Mitigation interventions and threat-appropriate awardees and other stakeholders. l M edical countermeasure dispensing travel and border health measures. is the ability to provide medical countermeasures in support of treatment or prophylaxis to the identified population Through its annual Public Health Preparedness National Snapshot, CDC highlights in accordance with public health national, state and local progress in the 15 public health preparedness capabilities guidelines and/or recommendations. as the basis for state and local public health preparedness. Its 2016 report highlights how CDC strengthens the nation’s health security to save lives and protect against l M ateriel management and distribution public health threats within the context of its 2014-2015 Ebola response and its three is the ability to acquire, maintain, overarching priorities: 1) improving health security at home; 2) protecting people from transport, distribute and track medical public health threats; and 3) strengthening public health through collaboration. Each materiel during an incident and to state profile reflects the five capabilities with the largest Public Health Emergency recover and account for unused medical Preparedness cooperative agreement investments.161 materiel, as necessary, after an incident. HEALTHCARE PREPAREDNESS CAPABILITIES: NATIONAL GUIDANCE FOR HEALTHCARE SYSTEM PREPAREDNESS162 The Hospital Preparedness Program national stakeholder-created and vetted healthcare organizations and relevant grants to 62 State and territory healthcare-specific capabilities, to enable agencies in their jurisdictions to plan departments of public health support the the healthcare delivery system to prepare and collaborate to share information, building of healthcare capabilities outlined for and response to emergencies that resources and strategies to deliver in Healthcare Preparedness Capabilities: impact the public’s health. These include: medical care during emergencies. National Guidance for Healthcare System 1. oundation for Health Care and F 3. ontinuity of Health Care Service C Preparedness 2017-2022. The program Medical Readiness. The goal of this Delivery. The goal is for healthcare is managed by ASPR, which provides capability is to support the community’s organizations to provide uninterrupted programmatic oversight and works with its healthcare organizations and other care to all populations, have a well- partners in State, territorial, and municipal stakeholders, coordinated through trained healthcare workforce and a government to ensure that the program’s healthcare coalitions, to have strong return to operations. goals are met or exceeded. Funding relationships, identify hazards, and awards help state and local governments, 4. edical Surge. Healthcare organizations M address gaps through planning, training, healthcare coalitions, and ESF #8 and coalitions should coordinate exercising and managing resources. planners identify gaps in preparedness, resources to provide care when demand determine specific priorities, and develop 2. ealth Care and Medical Response H exceeds available supply.163 plans for building and sustaining four Coordination. The goal is for coalitions, 46 TFAH • healthyamericans.org A. Reforming Baseline Abilities to Diagnose, Detect and Control Health Crises: Foundational Capabilities Americans deserve and should expect basic health protections, no matter where they live. Yet, while there have been many improvements in national health security, funding has been unstable and insufficient to maintain baseline capabilities and meet the changing threats facing our communities. As a result, the public health services and the funding of these programs vary dramatically from state to state and among communities and territories. While many public health agencies PHEP, HPP, FEMA and other homeland l U sing integrated data sets for are able to prepare for and respond to security grants and public health assessment, surveillance and evaluation many small scale emergencies, such as programs for states. to identify crucial health challenges, foodborne outbreaks and some types best practices and better health; The expert-defined foundational of natural disasters, the fluctuation in services should include: 1) l C ommunicating with the public and funding has harmed the government’s communicable/infectious disease other audiences to disseminate and ability to respond to significant health prevention; 2) chronic disease and receive health-related information in crises and leaves first responders without injury prevention; 3) environmental an effective manner, including health adequate tools and systems and a public health; 4) maternal, child and promotion opportunities, access to shaky foundation to build upon when family health; and 5) access to and care and prevention; significant emergencies arise. In addition, linkage with clinical care.166, 167 unstable funding means that public health l M obilizing the community and forging must reorient its resources and operations In addition, 30 state, 179 local, and partnerships to leverage resources when a major disaster hits, resulting in one tribal health department have (including funding); gaps in basic public health functions. been accredited through the voluntary l B uilding new models that integrate national accreditation program (as of A leading recommendation by the clinical and population health; November 2017) — a measurement of Health and Medicine Division of health department performance against l C ultivating leadership skills, along with the National Academies of Science, a set of nationally recognized, practice organization, management and business Engineering and Medicine (formerly focused and evidence-based standards.168 skills, needed to build and sustain the Institute of Medicine) and other The Public Health Leadership Forum an effective health department and experts is to establish and maintain a has recommended that there should be workforce to effectively and efficiently clear, consistent set of key foundational financing mechanisms to help all states promote and improve health; capabilities that focus on performance and localities achieve accreditation and outcomes in exchange for increased l D emonstrating accountability for the ability to deliver foundational public flexibility and reduced bureaucracy.164, 165 what governmental public health health services, either directly or through does directly and for those things that These foundational capabilities cross-jurisdictional collaboration.169 it oversees through accreditation, would help support preparedness and The defined foundational capabilities continuous quality improvement and readiness, helping provide a stronger, include: transparency; and more consistent core foundation for public health activities in states and l A ssessment (surveillance, epidemiology l P rotecting the public in the event of localities. The foundational capabilities and laboratory capacity); an emergency or disaster, as well as approach would complement and help responding to day-to-day challenges or l D eveloping policy to effectively provide a backbone to build and expand threats, with a cross-trained workforce. promote and improve health; the capabilities that are supported by TFAH • healthyamericans.org 47 RECOMMENDATIONS: l P rioritizing and fully funding a surveillance support are administered capabilities could be given greater foundational capabilities approach separately and for specific diseases. flexibility in their use of federal support for public health departments at all for core public health functions. Ensuring A foundational capabilities model also levels of government. The foundational the workforce is well trained to carry out includes flexibility for communities to capabilities model is key to strengthening these capabilities and that a mechanism build upon the basics to meet their preparedness for public health for continuous quality improvement and specific needs and concerns, contingent emergencies and focuses on core stable, sufficient funding are in place are on additional available resources. functions of modern public health — all inherent to the success of this model. Jurisdictions that meet foundational such as a modern laboratory, workforce and surveillance capabilities — as well as organizational efficiency and VISION FOR A BASELINE PUBLIC HEALTH SYSTEM: coordination. This means changing siloed To Address Emergencies and Ongoing Health Concerns grant and budget structures that often fund different aspects of these core Surveillance & Data/ Laboratory Capacity Epidemiology/Investigations Information Systems capabilities separately and do not focus on performance, capabilities or outcomes Trained, Expert Workforce + Research/Evidence-Informed Strategies for the overall integrated, coordinated Accountability + Continuous Quality Improvement system. For example, many current Sustained, Stable Funding grants for epidemiological, laboratory and EXAMPLES OF STATES ADOPTING FOUNDATIONAL CAPABILITIES A number of states, including Colorado, funding; identified which services can be moved forward to consolidate some Oklahoma and Washington, have taken provided by state health departments local health departments and cross- steps to move toward a foundational versus local health departments; and jurisdictional services and programs capabilities approach within the state engaged with policy makers to gain and to prioritize funding streams.172, 173 and local public health departments. support of legislative changes needed to Colorado legally defined foundational fully develop and implement foundational “minimum quality standards,” and For instance, Washington State public health services.170 The state’s within two years has shown significant has engaged stakeholders (such Department of Health estimated it would increases in the delivery of several as hospitals, community health require an additional $21.8 million programs and service areas.174 organizations, service providers and and local health jurisdictions in the laboratories) to partner with public The Public Health Cost Estimation Work state would need an additional $78.0 health departments and improve or Group has developed a methodology million (2013 dollars) (totally $99.9 increase health information exchange; to help state and local health million statewide) to fully and effectively reviewed state public health laws to departments determine the cost of implement foundational capabilities.171 identify governing power and regulations adopting foundational capabilities across jurisdictions; reviewed funding Ohio has also been developing and the data will be used to generate streams to determine what mandatory strategies for implementing national estimates.175, 176 services may or may not be attached to foundational capabilities and has 48 TFAH • healthyamericans.org KEY CDC HEALTH SECURITY PROGRAMS l C DC’s Epidemic Intelligence types of major health emergencies.178 l S trategic National Stockpile: The Service (EIS): EIS officers serve PHEP focuses on 15 key capability areas, stockpile is a national repository of as expert “disease detectives” who including community preparedness; antibiotics, chemical antidotes and other conduct investigations, research and community recovery; emergency medicines and medical supplies for use surveillance — in the United States and operations coordination; emergency during a major disease outbreak, bioterror abroad. EIS is a two-year post-graduate public information and warning; facility or chemical attack or other public health training program for physicians, nurses, management; information sharing; emergency.180 Medical countermeasures veterinarians and PhD-trained scientists mass care; medical countermeasure in the SNS are kept in secure locations and other health professionals. 177 dispensing; medical materiel management around the country and can be delivered and distribution; medical surge; non- to the affected area within a clinically- l ublic Health Emergency Preparedness P pharmaceutical interventions; public relevant time frame. The federal Cooperative Agreement Program: PHEP health laboratory testing; public health government also can employ systems to provides formula-based cooperative surveillance and epidemiological work with some private pharmaceutical agreement funds to states, territories investigations; responder safety and distribution companies and pharmacies and urban areas to build and sustain the health; and volunteer management. 179 to be able to distribute vaccines or ability to prepare for and respond to all medicines during an outbreak. To prepare and support partners and DIVISION OF STRATEGIC NATIONAL STOCKPILE provide the right resources at the right time AMERICA’S EMERGENCY MEDICAL SUPPLIES TO PROTECT THE PUBLIC’S HEALTH to secure the nation’s health THE STRATEGIC NATIONAL STOCKPILE PARTNERSHIPS IN PREPAREDNESS THE STRATEGIC NATIONAL STOCKPILE (SNS) CDC’s Strategic National Stockpile works with contains state and local health departments, as well as >$7 billion Managed Inventory CHEMPACK the private sector, to ensure that medicine and supplies get to the people who need them most worth of medicines and medical supplies Includes specific medicines, Forward-placed containers of during an emergency. vaccines, and supplies for nerve-agent antidotes that can be used SNS HAS THE ABILITY TO HOW? a defined need to respond to a chemical attack RESPOND TO: Practice: Leading training courses and exercises to Bacterial and prepare state and local viral diseases Federal Medical Station 12-hour Push Package partners to receive, distribute Rapidly deployable reserve of beds, 50 tons of emergency and dispense SNS resources supplies, and medicines to accommodate medical resources that can be during an emergency. 50–250 people with health-related delivered anywhere in the U.S. needs and low-acuity care within 12 hours Send in the SNS Experts: Pandemic influenza If needed, multiple teams of experts are prepared to CHEMIC ALS ANTITOXI NS deploy to locations receiving ANTIDOTE SNS resources. AL Radiation/nuclear VACCINES ANTIVIR Community Resilience: DRUGS Create relationships between emergency public health and community TICS MEDIC AL partners to support optimal ANTIBIO SUPPLIES distribution of medical counter- measures (MCM) in the U.S. healthcare supply chain during Chemical attacks public health emergencies. Natural disasters The SNS holds medical supplies unavailable from other 90% of the U.S. population is within one hour of a sources and specially designed CHEMPACK location for unusual or rare threats CS256096B TFAH • healthyamericans.org 49 l E pidemiology and Laboratory Capacity: territorial, federal and international — to ELC is a cooperative agreement to share notifiable disease-related health provide funding and technical assistance information allowing health officials for cross-cutting as well as disease- to monitor, control and prevent the specific epidemiology, laboratory and occurrence and spread of selected surveillance systems capacity. Funding infectious and non-infectious diseases supports all 50 states, eight U.S. and conditions.183 NNDSS has territories and six cities to strengthen undergone an initiative to modernize the workforce and disease detection systems and processes used to receive systems.181 The funding has allowed nationally notifiable disease data that will states to maintain modern capabilities improve public health decision making and speed the detection of outbreaks and interventions by providing more and health threats. Zika supplemental comprehensive and higher quality data in awards through ELC cooperative a timelier manner. NNDSS data was used agreements also supported the U.S. Zika by CDC-EOC for the first time to monitor Pregnancy Registry to monitor pregnant for increases of disease in the areas women with Zika and their infants and to affected by Hurricane Harvey. help jurisdicitons sustain Zika prevention l N ational Syndromic Surveillance and surveillance efforts through the next Program: This program is a collaboration mosquito season.182 among public health agencies for timely l W HO Influenza Collaborating exchange of syndromic data to improve Center: CDC’s Influenza Division national situational awareness and has served as a WHO Collaborating responsiveness to hazardous events Center for Surveillance, Epidemiology and disease outbreaks.184 Syndromic and Control of Influenza in Atlanta, surveillance uses syndromic data and Georgia since 1956 and is the largest statistical tools to detect, monitor global resource and reference center and characterize unusual activity for supporting public health interventions further public health investigation or to control and prevent pandemic and response. Syndromic data include seasonal influenza. It also plays a patient encounter data from emergency major role in year-round surveillance departments, urgent care, ambulatory for early detection and in identification care and inpatient healthcare settings. of changes in seasonal influenza In addition to these data sources, HHS viruses, influenza viruses that may Disaster Medical Assistance Team have pandemic potential, and those (DMAT) data was transmitted to CDC’s with antiviral susceptibility. CDC also syndromic surveillance infrastructure supports the WHO Collaborating Center (the BioSense Platform) for the first time for Implementation of International in 2017 to support situation awareness Health Regulation Core Capacities and for Hurricanes Harvey, Irma and Maria. for International Monitoring of Bacterial Though these data are being captured for Resistance to Antimicrobial Agents. different purposes, they are monitored in near real-time as potential indicators l N ational Notifiable Diseases Surveillance of an event, a disease, or an outbreak of System (NNDSS): The system is a public health significance. nationwide collaboration that enables all levels of public health — local, state, 50 TFAH • healthyamericans.org B. Supporting Stable, Sufficient Funding for Ongoing Emergency Preparedness — and Funding a Permanent Public Health Emergency Fund for Immediate and “Surge” Needs During an Emergency Natural disasters, infectious disease outbreaks and other public health emergencies can strike at any time and have devastating public health impacts. Infectious diseases alone — including the regular seasonal flu — cost the country more than $120 billion each year.185 Baseline funding for public health and healthcare preparedness and response is not sufficient to address ongoing needs, yet alone emerging problems. Over the past 15 years, federal funds to support and maintain baseline state and local preparedness have been cut by about one-third (from $940 million in FY 2002 to $667 million in FY 2017) and hospital emergency preparedness funds have been cut in half ($515 million in FY 2004 to $255 million in FY 2017).186 As crises arise, they pull funding, personnel and attention from ongoing Strategic National Stockpile needs. Major crises may cause enough Medical Logistics Support Puerto Rico disruption to demonstrate the 2017 Hurricane Maria need for emergency supplemental 10,000 $4.2 funding. This type of support usually is considered after an emergency has MILLION sq. ft. of warehouse in supplies operations in P.R. reached a critical mass, but the funds 115 are often too little to address all of the needs and expenses and get delayed 6 Federal Medical Stations with 1,500 beds total Stockpile personnel in bureaucratic processes. One of the working the response $ 2.1 million vaccines for public health needs biggest problems is the effect on the workforce. Budget cuts over time — or when money is diverted during an $ 543,600 additional medical supplies purchased 19 total flights with supplies emergency — lead to layoffs of highly 177,000 bottles of water trained public health experts, many of whom cannot be hired back with short- 42,000 meals ready to eat 343+ tons of cargo term emergency funds. Source: CDC The 2017 hurricanes demonstrated www.cdc.gov/phpr/stockpile As of 12/04/2017 that the nation is well-prepared for Rico and the U.S. Virgin Islands at disasters in many areas, but has little risk for outbreaks caused by unsafe ability to mount an effective public water and food, and long-term health health response when the infrastructure problems caused by mental and physical is devastated. The devastation in U.S. trauma — all with limited access to territories has left residents of Puerto healthcare. These crises illustrate the TFAH • healthyamericans.org 51 need for both underlying public health — resources, supplies and training capacity and a surge of resources after — needed to be able to be able to disaster strikes. effectively manage crises. Maintaining a steady public health system is Public health and healthcare analogous to having a ready military professionals are first responders, defense — where the country maintains like police, firefighters and FEMA a standing, trained force on a consistent personnel. However, under the current basis, but additional resources and systems and approach, they do not support are needed to fight a war. currently have the ongoing support CDC OFFICE OF PUBLIC HEALTH PREPAREDNESS AND RESPONSE FUNDING TOTALS AND SELECT PROGRAMS FY FY FY 2017 FY 2002 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 FY 2014^ FY 2015^^ 2003*** 2016^^^ (est.) 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 $1,405,000,000 $1,401,708,000 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 $668,200,000 $666,634,000 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 $575,000,000 $573,653,000 * CDC Total also includes CDC Preparedness and BioSense ** ay 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 M Readiness Initiative, U.S. Postal Service Costs (FY 2004), and Smallpox Supplement (FY 2003) *** Y2003 included one-time supplemnetal funds of $100 million for the smallpox vaccination program. Source: https://fas.org/sgp/crs/homesec/RL31719.pdf F ^ 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 ^^ otals do not include Ebola funding T ^^^In FY2016, CDC transfered money away from CDC preparedness program for the immediate Zika response. That money was replaced by the FY 2016 Zika Response and Preparedness Act (P.S. 114-223). Source FY2017: https://www.cdc.gov/budget/documents/fy2017/fy-2017-cdc-operating-plan.pdf Source FY 2016: https://www.cdc.gov/budget/documents/fy2016/fy-2016-cdc-operating-plan.pdf Source FY 2015: https://www.cdc.gov/budget/documents/fy2015/fy-2015-cdc-operating-plan.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 OFFICE OF ASSISTANT SECRETARY FOR PREPARDNESS AND RESPONSE FUNDING TOTALS AND SELECT PROGRAMS FY 2017 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^^ FY 2016 (est.) 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 $1,112,559,000 $1,402,628,000 $1,399,410,000 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 $254,555,000 $253,958,000 BARDA** $5,000,000 $54,000,000 $103,921,000 $101,544,000 $275,000,000 $304,948,000 $415,000,000 $379,639,000 $415,000,000 $415,000,000 $415,000,000 $511,700,000 $510,499,000 BioShield Special -- -- $5,600,000,000* -- -- -- -- -- -- -- -- -- $255,000,000 $255,000,000 $520,000,000 $508,803,000 Reserve Fund * One-time Funding Source FY 2012: http://www.hhs.gov/budget/safety-emergency-budget-justification-fy2013.pdf ^ HPP moved from HRSA to ASPR in 2007 Source FY 2010-11: http://www.hhs.gov/asfr/ob/docbudget/2011operatingplan_phssef.pdf ** BARDA was funded via transfer from Project BioShield Special Reserve Fund balances for FY2005-FY2013 Source FY 2008-09: http://www.hhs.gov/asfr/ob/docbudget/2010phssef.pdf, p. 8 ^^ Totals do not include Ebola funding Source FY 2007: http://www.hhs.gov/budget/09budget/budgetfy09cj.pdf, p. 288 Source FY 2017: https://www.hhs.gov/sites/default/files/fy-2017-phssef-operating-plan.pdf Source FY Source FY 2006: http://www.hhs.gov/asfr/ob/docbudget/2008budgetinbrief.pdf, p. 109 2016: https://www.hhs.gov/about/budget/phssef-operating-plan/index.html?language=en Source BARDA FY 2005-06: http://www.hhs.gov/asrt/ob/docbudget/2010phssef.pdf, p. 45. Source FY 2015: https://www.hhs.gov/about/budget/fy2015/phssef-operating-plan/index.html 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- Source HPP FY 2002: http://archive.hhs.gov/budget/04budget/fy2004bib.pdf, p. 14 budget-justification.pdf 52 TFAH • healthyamericans.org RECOMMENDATIONS: l S upporting stable, sufficient funding guardrails that govern access to the automatic replenishment, outside of for ongoing preparedness and public fund. A Public Health Emergency Fund is discretionary budget caps. 4) A response health capacity. There is a need to currently authorized (section 319 of the fund should only be tapped for acute rethink how health security is funded — Public Health Service Act (42 U.S.C. § public health emergencies, not ongoing to maintain a steady, ongoing defense 247d)) that allows the Secretary of HHS health needs or existing programs. as well as having the ability to quickly to access funds when a public health The President’s Council of Advisors ramp up to meet surge needs and cover emergency is declared, but it is nearly on Science and Technology (PCAST) the costs when major new emergencies empty and has not received resources recommends a response fund of at least arise. Public health programs require since FY 1999. $2 billion, contingent upon authorization stable and sufficient funding to be able of the President or joint agreement of the • standing response fund should A to address ongoing public health and secretaries of HHS and DHS.187 meet the following principles: 1) the healthcare readiness priorities. fund should not come at the expense • A standing Public Health Emergency Fund l F unding a permanent Public Health of other health programs, either from would complement, but cannot replace Emergency Fund and expedited cuts to discretionary health spending ongoing funds to support baseline emergency spending processes to be or by transfer. Strong national health preparedness. This Fund would need ready when crises arise. In addition security requires both preparedness to be paired with continued support for to ongoing investments, the federal and response, and a response fund preparedness through programs like government needs immediate, flexible should supplement, not supplant PHEP and HPP and funding for medical funds to respond to significant crises. existing programs. 2) The fund should countermeasures development, as well Delays in appropriation of emergency serve as an interim bridge between as cross-cutting programs that support funds for Zika, for example, meant health underlying capacity-building funds and capacity. Without this base of support, departments, healthcare providers and emergency supplemental funds, if the cost of ramping up quickly during an researchers were ill-equipped to respond needed. The existence of an emergency emergency is significantly higher than if to a complex, multipronged outbreak, fund would not preclude the need for a solid foundation is maintained. And while federal agencies were forced to future emergency supplemental funding. in major disasters, supplemental funds reallocate funds from other important 3) Such a fund would need to be are often still needed to support the health programs, like the Ebola response maintained and replenished at a funding long-term needs — such as vaccine and the all-hazards PHEP cooperative level sufficient to respond to an emerging development — to contain an emergency agreement. Supporting a standing public health threat. There should be after the initial response has concluded. Public Health Emergency Fund as a complement to ongoing funding streams is an important step to be able to provide PHEP/HPP Funding Over Time “surge” resources and immediately and $1,200,000,000 effectively respond to a new serious $1,000,000,000 threat when it emerges. Federal agencies could release the emergency $800,000,000 Proposed funds to aid the immediate state and local response and jumpstart research $600,000,000 and development until additional funds $400,000,000 arrive. And such a contingency fund, if deployed early in a crisis, could help $200,000,000 prevent an event from becoming a disaster. Rules around a contingency $- FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 FY17 FY18 fund should include transparency and (PBR) CDC State & Local Preparedness & Response ASPR Hospital Preparedness Grants accountability, including triggers and TFAH • healthyamericans.org 53 • xisting structures for funding public E be used to improve community resilience health — at the federal and state level and “build back better,” such as for — are also not built for supporting an flood-resistant and sustainable design. emergency response. Health emergency l B raiding of Grants. The federal response funding — whether through government can facilitate more efficient a permanent fund or supplemental and effective response efforts by dollars — requires greater speed and allowing states and grantees the flexibility than is often allowable under flexibility to braid or blend funding existing federal and state authorities streams that support recovery after and practices. CDC and other grant an emergency or disaster.  Braiding making health agencies should be is coordinating funding and financing given the needed authority to distribute from various sources to support a emergency funding to partners as single initiative or strategy, at the quickly as possible after approval by state, community or program-level. Congress (or through disbursement Braided funds remain in separate and from an emergency fund). In the midst distinguishable strands, to allow close of a crisis, HHS agencies — as well tracking and accounting of expenses as states — should have authorities related to each separate funding to use flexible hiring, contracting and source. These funding and resource transaction mechanisms. A recent allocation strategies use multiple announcement from CDC seeks to existing funding streams to support expedite emergency response funding a single initiative or strategy, such to state and local health departments as a coordinated recovery effort in a through the establishment of an way that produces greater efficiency “approved but unfunded” list so that and/or effectiveness. An associated CDC can fund emergencies more rapidly waiver can provide flexibility around and reduce administrative burden statutory, regulatory, or administrative associated with response by having requirements to enable a State, locality, approved applications in place before or tribe to organize its programs and the need arises.188 CDC will activate systems or provide services in ways funding when it determines a public that best meet the needs of its target health emergency has occurred or is populations.  This flexibility could have imminent so health departments can implications in disaster recovery as quickly set up response operations.189 grantees receive funding across federal Other HHS agencies should establish agencies or funding lines, yet face a similar mechanism for grantees and gaps in coordinating between grants national organizations that are critical to and meeting unexpected needs that emergency responses. Recovery funding, fall through cracks between emergency such as that provided through the support functions. Stafford Act, should also be allowed to 54 TFAH • healthyamericans.org C. Supporting Global Health Security Due to worldwide connectivity, diseases can travel around the world quickly if left unchecked. Global health security — an effort to security and economic components make the world safe from infectious and implications. Outbreaks and disease and other health threats — is other health emergencies can cause integral to the health of Americans and political and economic instability in a others around the world. The Ebola region, with global implications. These outbreak in West Africa illustrated outbreaks can cause ripples in the the dangers that an infectious disease U.S. economy, as American businesses can pose in countries with little public are dependent upon trade, supply health infrastructure. The costs in lives chain and travel with these regions. and money were much more severe The Global Health Security Agenda than they would have been had the (GHSA) is an international, multisector outbreak initiated in a country with a commitment by the United States stronger health system — as illustrated and over 50 nations, international in the rapid response to Ebola flare-ups organizations and non-governmental in these nations after response systems stakeholders to build countries’ capacity were established. These responses are to protect against infectious disease often complicated, with diplomatic, threats before they become severe.190 public health, healthcare, national WORLD BANK PANDEMIC SIMULATION During its annual meeting in Washington in Madagascar killed over 100 people, in October 2017, the World Bank held and in Uganda, one person died and its fourth pandemic simulation where hundreds of people were exposed to global leaders practiced responding to Marburg virus — a highly infectious a hypothetical outbreak scenario. The hemorrhagic fever. The simulation World Bank was motivated to hold these focused on the hasty spread of simulations by the inadequate early information — and misinformation — response to the 2014 Ebola outbreak on social media, and highlighted the in West Africa and the awareness that need for accurate, real-time information another global pandemic is inevitable. sharing to stop outbreaks.191 Recently, a pneumonic plague outbreak TFAH • healthyamericans.org 55 RECOMMENDATIONS: l M aintaining a long-term investment public health capacity and response in the Global Health Security capabilities include CDC’s Center for Agenda (GHSA) framework and Global Health, the State Department, global preparedness and response Department of Defense, ASPR and NIH. programs. The United States is a The GHSA should include commitments key partner in the GHSA and must to advancing biosecurity and biosafety maintain its leadership in the effort. — as well as specific national or The current U.S. funding commitment regional mechanisms to track progress to GHSA, funded through the Ebola and announce setbacks. supplemental, expires in FY 2019. l P rioritizing biosecurity and biosafety The United States has advocated for in global pandemic preparedness, as continuation of the GHSA through 2024, well as mechanisms to track progress. but that obligation must be backed Nuclear Threat Initiative (NTI) analyzed by a funding commitment and a U.S. 39 published Joint External Evaluation strategic plan that prioritizes support (JEE) reports and found that 74 percent to build capabilities in low and middle- of assessed countries had limited or income countries, as outlined by PATH no capacity for a coordinated national in a recent report on global pandemic biosafety and biosecurity system across prevention.192 Important global health all aspects of the government.193 programs that seek to build local U.S. Funding for Global Health Security (With Emergency Ebola and Zika Funding), FY 2006-FY 2018 Request In Millions USAID/GHS in Development^ CDC/Global Public Health ProtecƟon DoD/CBEP DoD/GEIS* 600 525 450 375 300 225 150 75 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 NOTES: Includes Global Health Security funding through USAID, CDC, and DoD. Includes base and supplemental funding. FY13 includes the effects of sequestraƟon. FY15 includes Request emergency Ebola funding specifically directed to global health security through the USAID/GHP account and CDC; this funding is part of the $1 billion announced by the U.S. government that will be spent in 17 high-priority countries over five years (FY15-FY19). FY16 includes emergency Zika funding. FY17 is based on funding provided in the “Consolidated AppropriaƟons Act, 2017” (P.L. 115-31) and is a preliminary esƟmate. For FY17, in addiƟon to this funding, $70 million was provided for the USAID/GHP Emergency Reserve Fund for contagious infecƟous disease outbreaks "may only be made available if [prior to obligaƟon] the Secretary of State determines and reports to the CommiƩees on AppropriaƟons that it is in the naƟonal interest to respond to an emerging health threat that poses severe threats to human health.” For FY18, while the AdministraƟon is proposing to eliminate direct funding for Global Health Security through the USAID/GHP account, it is proposing a one-Ɵme transfer of $72.5 million for Global Health Security acƟviƟes from unspent emergency Ebola funding in the USAID/IDA account. ^ indicates this was previously referred to as “Pandemic Influenza and Other Emerging Threats” (PIOET). * For FY18, GEIS funding request is not publicly available; total assumes level funding from FY17, which was $57.7 million. SOURCES: Kaiser Family FoundaƟon analysis of data from the Office of Management and Budget, Agency Congressional Budget JusƟficaƟon s, Congressional AppropriaƟons Bills, U.S. Foreign Assistance Dashboard [website], available at: www.foreignassistance.gov, GEIS and AFHSC/AFHSB annual reports, communicaƟon with GEIS personnel, and IOM, Review of the DoD-GEIS Influenza Programs: Strengthening Global Surveillance and Response, 2008. Source: Kaiser Family Foundation 56 TFAH • healthyamericans.org In November 2016, President tasked with issuing policy guidance Obama signed an Executive Order for GHSA implementation; committing Advancing the Global Health Security the United States to another Joint Agenda to Achieve a World Safe External Evaluation in three to four and Secure from Infectious Disease years, providing time for the United Threats.194 The order was intended States to address gaps and challenges; to strengthen the U.S. commitment and designating the National Security to the GHSA, including roles and Council staff to serve as the convener responsibilities of U.S. agencies for the Review Council. In October like State, HHS and CDC, USDA and 2017, President Trump’s Administration DoD; outlining responsibilities for the advocated for extending the Global GHSA Interagency Review Council, Health Security Agenda to 2024.195 ONE HEALTH INITIATIVE: Unifying Human and Veterinary Medicine Recognizing that human health, animal American Medical Association, American health and ecosystem health are Veterinary Medical Association, inextricably linked, the One Health American Academy of Pediatrics, Initiative was developed as a global American Nurses Association, American effort to promote and improve health by Association of Public Health Physicians, enhancing cooperation and collaboration American Society of Tropical Medicine across physicians, veterinarians and and Hygiene, CDC, USDA and the other scientific health and environmental U.S. National Environmental Health professionals.196 Worldwide, more Association. Some efforts include joint than 850 leading scientists, physicians educational and communications efforts and veterinarians have endorsed the and improved coordination of tracking of initiative. Some partners include: health problems and concerns. Source: One Health Initiative TFAH • healthyamericans.org 57 D. Improving Federal Leadership Before, During and After Disasters In addition to funding, recent disasters have illustrated gaps in federal leadership in the United States. In particular, emergencies that cross federal agencies’ jurisdictions and/or have both an international and domestic component, such as the Ebola and Zika outbreaks, have demonstrated the lack of clear roles and responsibilities and the need for cross-cutting national leadership, as well as coordinated national/state/local leadership. In June, the Johns Hopkins Center national, and subnational emergency l B uild global capacities for bio-threat for Health Security convened a preparedness and response efforts; and preparedness and response meeting of over 50 biosecurity priorities for strengthening the national l P rioritize prevention efforts experts from government, industry, biodefense enterprise. l O rganize the U.S. government for and academia to solicit inputs to the The group’s key recommendations were: biodefense forthcoming National Biodefense Strategy and Implementation Plan.197 l I mprove biosurveillance capabilities l L everage private sector capabilities to Discussion topics included the nation’s and laboratory networks counter biological threats biological threat landscape; existing l P erform risk assessments and l C atalyze innovation in medical programs, policies, and mechanisms characterize threats countermeasures research, for mitigating the broad spectrum of l S trengthen emergency development, trials, and delivery naturally occurring, accidental, and response capabilities, including l S trengthen healthcare system response deliberate biological threats facing the decontamination efforts and workforce nation; unmet challenges in global, RECOMMENDATIONS: l S trengthening senior leadership on There must be better coordination needs — rather than acute emergencies health security. Many recent crises across levels of government; agencies — falling through the cracks between have jurisdictions across federal within government; regions, states and state/territorial and between state/federal agencies, so there is an ongoing need jurisdictions; and the public health, responsibilities. Additionally, there must for senior leadership and coordination healthcare and other emergency responder be better use of existing authorities, such for a government-wide approach to sectors. This includes the need to review as roles outlined in the Public Health preparedness, response and recovery roles and responsibilities across the Services Act (PHS), and an agreed-upon efforts. High-level leadership is needed federal agencies (with national, state and framework for response — including the to trigger and coordinate a multi-agency local stakeholder participation) involved in use of a Public Health Emergency Fund. response, identify the lead agency and emergency health response — including The President’s Council of Advisors on clear chain of command and be the ASPR, CDC, CMS, the agencies within Science and Technology, in their 2016 ultimate arbiter for contested decisions. DHS, FDA, NIH and USAID — to ensure report, recommended a new interagency efforts are as efficient and effective as entity charged with planning, coordination l I mproving federal, state, local and possible, roles/responsibilities are clear and oversight of biodefense activities interstate coordination during multi- and bureaucracy is limited. For example, across agencies, co-led by the Assistant agency responses. At the federal level, HHS and FEMA should clarify roles in to the President for Homeland Security in addition to senior leadership and how to address gaps between Emergency and Counterterrorism, the Assistant to the engagement, there must be improved Support Functions. There have been President for Science and Technology and interagency synchronization and integration reports of individuals with chronic medical the Chair of the Domestic Policy Council.198 in response to health emergencies. 58 TFAH • healthyamericans.org E. nnovating and Modernizing Infrastructure, Including Biosurveillance, Medical I Countermeasure Development and Wider Implementation of Faster Diagnostics A range of public health systems are outdated and have not kept pace with current technologies. Some key areas that are lagging include upgrading the biosurveillance systems to be real-time and interoperable; expanding research and development for medicines and vaccines to counter infectious diseases and bioterror threats; and supporting investments to be able to use and implement modern diagnostic technologies around the country. l isease Surveillance. U.S. health D surveillance systems are often disjointed and out-of-date. Public health departments tend to each have different, unconnected systems tracking different health problems, which often contributes to a significant time lag in the collection, analysis and reporting of information, including of new infectious or foodborne illness outbreaks. Although, health departments are often burdened with redundant and siloed disease reporting systems, efforts are underway to standardized and harmonize data requirements that will create a more streamlined reporting and notification process, and lead to the retirement of l edical Countermeasures M • ongress created Project BioShield C outdated legacy systems Development. The U.S. government (in 2004) and authorized the • he lack of cross-cutting surveillance T has invested in the research, Biomedical Advanced Research capacity has led to serious gaps in development and stockpiling of and Development Authority in visibility on pressing health crises. emergency medical countermeasures 2006. HHS created a multi-agency For instance, there has been a lag in for a pandemic, bioterror attack, Public Health Emergency Medical a number of communities in tracking emerging infectious disease outbreak, Countermeasures Enterprise and recognizing hepatitis C and or a chemical, radiological or nuclear (PHEMCE) partnership (in hepatitis B outbreaks — stemming event. A successful domestic medical 2006) to speed the development from a rise in injection drug use — countermeasure enterprise is an of medical countermeasures by which has exacerbated the spread important aspect of preparing for supporting advanced research, of the disease and constrained the new threats by building the science, development and testing; working ability to use early containment policy and production capacity in with manufacturers and regulators; and prevention strategies. A advance of an outbreak, particularly and helping companies devise large- foundational capabilities approach since governments tend to be the scale manufacturing strategies.199 could help address these types of only customers for certain medical The Project BioShield Special gaps (see Section 2A for more on a countermeasure products, such as Reserve Fund (SRF) was originally foundational capabilities approach). anthrax and smallpox vaccines. established as a $5.6 billion fund TFAH • healthyamericans.org 59 over 10 years, to guarantee a market budget requests and funding levels for newly developed vaccines and have not kept up with estimated medicines needed for biodefense needs, including replenishing that would not otherwise have a expiring products already in the commercial market.  The investment Strategic National Stockpile.205 has supported more than 190 new l ider Implementation of Faster W candidate projects. Twenty-three Diagnostics. New technologies, products supported by BARDA such as whole genome sequencing, through Project BioShield have are increasingly used by CDC, the been added to the Strategic military and other state-of-the- National Stockpile.200 After the art national laboratories to more initial investment was depleted, quickly and effectively identify the Congress began funding BioShield reason for and extent of a disease by an annual appropriation for outbreak. The leading current use purchase of products, appropriating of these technologies is in the area of $510 million in FY 2017. The foodborne illnesses — in some cases FDA also launched the Medical speeding up investigations by several Countermeasures Initiative (MCMi) days or being able to determine the in 2010 to coordinate medical cause of an outbreak that would not countermeasure development, have been possible using the last preparedness and response.201 generation of investigative tools. • ome recent advances via BARDA S • cientists are working on similar S have included developing potential technologies for other pathogens. Ebola vaccine and therapeutic Other emerging technologies, such as candidates and assisting in metagenomics, hold the potential to Zika vaccine and diagnostics advance the ability to better diagnose advancements, a new anthrax and track patients for diseases ranging vaccine and diagnostic, new from Zika to Ebola to new strains of broad spectrum antibiotics and antibiotic-resistant superbugs. pathogen reduction technologies for blood products.202, 203, 204 Once Being able to use and scale these a new medical countermeasure is advances around the country will developed, the FDA can expedite the require an investment to upgrade ability to use the product if needed technology, as well as provide training to and if there is no other alternative staff and conduct these different types available under the Emergency Use of epidemiological (disease detective) Authorization (EUA) authority. investigations. The underlying public health system would also need to adapt • n 2016, ASPR released an I to match a faster pace and different updated PHEMCE Strategy and types of investigations and containment Implementation Plan for the next strategies. These scientific changes five years. Federal law requires them provide an important new opportunity to send a five-year spend plan to to overcome longstanding gaps and Congress for the enterprise based on problems within the system. anticipated needs. However, recent 60 TFAH • healthyamericans.org RECOMMENDATIONS: l odernizing to real-time, interoperable M disease surveillance. One of the most fundamental components of disease prevention and control is the ability to identify and track new or ongoing outbreaks and threats. A national surveillance capability should be able to integrate data from human, environmental, and animal health to detect emerging threats. The President’s Council of Advisors on Science and Technology recommends strengthening federal, state and local public health infrastructure for disease surveillance as part of the national biodefense strategy.206 • Health information technology is transforming the way healthcare is delivered, and public health must adapt to take advantage of these advancements, envision public-private partnership in new ways and more effectively leverage healthcare data. level to identify concentrated health New data systems and sources, problems, outbreaks and/or contributing electronic health records and electronic factors that cannot be discerned case reporting, electronic laboratory through county or state level data. reporting, mapping systems, cloud-based • Achieving a modern biosurveillance disease reporting systems and relational system would boost identification databases have the ability to significantly and tracking of outbreaks and other improve the dissemination of real-time, health problems, while reducing the interoperable and interactive information burden on state and local public health across public health, healthcare departments and healthcare providers. providers and other systems. It is also It will require an investment, including: essential to ensure systems are built to upgrading hardware and software; protect privacy and incorporate strong maintaining these technologies around cyber-security measures. the country; standardizing efficient • here is growing capability to connect T reporting standards and language; health trends with risk factor data and hiring and training staff with sources — to look at the impact of computer science and information different factors on health and identify technology skills, including in how to outbreaks or the potential causes use systems and to interpret data. of health problems in particular In addition, there will need to be neighborhoods or local areas. Any new effective integration with electronic system should be able to classify health health records and electronic trends at the neighborhood or zip code laboratory reporting. Supporting and TFAH • healthyamericans.org 61 incentivizing real-time and two-way • AO recommends that HHS complete G communications between healthcare a plan for establishing a nationwide, providers and health departments are real-time public health situational critical components. There are also awareness network, as required significant barriers in changing the by PAHPRA of 2013, including culture and practice of how disease measurable steps for progress and surveillance is conducted at all levels IT management processes.210 A of public health. Agencies may have September 2017 GAO report found to discontinue legacy systems, while HHS still lacks the structure and public health may have to work with mechanisms to plan, manage and state lawmakers to address barriers in oversee this type of network.211 electronic disease surveillance while • ational Academy of Medicine’s Vital N maintaining patient privacy. Directions for Health and Health Care • unding at the federal, state and local F paper on “Information Technology level remains a significant challenge. Interoperability and Use for Better Health From 2012 to 2014, the federal Care and Evidence” identified that government released a series of “if managed more effectively, federal biosurveillance strategies and road investment in HIT and public-health maps to help consolidate systems, surveillance … could achieve better eliminate redundancies and reduce outcomes without necessarily requiring unnecessary reporting burdens. These new resources.”212 To help improve focus on the ability to integrate with the integration and alignment of public electronic health record systems and health and healthcare surveillance, they other emerging health information identified policy initiatives including that: technologies, including a call for • ublic health departments should P partnerships across private and public have the right workforce and healthcare systems and state and local technology to advance surveillance public health departments.207, 208, 209 and epidemiological functions, However, most of these plans do not including by aligning CDC programs to include funding estimates and there support foundational capabilities; and often is insufficient funding to carry out all of the aspects of these plans. • ffice of National Coordinator for Health O Implementing a modern disease Information Technology (ONC)] should surveillance system will require set standards for the nation’s HIT up-front investments in technology system that ensure better coordination and a trained workforce, as well as with public health departments as the political will to let go of legacy they develop the capability to work in systems. There must also be a long- the HIT system, and that ONC should term funding strategy for federal, state work with CDC and other public health and local public health to achieve the agencies to ensure interoperability of goal of a modernized system. their systems. 62 TFAH • healthyamericans.org CDC’S SURVEILLANCE STRATEGY In 2014, CDC released a new CDC message validation, processing surveillance strategy to work towards and provisioning system, and providing consolidating systems, eliminating technical assistance to jurisdictions.214 redundancies in reporting and reducing Standardizing and harmonizing the reporting burdens on state and local data will significantly reduce the burden health departments in order to improve of reporting on state and local health the speed, quality and accuracy of departments and, at a future date, disease tracking. The strategy includes will lead to the retirement of older, four major components: standardizing less efficient legacy systems. As of health data and exchange systems, October 2017, guidance to state on enhancing situational awareness, how to package case data into the HL-7 accelerating electronic laboratory message format is in production, test reporting and modernizing mortality ready or in development for 95 percent surveillance systems. 213 One initiative of conditions. Currently, 16 of 57 is the NNDSS Modernization Initiative reporting jurisdictions have implemented (NMI), which standardize the reporting at least one of the new HL7 formatted format (HL7) for more than 100 message guides, and 8 of those 16 nationally notifiable diseases, enhance have implemented more than one. SHARING DATA TO IMPROVE CLINICAL CARE AND PUBLIC HEALTH: THE DIGITAL BRIDGE INITIATIVE215 RWJF, the de Beaumont Foundation, Beginning in 2018 eCR will be a Public Health Informatics Institute and public health reporting measure that Deloitte Consulting have convened a wide eligible hospitals and professionals range of public health, healthcare and may perform for credit under specific health information technology partners to Medicare or Medicaid programs develop the Digital Bridge initiative. The under Meaningful Use.216 In order initiative aims to identify a consistent, to be an effective reporting system, nationwide and sustainable approach to jurisdictional public health agencies using electronic health records data to must be ready to receive and interpret improve public health surveillance. The that data. In 2017, the Digital Bridge effort focuses on advancing electronic has been working to coordinate eCR case reporting (eCR) to move toward a implementation in seven sites to test more real-time, interoperable and secure technical specifications, demonstrate process where reportable conditions, the viability of eCR for public health including a wide range of infectious and healthcare, and determine what diseases and infections, would be assistance health departments will automatically generated from EHRs and need to receive and incorporate eCR transmitted to public health agencies. data effectively. TFAH • healthyamericans.org 63 RECOMMENDATIONS: Incentivizing and supporting emergency funding runs counter to medical intervention, such as an medical countermeasure research, industry planning standards and creates anthrax release. If health departments development, stockpiling and uncertainty in long-term partnerships are not able to develop such capacity distribution. with the federal government. Project internally, they must have contingency l A chieving a strong U.S. medical BioShield should receive multiyear plans to contract with and train private countermeasure enterprise — one funding to allow for improved planning sector personnel for mass dispensing. that sufficiently supports research and and flexibility in procurement of MCMs. These plans should include insurer development of vaccines, antivirals and support for medical countermeasure l I n addition, there should be ongoing other countermeasures — requires payment when appropriate. Furthermore, funding to restock and upgrade the incentives for biopharmaceutical CDC should work with providers to Strategic National Stockpile so medical companies and researchers to continue develop a standardized template for countermeasures are available and research and development of medical distributing MCMs to children, people unexpired when needed for patients. countermeasures, particularly due who are home-bound and other specific to the limited funding for purchase l G aps remain in MCM distribution and populations. Finally, HHS must monitor under Project BioShield. Furthermore, dispensing capabilities, especially for and assess MCM use nationally during unpredictable annual and short-term disasters that require an immediate emergencies.217 ALTERNATIVE MODELS TO SPUR RESEARCH AND DEVELOPMENT l G lobal efforts in vaccine development Bacteria (CARB), HHS partnered with l $ 41.6 million was awarded in funding to are long, expensive processes. A academic and philanthropic entities the 18 projects with an additional $52.6 recently formed collaboration — the (including BARDA, NIAID, the AMR million if project milestones are met; Coalition for Epidemic Preparedness Centre, Wellcome Trust, California Life l 3 68 applications were reviewed from Innovations (CEPI) — seeks to provide Sciences Institute, MassBio, The Broad around the world and 18 projects an alternative model for funding vaccine Institute, Boston University and RTI selected in 6 countries; development. The public, private and International) to form the Combating l 6 0 world-leading experts sit on philanthropic partners seek to finance Antibiotic Resistant Bacteria CARB-X’s Science Advisory Board, and coordinate vaccine development Biopharmaceutical Accelerator, or making recommendations on which against priority threats, particularly CARB-X, in July 2016. The partnership projects to support; when current markets are unlikely to funds research and development of pursue development. The partnership, therapeutics, vaccines, diagnostics l 9 6 percent of CARB-X spending which is in the start-up phase, is and devices as well as provides in year one went directly to fund between the Government of India, technical assistance for companies scientific research; and Government of Norway, Wellcome Trust, with promising solutions to antibiotic l S ince its launch, CARB-X has established Bill and Melinda Gates Foundation and resistance. 219 BARDA has committed scientific standards and criteria to review World Economic Forum.218 up to $250 million over five years and applications, and built a network with its other entities have promised additional world-class partners.221 l A s part of the National Action Plan funding. 220 In its first year: on Combating Antibiotic Resistant 64 TFAH • healthyamericans.org RECOMMENDATIONS: l U pgrading to modern molecular technology, identify both emerging and technologies. Advances in diagnostic ongoing health problems in a community technologies, like DNA sequencing, and track patterns to better discover the allow scientists to identify the causes causes and cures of diseases. of outbreaks and connections between • ew diagnostic technologies; changes in N different cases more quickly. This helps data-management capabilities to more identify how widespread an outbreak quickly identify and track outbreaks and may be and guide treatment. However, problems; and the ability to develop new historically the public health system vaccines, diagnostics and antivirals — has not had built-in mechanisms to particularly for emerging diseases — and support and incorporate developments to counter growing antibiotic-resistant in science and technology. Indeed, threats all hold tremendous promise. for many years, there had not been a This will not be realized unless there is meaningful investment toward upgrading continued investment and a fundamental many of the basic systems used by change in how the country thinks about public health laboratories — which and invests in public health. hampered the ability to incorporate new CDC’S ADVANCED MOLECULAR DETECTION (AMD) PROGRAM CDC’s Advanced Molecular Detection and pilots next-generation diagnostics and CDC is starting to scale broader use (AMD) program was established in 2014 protocols with and for CDC and state and to public health labs, including state to bring DNA sequencing (“next-generation local public health labs. These tools are health laboratories, to be able to test for sequencing” (NGS) which enables then leveraged across CDC to be brought pathogens. With improved funding and “whole-genome sequencing” (WGS)), to scale in public health labs nationwide. reduced price points, the technology could bioinformatics and related technology into Rollout of NGS to all 87 PulseNet be used to support disease investigations public health in the United States. With labs (which includes all 50 states and of many infectious diseases. While this funding through the AMD program, these Washington, D.C.) is currently underway. means that more outbreaks are being technologies are now being brought to detected earlier, it has also increased To explain the impact of the technology, bear against a wide range of infectious the need for epidemiologic investigators CDC has said, “imagine doing a 10,000- disease threats across the United to look into sources of illness. On top piece jigsaw puzzle in the time it takes to States and are rapidly transforming the of this, the revolution in sequencing finish a 100-piece puzzle. Apply that to monitoring of these threats, as well as technology and analysis is continuing, with infectious disease control, and that is AMD the response to outbreaks. CDC’s AMD sequencing costs decreasing, automation at work. Now imagine putting together that program works with other experts at CDC increasing and analytic methods 10,000-piece puzzle when key pieces are to ensure the U.S. has the infrastructure, improving, all of which are continuing to missing, disease is spreading and people including technology, needed to protect open up opportunities to prevent disease, are dying. AMD gives CDC scientists the Americans from infectious disease intervene earlier in outbreaks and, ‘key pieces’ to protect people from ever- threats. Four years ago, U.S. public ultimately, to save costs. Scaling these changing infectious disease threats.”222 health agencies were behind in the and other emerging technologies requires adoption of these technologies, but now AMD technologies are being used to a long-term strategy and an investment they are now leading the world in many identify emerging pathogens, improve in the technology and the training of areas. The CDC AMD program develops vaccines, and develop faster tests.223 scientists to use equipment effectively. TFAH • healthyamericans.org 65 F. Maintaining a Robust, Well-Trained Public Health Workforce Many leading experts and programs — including initiatives led by the Association of State and Territorial Health Officials, the National Association of County and City Health Officials (NACCHO), the Association of Public Health Laboratories, the de Beaumont Foundation, schools of public health and other expert groups — are focused on the need to recruit and retain a next generation of public health workforce. The current state and local public 38 percent of state and local public health professionals plan to leave health workforce is not large enough governmental public health by 2020 nor professionally diverse enough to meet community needs, and there are major gaps in the training and capabilities of the existing workforce to meet modern health problems.224, 225 l T he public health workforce experienced significant job losses during the Great Recession, resulting 48 percent of state and local public health professionals are over 50 years old in more than 51,000 job losses from 2008 to 2014; l F rom 1980 to 2000, the ratio of public health workforce to the U.S. population has decreased dramatically from 220 to 158 per 100,000 people; l R etirements and high turnover rates address principal factors that influence l 3 8 percent of state and local public present challenges in maintaining health, such as for systems changes that health professionals plan to leave their experience, leadership and continuity incorporate health into housing and government public health positions in core capabilities; economic development and working by 2020 — 25 percent of state public effectively across diverse populations. l M any public health jobs require health employees plan on retiring and highly-trained, specialized scientific A wide range of reviews and assessment 13 percent plan on leaving their job; skills — such as laboratorians and have demonstrated the vital importance l 4 8 percent of state and local public epidemiologists — and it is important and value of also specifically training health professionals are over 50 years to build career tracks that attract a new for emergencies and disasters — to be old, 15 percent are over 60 years old. generation of experts and retention of prepared and understand roles and expert professionals. Only 17 percent responsibilities.227, 228, 229 Ongoing training, Some key issues raised in the Public of the public health workforce has any including drills and scenario exercises, Health Workforce Interests and Needs kind of degree in public health; help better prepare public health and Survey (PH WINS) conducted by ASTHO healthcare professionals to respond and the de Beaumont Foundation to l T here is a need to expand training of efficiently and effectively during crises. highlight the issues at hand:226 skills and strategies for how to effectively 66 TFAH • healthyamericans.org In June 2017, NACCHO released results of its second Preparedness Profile assessment conducted in June 2016.230 Preparedness coordinators at local health departments (LHDs) were asked to respond to 18 closed- and open-ended questions about their LHDs’ preparedness workforce, planning, and activities, including those around current and emerging threats, healthcare coalitions, administrative preparedness and the National Health Security Strategy. Findings include: l A pproximately one-third of LHDs l L HDs most frequently selected reported a decrease in preparedness terrorism-related events staff, mainly among larger LHDs. and accidental nuclear/radiation Compared to 2015, 12 percent more releases as the current threats they LHDs reported staffing decreases. feel least prepared to address. l M ost preparedness coordinators l E xtreme weather and infectious (73 percent) in large LHDs dedicate diseases are the top global/ all their time to preparedness emerging threats that LHDs are efforts, while preparedness most concerned will affect their coordinators in smaller LHDs spend community in the future. their time working in a variety of l O verall, the broadest range of public health areas. activities conducted by LHDs in l M ost LHDs reported excellent the past year were focused on partnerships with emergency medical countermeasure, community management services, emergency preparedness, and infectious management agencies, and hospitals. disease topics. Conversely, LHDs LHDs were least likely to report strong most often report not conducting any partnerships with pharmacies and preparedness activities in climate local businesses. change/adaptation, cybersecurity, and l I n both 2015 and 2016, the counterterrorism and response. majority of LHDs reported being l A pproximately half (51 percent) of members of a regional healthcare LHDs were not aware of the National coalition to plan and implement Health Security Strategy, but this has preparedness activities. decreased slightly from 2015. TFAH • healthyamericans.org 67 RECOMMENDATIONS: l B olstering efforts to recruit and retain • 2013 CDC Public Health Workforce A trained and experienced public health Summit Report identified multiple factors professionals. There needs to be a that lead to the public health workforce major push to ensure a strong public crisis, including the insufficient number health workforce with the capabilities of current workers across public health to detect, diagnose and track health disciplines and insufficient investment problems as well as develop strategies in training and training evaluations.234 to improve health and reduce chronic Summit leaders called for public health and persistent problems. This includes agencies to develop a plan to recruit the need to maintain an ongoing professionals to enter the public workforce — job cuts over the past two health workforce; including those with decades have left major gaps in the backgrounds in informatics, business workforce that must be addressed. A and finance management and law; and competent workforce requires being for agencies to encourage mentorship able to work with a wide range of between those in supervisory and non- partners and sectors to implement the supervisory positions to prepare mid- strategies. Some priorities for workforce level staff for leadership positions. development include: systems thinking; • orkforce recruiting should also focus W communicating persuasively within and on skill sets outside of traditional outside of public health; influencing public health. Modern health crises and developing policy; business and require experts in communications and financial management; the ability to social media to ensure accurate, direct be flexible and manage a changing engagement with the public before environment; analytic and technical and during emergencies. In addition to skills and informatics; information recruiting highly trained informaticians, technology (IT) and computer science HHS and health departments should experts of various levels; and being able be able to infuse the workforce with to work with diverse populations.231 As skilled technology specialists and data technological and informatics needs scientists with experience outside the of health departments increase, it will traditional health sciences. be especially challenging to sustain a public health workforce, particularly if l E asing barriers to hiring at the federal, public health funding remains unstable. state and local level. In the midst of an emergency, it can be difficult to hire people • o help better train and maintain the T quickly. Each state has its own rules for workforce, NACCHO and ASTHO have staffing and contracting, which may not recommended the implementation align with priorities during an emergency of a workforce development plan response. HHS should provide guidance tied into quality improvement that is to states on effective policies to ease regularly updated based on training the hiring and contracting process during needs assessments and changing emergencies. HHS agencies should also agency and community needs.232, have authority to make immediate offers 233 Assessing optimal public health to a range of emergency response staff, workforce needs should be considered such as epidemiologists and logisticians, as part of Community Health Needs saving time during an emergency. Assessment reviews. 68 TFAH • healthyamericans.org G. Rebooting and Developing a New Strategy for Hospital and Healthcare Readiness HPP, administered by ASPR, was created after September 11, 2001, to help build capabilities in health system preparedness for major emergencies.235, 236 The program is a vital lever in building the readiness of the healthcare system to prepare, respond to and recover from disasters and outbreaks. HPP helps build regional coordination priorities to work together to focus on and collaboration between healthcare the common needs of the communities entities, such as hospitals, public and regions that they serve.237 Currently, health, emergency medical services there are over 475 HCCs nationwide, and emergency management to ensure with more than 31,000 members.238 the healthcare system is able to save These coalitions vary in size and lives and provide care during and after capacity. HHS recently updated the emergencies. HPP is currently the only healthcare preparedness and response source of federal funding for health capabilities that the healthcare system system readiness. The program’s peak should achieve, including a greater funding was $515 million in 2004 focus on building a foundation for and has been cut over time to about healthcare readiness, assessing risks $255 million in 2017. The program and needs, training the workforce and establishes regional healthcare ensuring preparedness is sustainable.239 coalitions (HCCs) that incentivize The vision for 2017 and beyond is to diverse and often competitive focus on operationalizing HCCs for healthcare organizations with differing effective response. Leonard Zhukovsky / Shutterstock.com TFAH • healthyamericans.org 69 RECOMMENDATIONS: l olstering the Hospital Preparedness B should avail themselves of these order to meet both CMS’ requirements Program. There is wide variation and resources, ASPR should continue to and ASPR’s healthcare preparedness limited transparency in how well states conduct targeted outreach to new and and response capabilities, such as and the coalitions within them are doing less effective coalitions; and the resources dedicated to the CMS in achieving capabilities defined by • s the program — and the field of A rule on ASPR TRACIE. CMS and HHS. While some have achieved notable healthcare preparedness — matures, ASPR should coordinate to ensure successes, other coalitions are in nascent ASPR should continue to strengthen compliance with the CMS rule includes stages or lack buy-in from healthcare the focus of HPP on the readiness meaningful planning and engagement, organizations with the region. In order to and responsiveness of the healthcare not just paper plans. make HPP as effective as possible: delivery system as distinct from • nother important preparedness A • PP must receive stable, robust H public health preparedness. HPP asset could be value-based funding to ensure the program can should bolster both preparedness and healthcare models, such as achieve its goals. The funding is response capacity to ensure the health Accountable Care Organizations important to support coalitions care delivery system is integrated into (ACOs).242 Healthcare Ready has and build and sustain better jurisdictional incident response. proposed ACOs, collaboratives to coordination and connections across bring doctors, hospitals and other l E xploring Innovative Mechanisms to key healthcare, public health and healthcare providers to join together Build Readiness. With its limited funding other emergency responders before and coordinate high quality care base (current total hospital spending and during crises. There must be to Medicare patients. This model is around $971 billion per year), HPP strong healthcare preparedness would help create a more resilient cannot be the only driver of health capabilities across the country — not healthcare system by providing some system preparedness and response. just in a handful of states. Cutting care away from a centralized location While HPP should continue to play an preparedness in one state means (thus reducing surge in a disaster), important leadership, coordination and neighboring states have to shoulder promoting wellness and helping in standard-setting role, there also need to additional burden during a disaster; coordinating care and tracking of be new models and additional resources • SPR should make certain A vulnerable patients in an emergency.243 to support and augment the program’s performance measures come with basic functions and to engage the health • number of additional levers can A transparency, accountability and delivery system and broader community be further explored for engaging the quality improvement. HPP must focus into building and investing in better health system, such as tax incentives, funding and technical assistance emergency health plans and strategies. Medicare Shared Savings Program on meeting gaps identified in those and Merit-Based Incentive Payment • he recently finalized CMS emergency T measures. ASPR should assess System, Joint Commission standards preparedness requirements for the performance of coalitions on an and National Quality Forum measures Medicare- and Medicaid-participating annual basis, publicly report results to help support preparedness and providers and suppliers is an important and develop strategies to strengthen healthcare coalition participation. lever for building preparedness across ineffective coalitions. ASPR has • tates should clarify and ease S the delivery system.241 Healthcare created a Technical Resources, healthcare volunteer response rules, facilities should use the rule as Assistance Center or Information including the Uniform Emergency an impetus to engage with local Exchange (TRACIE) and has developed Volunteer Health Practitioners Act healthcare coalitions and to leverage tools for coalition quality improvement, (UEVHPA). As recommended in a the collective assets of these including a new course curriculum recent National Academies of Science coalitions. CMS and ASPR should focused on healthcare coalition Engineering and Medicine (NASEM) work together to promote coordination leadership, developed by ASPR report, “If licensed personnel, certified between healthcare coalitions and and FEMA’s Center for Domestic personnel, or those with special skills facilities within the coalition’s region in Preparedness.240 While all coalitions 70 TFAH • healthyamericans.org are used to augment public health recovery resources, care should be taken to verify their credentials and skills before deployment. Disaster response plans should include provisions for the licensing and certification of incoming volunteer resources in two categories: those that are planned and those that are spontaneous.”244 • tate policies and practices S governing the delivery of healthcare during emergencies — including contracting and hiring, healthcare and volunteer liability and adoption of crisis standards of care in the context of scarce resources — can vary from state to state. ASPR should conduct a review of barriers to healthcare response and recovery and provide guidance for states to Dennis Sabo / Shutterstock.com clarify laws and policies regarding should know its health needs will l P ublic-Private Collaboration. A number healthcare disaster readiness. be met during a major emergency. of examples of health emergencies have • otential support mechanisms from P The tiered Ebola response system shown the importance of developing broader community institutions, such demonstrated one model of creating better collaborations between the as universities, businesses, economic regional hubs for care, although that private sector — including hospitals, and community development agencies system requires continuous funding pharmacies, suppliers and health and other prominent partners that beyond the initial starting funding systems — and public health agencies. benefit from stability and vitality of in order to be maintained.247 A This must include ongoing planning to their neighborhoods can also serve as standing regional network system be prepared for potential emergencies levers.245 Non-profit hospitals should would require continuous incentives as well as for coordination during and consider incorporating community- and reimbursement to maintain after emergencies have happened. wide disaster planning participation supplies, workforce and ensure HHS should clarify who assesses into their community benefit efforts buy-in of hospital leadership. The medical needs from the private sector to reflect a recent change in Internal Report of the Independent Panel on and how private sector responses are Revenue Service (IRS) rules that the U.S. Department of Health and communicated and incorporated into allows community resilience to Human Services Ebola Response also the federal response structure. The count for community benefit.246 And, recommends HHS maintain a national Emergency Management Assistance communities could also investigate network of identified treatment centers Compact — which enables sharing of incorporating local health improvement for urgent public health threats, public resources across state lines — partnerships into healthcare coalition including standardized requirements does not have a corollary for private planning efforts to ensure health and protocols. 248 A standing system of sector medical needs and resources. needs and assets of communities are regionalization could help to overcome being considered in disaster planning. l B uilding healthcare facilities’ resilience barriers to meaningful preparedness for disasters. All healthcare facilities • Not every individual hospital or facility planning — such as concerns over — including nursing facilities — should requires the same preparedness liability, loss of profit and competition be assessed for their resilience for capabilities, but a community between healthcare systems. TFAH • healthyamericans.org 71 flooding, extended power outages, l P rivate Sector Engagement. The private in disaster exercises and emergency extended shelter-in-place scenarios, and sector owns roughly 85 percent of the operations responses. The National excessive heat. Possible mechanisms nation’s critical infrastructure, 251 yet is often Center for Disaster Preparedness at include infrastructure investments, excluded or only given nominal involvement Columbia University recommends federal CMS conditions of participation and in disaster planning and response. In many technical assistance programs that can directing of disaster recovery dollars cases, the private sector will be integral to help local communities and private sector for disaster-resilient rebuilding. States disaster response, through supply chains, representatives connect with each other should ensure facilities that serve services, and employee protection. The and navigate legal and logistical barriers to medically vulnerable people — like private sector needs to be fully engaged collaboration.252 nursing facilities and dialysis centers — are considered critical infrastructure. Regulators and payers should ensure NEW EMERGENCY PREPAREDNESS REGULATIONS FOR the quality of these facilities before disasters strike and ensure standards MEDICARE AND MEDICAID PROVIDERS AND SUPPLIERS are being met. There must be sufficient CMS finalized rules in 2016 that 1. mergency plan: Based on a E funding for appropriate state or local went into effect in November 2017 risk assessment, develop an health regulators to inspect facilities to establish consistent emergency emergency plan using an all-hazards such as nursing homes to ensure quality preparedness requirements for approach focusing on capacities before disasters strike. healthcare providers participating and capabilities that are critical to l M eeting the disaster health needs in Medicare and Medicaid, increase preparedness for a full spectrum of of children. The American Academy patient safety during emergencies and emergencies or disasters specific to of Pediatrics recommends that both establish a more coordinated response the location of a provider or supplier. HPP and the Public Health Emergency to natural and man-made disasters.253 2. Policies and procedures: Develop and Preparedness programs should be After reviewing the previous Medicare implement policies and procedures assessed to ensure they are meeting emergency preparedness regulations based on the plan and risk assessment. the needs of children, including full for both providers and suppliers, CMS integration of the needs of children 3. ommunication plan: Develop and C found that regulatory requirements into performance measures for the maintain a communication plan were not comprehensive enough to program. 249 There also should be that complies with both federal and address the complexities of emergency extended authority for the National state law. Patient care must be well- preparedness, including communication Advisory Committee on Children and coordinated within the facility, across and coordination, contingency planning Disasters, an HHS advisory committee healthcare providers and with state and training of personnel. to counsel HHS on preparedness and local public health departments for children. According to Save the To ensure a consistent foundation and emergency systems. Children, the United States still lacks a of emergency preparedness across 4. raining and testing program: Develop T coordinated national strategy to improve the healthcare system, Medicare and and maintain training and testing pediatric emergency transport and care Medicaid-participating providers and programs, including initial and annual in disasters, and no federal agency has suppliers must meet the following four trainings and conduct drills and been designated as the lead on pre- industry best practice standards, as exercises or participate in an actual hospital emergency medical services appropriate for their function: incident that tests the plan. preparedness.250 72 TFAH • healthyamericans.org HEALTH SECTOR RESILIENCE CHECKLIST FOR HIGH-CONSEQUENCE INFECTIOUS DISEASES—INFORMED BY THE DOMESTIC U.S. EBOLA RESPONSE254 CDC and the Johns Hopkins Center for activities as knowledge, facts, and resulting Managing Uncertainty Health Security developed an evidence-in- guidance evolve during the incident. l T he organization has established formed checklist that outlines action steps a decision-making process that l T he organization has practiced (through for medical and public health authorities— incorporates the most current and exercises) adjusting operational procedures in partnership with nongovernmental orga- authoritative information available, during an outbreak in the context of new nizations and private industry—to assess including a process for adjudicating knowledge, uncertain science, and/or and strengthen the resilience of their com- conflicting information. differences in professional opinions. munity’s health sector in the face of Ebola l T he organization is committed to taking Virus Disease or other high-consequence Command Structure actions that are supported by scientific infectious disease (HCID). The report in- l T he organization is prepared to use evidence and avoiding, wherever cludes specific checklists for public health the familiar Incident Command System possible, actions that are taken “out of agencies, healthcare organizations, EMS, chain of command/command structure an abundance of caution.” and elected officials, but the overarching that is used for other events/responses. l T he organization is committed to being resilience actions are as follows: l I ncident Commanders have ready access honest and transparent with the public Preparedness to information on the roles and authorities in cases where there are genuine l T he organization has the trained of the federal, state, and local agencies differences of professional opinion in personnel needed to prepare for and during infectious disease emergencies. the context of uncertain science. respond to a major outbreak. l I ncident Commanders are familiar with Crisis & Emergency Risk l T he organization partners with other the larger incident command structure of Communication organizations that may be involved in a the jurisdiction/state. l T he organization has trained risk response, such as through a Healthcare communicators to craft and deliver clear, Public Trust Coalition. Such partnerships provide consistent, honest, and transparent l T he organization routinely engages a mechanism for information sharing, messages to the public (including the community stakeholders—including collaborative exercising and training, media) and response and non-response community and faith-based organizations planning, and surge response. personnel. These individuals should have and local opinion leaders—to identify a solid background in communication l T he organization has an all-hazards and address community health needs, science, and communication efforts emergency response plan with annexes for thus building public trust in advance of should be coordinated between healthcare infectious diseases and routinely exercises an event and developing partnerships and local/state public health entities. components of the plan with partners. that can prove valuable in a crisis. l T he organization is prepared to use l he organization has incorporated lessons T l T he organization is reaching out to the multiple communication approaches, learned from the 2014 domestic Ebola media, public, and elected officials in including town hall meetings, websites, response into ongoing organizational and advance of an event to educate them social media, guest spokespersons, community HCID planning. about HCID preparedness and response and information call lines/centers to activities and policies. Leadership get information out to the public quickly l T he organization is prepared to identify a l T he organization has a strong risk and to provide the opportunity for the single leader early in the response. communication capability and is public and media to ask questions and prepared to mount a robust media and voice concerns. Creative Flexibility community outreach campaign during l T he organization is prepared to adapt l T he organization is prepared to monitor an event as part of a coordinated effort existing plans in the midst of a response social media to rapidly identify and dispel between the healthcare delivery system in order to address the specific needs of rumors and correct misinformation. and state and local public health. the particular incident and adjust response TFAH • healthyamericans.org 73 EXPERT COMMENTARY The Private Sector’s Role in Preparing for and Responding to Public Health Emergencies By Nicolette A. Louissaint, Ph.D., Executive Director, Healthcare Ready The private sector can often respond to rapidly changing circumstances nimbly and usually knows the communities they serve incredibly well. As such, amidst an emergency, there is opportunity for private organizations to step in and fill response gaps. The public sector takes on an they can trust us with their proprietary enormous burden and works tirelessly information—and we won’t share with to respond to emergencies, and the any outside parties inappropriately. private sector sees its role, especially This designation also gives us a fuller when it operates in affected regions, to view of the resources in a community surge alongside the public sector, pivot during an emergency. For example, nimbly and augment public efforts— during a flood, we can know where thereby enhancing the public system’s emerging challenges in the medical response efforts. pipeline might be because roads are not Often to take advantage of public and accessible. We can inform the public private sector expertise, there just needs sector and work on a solution to ensure to be a connection between the two. vital supplies make it to the public workers who are saving lives. For example, during the Hepatitis A outbreak in San Diego, public officials The public sector knows we can provide reached out to the private sector for them with accurate status of response help locating a significant amount of supplies and what is or isn’t happening vaccines—since one of the solutions was along the supply chain. It’s absolutely to do a mass vaccination campaign. vital for the public sector to know what kind of relief they’ll be getting and Instead of suggesting they import or when and what might be missing so they special order something (possibly at an can adjust on the fly. extremely high cost), Healthcare Ready (HcR), my organization, checked the What we’ve learned from 2017’s levels of vaccines in pharmacies in the hurricanes area. We found the private sector had enough in stock to supply what was After this hurricane season, we realized needed. Sometimes you just need to that the private sector can do a lot know how and who to ask. quickly by getting around bureaucracy to rapidly fill gaps to supplement public As evidenced by this example, one sector efforts. important aspect of coordinating emergency response is sharing critical When faced with an emergency information. HcR is designated by the response, we initially focus on resuming Department of Homeland Security as an supply chain operation and work to information sharing and analysis center support any patients who might be (ISAC). So, the private sector knows falling through the gaps that naturally 74 TFAH • healthyamericans.org occur. The public sector can rely on us to gain insight into what the private sector sees—with us being a central hub coordinating private sector information. One recent example: There was a small group of patients on St. Thomas who needed a specific drug that could only be prescribed every 30 days. The public sector folks asked us to look for ways to get the drug from Puerto Rico and onto a plane that was making routine trips between the islands after Hurricane Maria. As we looked into that, we also were able to reach out to the pharmacies on St. Thomas that we knew had re-opened. And we asked them to speak with their distributors who supply them with medicine. We actually found that one pharmacy had the necessary medicine and it was already on the island. We just had to connect the dots. While this sounds easy written down, there are many competing priorities and everything is in flux during an emergency response. With the public Joseph Sohm / Shutterstock.com sector relying on the private sector for emergency preparedness and response these kinds of responsibilities it can free is about knowing the right organization them up to handle other vital activities. or person to contact to obtain the life saving measure/supply you need. How we can better use the private sector? Currently, in most places, states have While there are many examples of public just one Emergency Management and private sectors working well together, Coordinator for the entire private too often the private sector is only looked sector—encompassing industries like at as a supplier, notably of money and transportation, healthcare, agriculture, medicine, which is frustrating because food, etc. It really isn’t feasible for the clearly the private sector wants to and can level of coordination needed to go help in other ways. through a single node. This might seem like a minor As such, there should be a coordinator problem—but if the public sector is only for each industry, setup in advance engaging with the private sector amidst with regular meetings to fold private a crisis or when money is needed, the sector emergency capabilities into the relationships aren’t developed that public sector’s response plans—so are necessary to work alongside one when a hurricane makes landfall we all another during an emergency. A lot of know what to do. TFAH • healthyamericans.org 75 H. Readying for Climate and Weather-Related Threats Climate-related and extreme weather events have serious health consequences in the United States.255 Health departments have an important role to play in helping communities adapt and prepare for the adverse effects of climate change, given their role in building healthy communities. 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. In addition, public health departments are also on the frontlines when there is an emergency, whether it is a natural disaster or an infectious disease outbreak. These types of emergency preparedness and response skills are essential as extreme weather events and other effects of climate change become more common. The 2017 hurricane season acutely demonstrated that natural disasters can have a tremendous public health impact. From injuries in the immediate aftermath of the storm to long- term mental health effects, recovering communities face a range of challenges. And, public health is integral as part of the frontlines of the preparation, response and long-term recovery. In areas recovering from storms, public health departments work long hours for weeks on end — leading to extremely high costs and detracting from ongoing work of the department, such as routine disease prevention. In-between emergencies, public health can use data and find opportunities to engage more with at-risk populations (such as children, pregnant women, elderly, people with physical and intellectual disabilities and people with mental health conditions). For example, this could mean including members of at-risk populations in emergency drills, training first responders and emergency managers to understand the needs of at-risk populations and creating pilot programs with Medicare providers, home health organizations and others involved with the care of older adults. This should include addressing the health of our older population and having processes in place to maintain their connection to care during an emergency that might result in evacuations and/or loss of power. Source: APHA 76 TFAH • healthyamericans.org RECOMMENDATIONS: l P reventing and preparing for the greenhouse gas emissions through city l D eveloping sustainable state and local adverse impact of climate change on planning initiatives promoting active mosquito and other vector control infectious disease outbreaks. Every transportation options, for example, programs. A review by ASTHO found state should have a comprehensive can play an important role in reducing that many states and local communities climate change adaptation plan that existing health inequities by increasing are challenged to develop and maintain includes a public health assessment resilience, physical activity levels and vector control programs, but that these and response. Public health and social cohesion in communities most programs are a vital public health environmental agencies should work at risk.256 Urban planning policies can strategy to help control vector-borne together to implement strategies that also help vulnerable populations adapt diseases.260 And a NACHHO assessment help track concerns, coordinate risk to the predicted impacts of climate of Zika response among agencies in management and communications change. Policies ensuring buildings are high-risk U.S. areas also found that and prioritize key public health constructed to resist extreme weather 68 percent of those surveyed lacked capabilities needed to address events, for example, could help mitigate competency in mosquito control and environmental health concerns. the negative impacts for vulnerable surveillance, including many in Texas Climate change needs assessments populations located in areas heavily and Florida.261 The vector-borne disease should include an examination of what impacted by hurricanes or heavy rain. 257 program at CDC should be broadly additional capacities are needed and expanded to support state and local l M aintaining funding for the CDC’s identify vulnerable populations and capacity to prevent and detect mosquito- Climate and Health Program at the communities. borne illnesses such as Zika, Dengue National Center for Environmental and West Nile Virus. l B uilding resilience to climate-related Health. The program was created health effects at the federal, state in 2009 to translate climate change l I ncreasing funding for the National and local level. Climate change science to inform states and Environmental Public Health Tracking preparedness should be a required communities, create tools to build state Program at the National Center for element of PHEP and HPP plans and local capacity to handle extreme Environmental Health at the CDC. and grants. Funding also should be events happening today and in the Health tracking is important to identify significantly increased to build capacity future and lead efforts to mitigate the the link between environmental factors at the federal, state and local level public health impacts of climate change and their impact on health. The to understand the impact of climate and extreme weather. program should be expanded and fully change and apply this to long-range funded to cover every state. l I mplementing the Clean Air Act (CAA) health planning. in an effective and timely manner. The l I mproving coordination and moving to l I ncreasing funding for prevention CAA protects American health against integration across medical care, public and preparedness measures that dangerous levels of air pollutants. health and environmental agencies. promote health equity and help protect Investments to comply with the CAA Public health agencies at all levels must vulnerable populations from adverse have provided $4-8 of economic benefits work with environmental, homeland climate effects. Initiatives addressing for every $1 spent on compliance.258 security and other agencies to undertake the underlying causes of climate change Four major rules of the CAA alone would initiatives to reduce known health can simultaneously provide important yield more than $82 billion in Medicare, threats from extreme weather, food, health equity benefits to vulnerable Medicaid and other healthcare savings water and air and educate the public populations. Projects aimed at reducing for America through 2021.259 about ways to avoid potential risks. TFAH • healthyamericans.org 77 EXPERT COMMENTARY Local Public Health Preparedness and Response to Hurricanes and Other Emergencies: High Tech and High Touch By Umair Shah, MD, MPH, Executive Director and Local Health Authority for Harris County Public Health Harris County, Texas, is a large and rapidly growing community. We are the third largest county in the United States with 4.5 million residents spread over 1,700 square miles. We are diverse in every sense of the At the end of the day, the high tech gets word, making it vital to communicate in the visibility, but it’s the high touch that culturally competent ways. Additionally, allows the high tech to succeed. since we are growing and people This is the backdrop that all our come from all over, they might not preparedness activities take. have experience with mosquito or hurricane seasons. We cannot assume Being Prepared our constituents, year after year, are the same. So we must continue to reach out Even preceding Hurricane Katrina, to our community and educate. we made sure that every single Harris County Public Health employee had That means we need adequate capacity up-to-date Incident Command Systems within the department and a diverse (ICS) training—and new staffers get this team with a broad array of skills and training as part of initiation. experiences who continual drill and train. And, every year, we practice—drills, To ensure we reach all our constituents, exercises, call down lists, etc.—making we are mobile—we take public health to sure we can perform all the tasks we’ll the public. We’ve built health villages with need to do during a response. large RV units—that focus on all aspects of health from mosquito abatement to So, in reality, our response to Hurricane dental services to immunizations. Harvey started more than a decade before the hurricane ever made landfall. We didn’t stop there — we knew to be a trusted source during an Hurricane Harvey emergency we must foster a real Before Harvey even hit, our preparedness intimate sense of community. director alerted staff and the executive I mention this because, day-to-day, we rely team that a major response would be both on high tech and high touch. We necessary. With this advanced warning, must remember the importance of both. we put all assets in place before landfall. As much as we talk about technology, We set up communications pathways social media and sophisticated and communicated to all staff, ensuring surveillance systems, we cannot lose the they were aware of what was coming and high touch of knocking on a door or their roles and responsibilities. stopping to share a story, laugh or cry. 78 TFAH • healthyamericans.org Once we were in place, we turned to the community. Our communications team sent out messages before the storm about how to be prepared: get your kits ready; what will you do without power; what if you’re displaced; how will you care for the elderly, children and pets; and many more. Aside from those messages, we needed to make sure people avoided flood water—there could be any number of dangers from power lines to insects to animals to sewage to toxins. I highlight talking to the public because we’re all in this together. We can respond great from a systems perspective, but if, for instance, people lose access to medications or begin to eat unsafe foods, we could see infectious disease outbreaks or worsened chronic conditions. In addition to communicating, building and leveraging partnerships is key to a good response. For example, we worked with state public health and federal partners (the U.S. Air michelmond / Shutterstock.com Force) to continue ground and aerial Going forward To better prepare for and respond spraying for mosquitos to ensure there I’m always struck by the fact that to emergencies, we also must wouldn’t be increased levels of Zika everyone talks about the importance improve technology solutions, or dengue or chikungunya. All levels of health during an emergency, but, electronic surveillance activities, and of government coordinated to ensure when the emergency goes away, we infrastructure support. We need more we maintained adequate control over often forget that we need to adequately epidemiologists and environmental mosquitos and other infectious diseases. resource public health agencies so they toxicology experts. And, we need more Harris County also sheltered a number have the tools and resources to take on social workers and community health of people. Our epidemiologists relied on the next emergency. workers to fan into the community and outside experts and volunteers to help link folks with vital social services. them go cot-to-cot to make sure there It’s about capacity. The best response features a wasn’t an infectious disease outbreak I worry, one day, there will be an combination of high tech and high and that people maintained access to emergency that we haven’t trained touch. This is where our department medicines—a high touch strategy. for enough and don’t have adequate shines day in and day out. We’ve never This is just a small sample of all the resources in place. Public health can’t let one overtake the other. activities we did to keep people safe. all of a sudden be ready to respond Nationally, though, we can’t rest on our At the end of the day, a good response to a major emergency — we need laurels—the next storm could be different involves working across systems to to drill and train and have access to and we need to be ready and prepared. ensure strong partnerships are in place. infrastructure and technology. TFAH • healthyamericans.org 79 EXPERT COMMENTARY Q/A with Celeste Philip, MD, MPH, Surgeon General and Secretary of the Florida Department of Health TFAH: What are state public health monitors, investigates and controls responsibilities before a storm? any threats to human health; and Dr. Philip: The Florida Department of coordinates disaster behavioral health Health (DOH) is designated as the lead services with a sister agency. agency for State Emergency Support During Hurricane Irma, ESF8 assisted Function 8 (ESF8), health and medical with 76 patient movement missions that services. DOH coordinates the availability supported the transport of hospital, and staffing of special needs shelters; skilled nursing facility and assisted living supports patient evacuation; ensures facility clients. We conducted more than the safety of food and drugs; provide 1,000 post-impact facility inspections critical incident stress debriefing; and and more than 2,600 tests of public and provides surveillance and control of private water systems and operated 113 radiological, chemical, biological and special needs shelters. other environmental hazards. DOH administers two statewide TFAH: How do state health departments preparedness grants to build local coordinate the public health response to capacity within the public health and a major storm? health care community. The federal Dr. Philip: Preparedness and response Public Health Emergency Preparedness are driven by local leadership, personnel grant supports all 67 county health and assets. In Florida, each CHD departments (CHD) and public health coordinates and works directly with laboratories in developing community their local Emergency Management to preparedness, epidemiological meet the preparedness and response surveillance and investigation, and needs of their community. If the county medical countermeasure delivery. Emergency Operations Center (EOC) The Hospital Preparedness Program cannot meet the local need, they funds 10 health care coalitions to request assistance through the state build capabilities for medical surge, EOC via a web-based system that allows continuity of health care delivery, and us to track and ensure completion of preparedness partnerships among local mission requests. health care partners. Based on these mission requests, the state ESF8 assesses regional and state TFAH: What are state public health assets. If the requested resources are responsibilities after a storm? not available in-state, ESF8 next looks Dr. Philip: ESF8 assesses and stabilizes to resources available from other states the public health and medical system; through the Emergency Management supports the ongoing sheltering of Assistance Compact (EMAC), or, in the persons with special medical needs; case of a declared state of emergency, coordinates patient movement and potential federal assets such as Disaster evacuations of health care facilities; Medical Assistant Teams. conducts public health messaging; 80 TFAH • healthyamericans.org TFAH: Why are federal investments in public health critical on an ongoing basis? Dr. Philip: During a major event, we are often shoulder-to-shoulder with our federal partners in the state EOC. This includes representatives from HHS, ASPR, and also FEMA who help to coordinate any requests we make for federal assistance. Federal investment is critical for building a public health infrastructure that has the capacity to prepare for and recover from weather and other hazardous situations. If states are better prepared to respond, requests for federal assistance may be lessened. With the close succession of Hurricanes Harvey, Irma, and Maria, and wildfires in California, federal response agencies had to sustain their efforts across time and location which may not be feasible in the future. Better coordination of credentialing and contracted assets were mobilized to TFAH: What federal programs and health care professionals between states support sheltering operations but some supports are critical for preparedness would be helpful for patients who counties had to wait until the storm and response? evacuate with their provider and for passed to receive additional staffing. providers coming into disaster areas. Dr. Philip: Both the PHEP and HPP Because of the surge in last minute statewide preparedness grants are Streamlined and flexible funding to registrations to special need shelters, important for public health preparedness allow for nimble response as needed comprehensive planning and placement and response. Preparedness programs would greatly enhance public health’s for each registrant could not be in various HHS agencies hold meetings ability to be effective. conducted resulting in the shelter that provide training and networking having to accept clients with medical opportunities for states. TFAH: What lessons did you learn from needs that exceeded the shelters’ level the most recent storm? Was there of care capacity. TFAH: What is needed from the federal anything different or new that happened? Moving forward, we recognize a need to government to improve preparedness Dr. Philip: Hurricane Irma posed a anticipate future storms that may impact and response? unique challenge because the track much, or all of the state, a scenario not Dr. Philip: Knowing and having was very unpredictable, meaning that contemplated prior to Hurricane Irma. a relationship with our federal more hospitals decided to evacuate For DOH, statewide emergency response counterparts that will be deployed to and more residents decided to shelter. efforts could be bolstered by improving the state EOC improves communication This storm at some points was 500 miles planning for our special needs residents, and manages expectations more wide — which exceeded the width of including better training and increased effectively. A federal system that allows our state. And, personnel could not be collaboration with other state agencies for tracking of deployed assets would moved around in advance of the storm and the private sector to support improve situational awareness and real- as the track changed to support other Floridians with special needs. time decision-making. counties in the new path. EMAC, federal TFAH • healthyamericans.org 81 EXPERT COMMENTARY Hurricane Katrina: What We Learned, Then and Now By Karen DeSalvo, Former Acting Assistant Secretary for Health, US Department of Health and Human Services There are a significant amount of vital lessons that need to and have been learned from the preparation for, response to, and recovery from Hurricane Katrina. One long-term lesson that I think is worth highlighting and has shown its importance during recent weather-related emergencies is the need for public health to take a significant leadership and coordinator role before, during and after an emergency. In the immediate aftermath of And, if you look at the response in Hurricane Katrina, it was evident that Houston, you’ll note that public connections were missing—whether it health was everywhere. They were be local public health to state officials, in communities meeting people and public health to first responders, or alerting them to potential dangers and public health to the community. infectious diseases, what food and water was safe, etc. And, they were all over Public health leaders simply weren’t social media in a culturally competent the chief health strategists for their way, reaching more and more people. communities. The field was focused on an important set of discrete responsibilities If you compare the Houston Harvey or programs but not on the need to response to Katrina, it should be apparent build connections with community that one of the benefits in Houston was the leaders, first responders and other high level of connectedness between public critical infrastructure that could ensure health and the community they serve. people had safe places to go and access to How we can better prepare for the medications and other critical supports. next emergency With this realization, it was apparent In addition to public health continuing public health had to connect more with to be the coordinator for health for our the full gamut of organizations and communities in disaster and every day, people involved with an emergency to better respond to the next public response. And, since then, we have health emergency, the nation needs to: done so not only in New Orleans, but l E xpand funding; in communities across the country. l I mprove the foundational capabilities For example, during subsequent of public health; hurricanes in New Orleans, public l B etter leverage technology; health was able to work directly and quickly with hospitals and other care l I ncrease training; and facilities to know if power was on l F ocus on the underlying health and and what beds and medications were resiliency of our communities— available. particularly those who are most vulnerable. 82 TFAH • healthyamericans.org We need more funding for public When Katrina hit, we were using flip the Commissioned Corps—an health—we need public health phones, Blackberries and an early invaluable resource. Currently, when departments at the local and state levels version of Google maps. We’ve come the Commissioned Corps deploys to to have the foundational capabilities a long way with technology in little an emergency the connections with required to respond to public health over a decade, but our preparedness local responders aren’t there and emergencies but also to help build hasn’t quite kept up. We must do often the Commissioned Corps can be resilience between events. These better with technology. underutilized. funds can’t be categorical, they have We have a great start with this by better Lastly, we simply must do more to provide core funding that can be leveraging the Department of Health to improve the resiliency of our nimble for a community to address their and Human Services’ emPOWER, an communities. The healthier a group of biggest health needs. For instance, parts online tool that houses and provides people are, the better they respond to of California might be more prone to Medicare claims data to hospitals, first an emergency. wildfires while the Gulf Coast needs to responders, and health officials to focus on hurricanes. If we don’t have In-between emergencies, public health help map the electricity needs during these capabilities in place, we’re forcing must use data and find opportunities an emergency. emPOWER enables our public health workers to just react, to engage more with vulnerable responders to prioritize evacuations rather than prepare to respond. populations. For example, this could and can identify vulnerable populations include creating pilot programs with We also need more funding to go who will need follow-up services. But Medicare providers, home health directly to local health departments. it’s limited to the Medicare population. organizations and others involved States have a huge responsibility during This type of tool must be expanded with the care of older adults. We an emergency and often can’t funnel to or created for Medicaid and, where must improve the health of our older as many resources as you’d think to the appropriate, private payers. First population and, at the same time, local level. During Katrina, we saw this responders and public health must have have the processes in place that can front and center. real-time population level data. maintain their connection to care While more funding is important, An additional reason more resources during an emergency that might result it must be paired with concrete are needed is to increase drills and in evacuations and/or loss of power. expectations and accountability. training that specifically focus on The nation’s preparedness has improved Every single health department in the local leadership and the U.S. Public immensely since Hurricane Katrina—we country should be accredited which Health Service Commissioned Corps. must keep improving. will help ensure that they can stand up Annually, public health workers should emergency operations when necessary. drill in a vulnerable area alongside TFAH • healthyamericans.org 83 EXPERT COMMENTARY Ignore At Your Peril: Environmental and Occupational Dimensions of Health Security Originally featured in the National Health Security Preparedness Index project, September 7, 2017 By Anna Goodman Hoover, PhD, MA is an assistant professor in the University of Kentucky College of Public Health Department of Preventive Medicine and Environmental Health, and Glen P Mays PhD, MPH is the Scutchfield Endowed . Professor of Health Services and Systems Research at the University of Kentucky College of Public Health. Disasters always have environmental contributors and consequences. Hurricane Harvey provides the latest reminder of this fact as Gulf coast responders assess risks and resiliencies in the affected region’s water and food supplies, sewage systems, industrial and hazardous materials sites, housing stock, and other elements of the natural and built environment. Protecting communities and responders during disasters requires anticipating environmental and occupational health risks in advance and containing them as they emerge. The National Health Security protections 2.4 times greater than its recently hosted a meeting of Preparedness Index’s Environmental lowest-scoring counterpart. Furthermore, environmental and occupational and Occupational Health (EOH) more than 40 percent of all U.S. states health experts in Washington, DC to domain tracks the nation’s progress in have experienced declines in EOH explore EOH domain trends. Meeting this area, which appears underwhelming protections since Index tracking began, participants included representatives in recent years.  The Index measures while an additional 25 percent of states from the Centers for Disease Control capabilities for maintaining the security have held steady, seeing neither declines and Prevention, the National and safety of water and food supplies and nor improvement. Yet during the same Environmental Health Association, the testing for hazards and contaminants period, the United States has experienced National Institute of Environmental in the environment. These measures improvements in most other health Health Sciences, the National reveal some concerning trends. security domains tracked by the Index. Governors Association, the Association Although geographic disparities are of State and Territorial Health Officials, The National Conference of State reflected in many areas tracked by the the Association of Public Health Legislatures and the University of Index, variation across states is widest in Laboratories, the National Association Kentucky’s Index Program Office EOH, with the leading state achieving of County and City Health Officials, state environmental health leadership, and community-based organizations. The meeting’s purpose was threefold: 1) to identify specific policies, practices, and/or measurement issues contributing to variation and declines within the domain; 2) to discuss policy and practice implications for addressing potential drivers; and 3) to develop strategies for strengthening the domain in ways that can more accurately and completely measure environmental and occupational health contributions to health security. 84 TFAH • healthyamericans.org EXPERT COMMENTARY Local Public Health Responsibilities during Wildfire Emergencies By Dr. Karen Relucio, Chief Public Health Officer, County of Napa Responding to two wildfire events has taught me that public health has a significant role in wildfire emergency response. The role of public health includes shelter assessment, coordinating medical and mental health support in the shelter, ensuring environmental health and safety, and public health messaging. During our first response in September 2015, there was a 75,000 acre fire that destroyed 1,300 structures, resulting in the evacuation of more than 1,000 people, which required us to open and support an evacuation center. The fire was predominantly in Lake County, which is adjacent to Napa County. When something like this occurs, local public health works with our emergency management agency, fire and law, other County agencies and community partners to respond. Immediately, Napa County opened a shelter at the fairgrounds in Calistoga and stood up the emergency operations center. Napa County Public Health took on the responsibility of assessing the health with our local Federally Qualified nonprofits and were able to enlist a needs of most of the evacuees by using Health Center, healthcare providers number of mental health professionals a modified community assessment for from our local medical centers and to come onsite. We quickly found that it public health emergency response Medical Reserve Corps from Napa and was best to do more ad hoc checks and (CASPER). While Red Cross was on neighboring counties to see patients. have the mental health professionals site, they only handled doing health Most of the medical visits involved serve as support staff. They found it was assessments of the people that chose to refilling medications and treating easier to talk to folks—and avoid the stay inside the shelter. Surprisingly, we people who had respiratory issues from stigma that might come with needing had many people show up in cars or RVs smoke inhalation or exacerbation of mental health services. or with their own tents and with pets. underlying health issues (diabetes, Another important aspect of our Because animals were not allowed inside allergies and asthma). Thankfully, response was environmental health. the building, they stayed outside on the there were only a few people with slight These professionals ensured the shelter fairgrounds property. It became our job injuries from the evacuation itself. We was safe and clean and that food was to conduct health needs assessments of also provided flu and Tdap vaccinations. prepared and served safely. They went the majority of the 1,000 evacuees. It was also apparent that mental into the shelter and found donated Additionally, our other role was health needed to be addressed for the food served potluck style, not at the providing medical support within evacuees in a comprehensive way. We appropriate temperature. In addition, the evacuation center. We worked leaned on other local jurisdictions and there weren’t enough hand washing TFAH • healthyamericans.org 85 stations or bathroom facilities and Residential wildfire debris can include Residential wildfire debris can the pets of evacuees were relieving toxic materials such as asbestos, heavy include toxic materials such themselves in areas where people were metals, dioxins and polycyclic aromatic walking. We felt this was a prime setup hydrocarbons that can be harmful to as asbestos, heavy metals, for a gastrointestinal virus outbreak, human health, and cleanup needs to be dioxins and polycyclic aromatic which would make the situation worse. done carefully by experts. At this point, Our folks figured out how to maintain debris cleanup is still underway. hydrocarbons that can be the integrity of food, installed more Additionally, we opened a local harmful to human health, and portable toilets and hand sanitizing assistance center to help those who stations, and provided bags for pet waste. cleanup needs to be done have lost properties, homes, and jobs. carefully by experts. Throughout the response, public health And, there are many crews working on information included a smoke advisory, erosion control in burn areas around heat advisory, and repopulation safety water reservoirs, as we are now having for evacuees once they went back to heavy rains and anticipate debris flow their homes. We also had to ensure and possible water contamination. people knew they shouldn’t sort While we have begun to create an almost through the debris without personal turnkey response plan to wild fires, we protective equipment. could always be better prepared, especially This was great preparation for our for the recovery phase. And, we really need recent fire in October 2017—which to know a lot more about the long-term started at the same time our region was health impact of wildfires. For instance, experiencing hurricane level winds of will we see cancer rates go up? Will health 50 to 90 miles per hour, resulting in inequities be worsened due to loss of rapid spread of the fire to our county homes and income? If so, is that something and Sonoma County. The first 72 hours public health can work to prevent during was focused on evacuations and safety. the response or in the aftermath? We opened three different evacuation We also need more information and centers on that first evening and research on the impact of toxic debris immediately began the plans for the and additional long-term health type of medical coordination that we did consequences as a result of repopulating in 2015. We also coordinated ambulance an area that has suffered wildfire damage. strike teams all over the region to help The only studies that come close to evacuate residential care and skilled looking at long-term health impacts of nursing facilities. fire debris are the 2001 World Trade Center attacks. We can speculate on In many ways our response was similar health impacts based on knowing what is to 2015, except the scope of this contained in ash but, to my knowledge, emergency was much bigger and the there hasn’t been a long-term health recovery is much more complex. We impact study about residential wildfires. It had to declare a local emergency and is hard to make decisions and align future a local health emergency to receive resources when we are uncertain about assistance for toxic ash and debris the long-term effects. cleanup which is still in progress. 86 TFAH • healthyamericans.org I. Supporting Community Resilience — for Communities to Better Cope and Recover from Emergencies — With Better Behavioral Health Infrastructure and Capacity Another of the most difficult challenges in emergency health readiness is how to better prepare communities to mitigate impact and more quickly be able to recover when a disease outbreak, natural disaster or other emergency strikes. Hurricane Katrina provided one of to scale and diffuse strategies and SIX DOMAINS OF the most enduring examples of how engage additional funding support PREPAREDNESS vulnerable members of a community — such as children, the elderly, people from the broader health, business and community sectors themselves. with underlying health conditions or The Public Health Emergency Preparedness Community infrastructure and design Program works to advance six main areas of disabilities, pregnant women and those preparedness so state and local public health are also important for supporting who are lower-income and/or have systems are better prepared for emergencies resilience.264, 265, 266 Public health that impact the public’s health. limited-English proficiency — are often should also be engaged in community the most affected and least prepared and Community Resilience: planning and development, since protected during emergencies.262 Preparing for and recovering from having strategic infrastructure in emergencies The next phase of preparedness place can help prevent and mitigate Incident management: efforts must prioritize how to improve the impact of disasters — and Coordinating an effective response the resilience of all communities. infrastructure and community Information Management: Making sure people have information While building resilience is one of development — such as zoning and to take action two overarching goals identified by community design plans — have an Countermeasures and Mitigation: HHS in the Biennial Implementation ongoing impact on the health and well- Getting medicines and supplies Plan for the National Health Security being of the community. For instance, where they are needed Strategy, there is not sufficient funding supporting greenspaces in communities Surge Management: Expanding medical services to han- or other resources available to provide helps provide buffers during flooding dle large events broad support for efforts.263 Local as well as recreational spaces to support Biosurveillance: health improvement partnerships safe, accessible opportunities for active Investigating and identifying health could be one mechanism for helping living. threats Source: CDC www.cdc.gov/phpr/readiness RECOMMENDATIONS: l P rioritizing the need to improve the identify, plan for (and with), and respond l A ddressing health equity in disaster ability of communities to be resilient to the needs of persons with access and and recovery planning, with a focus on — to be able to cope and recover from functional needs. health outcomes. Preparedness grants emergencies.267, 268 Public, private and should assess and address gaps in l I mproving the overall health status nongovernmental stakeholders must work resilience and preparedness for children, of communities so they are in better together to develop innovative approaches the elderly, people with underlying condition to weather and respond to to build resilience, including leveraging health conditions or disabilities emergencies. Initiatives and programs the assets within the community. and communities of color. Disaster supported by the Prevention and Public preparedness and response needs to l L everage federal, state and local health Health Fund can assist in these efforts be applied equitably and ensure that all data and mapping to better anticipate by promoting health and addressing have access to resources. and plan for the needs of the whole underlying causes of health disparities. community, including by being able to TFAH • healthyamericans.org 87 l C ommunities should have child- care and intensified mental illness. Development (HUD), EPA and private focused disaster planning, so the Recovery grants after disasters or a grants to ensure resilience and planning child-serving infrastructure in states single, flexible grant funding mechanism efforts consider the health equity needs — schools, child care, pediatric should be targeted for delivery of of the whole community. providers and facilities, nutrition, and mental health services and increased, l P roviding job-protected paid sick housing — and emergency managers long-term access to mental and leave. Nearly 40 percent of private- can prioritize the needs of children behavioral health treatment. 271 sector employees — more than during disasters.269 Jurisdictions and l D isaster response research should 41 million workers — cannot earn public health agencies must also include behavioral health impacts paid sick days for their own illness ensure that children with special needs, of disasters and best practices for or injury or to care for an ill family including physical and developmental assuring treatment. member.272 When workers without disabilities, have access to appropriate paid sick leave get sick, they face the care and services. FEMA should l E ngaging members of the community impossible choice of going to work establish interagency agreements to and community-based organizations and potentially infecting others or provide disaster preparedness funding directly in emergency planning efforts. staying home and risking losing their to state and local child-serving systems l I ncorporating community resilience jobs. Allowing employees to stay home and child care facilities.270 considerations into other resilience when contagious is the most basic l P roviding clear, accurate, efforts at the local level. For instance, of outbreak prevention tactics, and straightforward guidance to the building long-term community resilience being able to take off time to receive public in multiple languages, should be integrated into efforts to essential preventive services like including formats for people with address areas such as climate change immunizations and routine screening vision or hearing impairments, via adaptation, infrastructure resilience, can save money in the future from trusted sources respecting different continuity of operations, recovery lost productivity. Some of the very cultural perspectives and delivered from disasters and transportation and industries and occupations that require via multiple media beyond the housing planning following a Health in frequent contact with the public are Internet, such as radio, racial and All-Policies Approach. Communities some of the least like to provide paid ethnic publications and television. should leverage various funding sick days, enabling disease spread streams, such as from FEMA, U.S. through contact with food, co-workers l D eveloping ongoing relationships Department for Housing and Urban and the general public. between health officials and members of the community so they are trusted and understood when emergencies arise. INFOSAGE — ELDER CARE NETWORK273 l A ddressing ongoing behavioral health InfoSAGE, short for “Information in their care network and it allows resources for communities, including Sharing Across Generations,” is a the patient to set different levels of integrating both mental health first new tool created by researchers from access to maintain his or her privacy. aid and long term mental health Harvard Medical School and Beth Available online and via mobile app, treatment into disaster response Israel Deaconess Medical Center the tool helps families keep track of and recovery strategies. Survivors of that helps families of elderly patients appointments and tasks through a natural disasters — especially children communicate and manage caregiving shared network calendar, as well the — may experience enduring mental outside of the hospital. Each as names and dosing instructions of health effects. In addition, those with network is built around one patient medications. underlying mental and behavioral health with connections to every member conditions could face disruptions in 88 TFAH • healthyamericans.org EXPERT COMMENTARY Business and Health Security: The Bottom Line on Preparedness By: Glen P. Mays, PhD, MPH, Scutchfield Endowed Professor of Health Services and Systems Research at the University of Kentucky College of Public Health In the midst of hurricane response and recovery efforts, the National Health Security Preparedness Index convened business and health experts for a robust virtual discussion about how disasters affect the economy, business and communities. We examined how company policies can support a healthy workforce and minimize the impact of unplanned absences, as well as how businesses can prepare for and quickly recover from a disaster. Panelists Christopher Bollinger, University Figure: Webinar Attendees collaboration and a multipronged of Kentucky Gatton College of Business approach, and we were pleased that and Economics; Marc DeCourcey, our participants joined from a variety U.S. Chamber of Commerce 17% of backgrounds. A plurality came from Academia Foundation; Jennifer Esposito, Intel governmental public health, with Corporation; and Lars Powell, Alabama 43% significant representation from the Center for Insurance Information and Government 12% private sector and academia. Public Health Other Research at the University of Alabama, The diversity of our attendees led to offered a range of perspectives on how 9% questions on a wide-range of topics, the private sector plays a pivotal role in Community nonprofits including: community preparedness and response. 19% Private sector l G lobal pandemics are arguably the Results from NHSPI clearly demonstrate only catastrophic threat that can that health security is not simply a simultaneously hit a business’s employees, governmental responsibility.  Individual customers, and suppliers worldwide. businesses and the private sector at collaborating on contingency plans to Do you think most corporate CEOs are large contribute to many of the health avoid large-scale business disruptions; fully aware of the risk and adequately security measures that comprise the l I ncreasing awareness about the need engaged in ensuring that all parts of the Index, such as by offering paid time for preparedness plans among the house (business continuity, HR, medical off and telecommuting options for business community, especially for services) are resourced and supported? employees, promoting vaccination small businesses with little influence Are most companies doing drills? coverage in the workforce, supporting over suppliers; workers who train and volunteer for l A s a Public Health Emergency l H ow business can foster social their local Medical Reserve Corps, and Preparedness Coordinator through a cohesion—often business owners participating in emergency planning Health Department, where should the work closely in the community and and exercises organized by regional line be drawn between helping private will need to rise above competition to healthcare coalitions and networks. businesses to prepare vs. just working recover from an adverse event; towards community preparedness? Panelists shared key insights for both l B usinesses as a catalyst for health and business stakeholders as they volunteerism in their workforce; and How do you handle the moral hazard consider strategies for strengthening aspect of private markets, like healthcare, l H arnessing technology to plan, health security and preparedness that may see these regional treatment respond, and recover, for both large activities, including: facilities as the primary source for and small companies. handling high-consequence pathogens l T he importance of leveraging the We also know health security and and therefore cut down on preparedness supply chain to prepare for events by preparedness require cross-sector and training? TFAH • healthyamericans.org 89 EXPERT COMMENTARY Mental Health is Vital to Preparedness and Response By Dr. Octavio N. Martinez, Jr., MD, MPH, MBA, FAPA, Executive Director, the Hogg Foundation for Mental Health at The University of Texas at Austin The health effects from a public health emergency go way beyond the physical, taking an enormous mental toll in the immediate aftermath and the years following—and often can harm our children the most. We must do more to know how to ensure mental health and physical health go hand-in-hand in response planning and efforts. We must also do a far better job of increasing our mental health workforce and ensuring and increasing access to mental health services both during and after an emergency. Using Data to Plan for Maintaining Access to Mental Health Services To prepare for any type of emergency, communities must be aware of vulnerable populations—typically children, the elderly and those who have an underlying medical condition or are mentally ill. We have gotten katz / Shutterstock.com better at identifying where groups of these populations live. transportation and physical and mental should focus on strengthening families And, we should also be able to access health services, others will struggle. and communities so they are resilient databases to predict what portion The neighborhoods that will struggle enough to weather an emergency. of a certain population might have should be identified in advance and For example, after Hurricane Katrina, substance use disorders, for example— plans created to help them. And, we New Orleans developed community and then understand what kind of can create plans based on any number leaders specifically focused on mental continued treatment and medication of scenarios: fires, floods, wind damage, wellness, resilience and recovery. The are needed and where they might best loss of power, etc. If you combine all the gains in improved access to care and be distributed. knowledge and data together, you can lessened stigma were noticeable—and then coordinate resources and everyone Paired with this, we should be able these should help ensure responders has a chance to be healthy. to identify geographically which and communities can work together communities will have the hardest time to forge a better response during the Long-term Strategies to Improve bouncing back from an emergency and next emergency. Responses to Emergencies will need more resources. While this is by no means a quick We also must acknowledge that human While some neighborhoods might have connections are incredibly important. fix, taking a long-term approach good infrastructure and better access to In-between disasters, preparedness work to emergency preparedness and 90 TFAH • healthyamericans.org community health will pay dividends in improved health of the entire population. We should bring this research to other cities and communities that will likely face similar events. Additionally, psychological effects can take years to manifest and get under control—especially if there isn’t access to mental health services. We learned from Hurricanes Katrina and Sandy that PTSD and suicidal ideation increased dramatically after these events. However, if we were able to step in earlier and connect individuals with mental health professionals, it’s likely these issues and potentially other health issues (substance use disorders, increased anxiety, depression, etc.) could have been prevented or lessened. Further, while we are getting better at recognizing that mental health is a key component to physical While the National Institutes of Health suffering secondary psychiatric distress health, the workforce in this area is has a Disaster Research Response themselves. We need better ways to inadequate—and we’ve known this Project, it needs to better include monitor them during but also after the for a while, especially as the opioid measures on mental health and crisis to ensure they are receiving the epidemic has continued. By increasing substance use disorders. We must take appropriate interventions and care. our workforce and ensuring they each disaster as a learning opportunity have the right skill sets; we could help Part of the solution is increased that can prepare us for the next one and tackle the opioid epidemic and better mental health providers, which would enable us to save more lives. Increasing prepare our communities to bounce serve many roles: keeping our first research would also help build a network back from a disaster. responders in good shape, filling of behavioral health disaster experts. gaps in mental health services and, by Additional Research is Needed First Responders increasing access to care, hopefully The devil is often in the details and preventing someone from developing a Our first responders and volunteers must coordination among the various federal, serious and chronic mental illness. be trained to identify and assist people state and local agencies, organizations who exhibit psychiatric symptoms, i.e., Quite simply, if we intentionally and others must be improved. To in “psychological first aid.” And, going make mental health part of our do so, the nation has to prioritize beyond this training, we know that preparedness and response systems funding into research and assessments mental health must be better integrated it will have untold benefits for post emergencies—so we can truly with the traditional health services. communities before, during and understand how these events affect the mental health and stability of a Responders and volunteers must also after an emergency—we will build community at a population level. be cared for—they are at risk for resiliency and improve well-being. TFAH • healthyamericans.org 91 J. Stopping Superbugs and Antibiotic Resistance Antibiotics have been a groundbreaking achievement in public health, and have greatly reduced illness and death from infections. However, with widespread use over the years, antibiotics have become less effective and there has been the emergence of an increasing number infections that are resistant to antibiotics. Each year in the United States, more than 2 million people become infected and 23,000 die from bacteria that are resistance to antibiotics.274 Experts advise that antibiotic resistance More than 30-Year Void in Discovery of New Types of Antibiotics and the rise and spread of superbugs will 10 continue to grow, unless much greater 9 action is taken. CDC has prioritized 18 9 organisms that that are urgent, serious Number of antibiotic classes discovered or patented 8 or concerning antibiotic resistant threats 7 7 — ranging from Methicillin-resistant No registered Staphylococcus aureus (MRSA) to 6 classes of antibiotic-resistant gonorrhea. Eight 5 5 antibiotics 5 discovered of the organisms listed as urgent or after 1984 4 serious threats are commonly linked with healthcare-associated infections, 3 including C. difficile.275 2 2 l E xperts have found that nearly 1 1 1 1 one-third of the 154 million annual 0 0 0 0 0 0 antibiotic prescriptions written in 1890s 1900s 1910s 1920s 1930s 1940s 1950s 1960s 1970s 1980s 1990s 2000s 2010s doctor’s offices and emergency Source: Pew Charitable Trusts Decade departments are unnecessary.276 Many are prescribed for viral respiratory illnesses that inherently will not including those that make people sick, about 60 percent of phase 3 drugs will respond to antibiotics.277 which has been demonstrated in test be approved by the FDA.282 The last tubes, laboratory animals, and the gut of time scientists discovered a truly new l I n addition, more than 80 percent of human volunteers. antibiotic that made it to market was in antibiotics sold in the United States 1984. It has grown increasingly difficult are used in agriculture (including l T he lack of market incentives for to find new antibiotics, in large part due ionophores not used in human pharmaceutical companies to invest to scientific challenges. Overcoming medicine).278 Pathogens can develop in new antibiotic research and these barriers is key to defeating some antibiotic resistance when food animals development and the difficulty of of the toughest bugs out there: drug- — such as poultry, cattle or swine — answering the scientific questions resistant Gram-negative bacteria. are exposed to antibiotics.279 They can required to defeat the superbugs spread to humans through consumption contribute to the problem. Antibiotics l A number of efforts are also aimed at of food animal products, direct contact typically are used for a short period addressing scientific road blocks to with infected animals or contact with of time and at a low cost, compared advancing antibiotic research, such environmental sources, such as water to more profitable drugs. As of May, as the Shared Platform for Antibiotic and soil contaminated by animal waste 2017, only 41 new antibiotics were in Research and Knowledge, which runoff.280  Additionally, bacteria of development, 11 of which had reached is a dynamic information-sharing animal origin can readily share resistance phase 3 testing and two of which had platform supported by The Pew traits with other types of bacteria, completed phase 3. 281  Historically, Charitable Trusts.283 92 TFAH • healthyamericans.org RECOMMENDATIONS: l F ully funding and implementing the l F unding research for non-antibiotic l S trengthening surveillance and tracking Combating Antibiotic Resistant strategies in animal agriculture. How of resistant bacteria and infections. Bacteria (CARB) strategy, including animals are housed, fed, and raised Congress and CDC must continue to invest CDC’s Antibiotic Resistance Solutions affects their health and thus the need for in our public health infrastructure to enable Initiative. The initiative is designed antibiotics. Improving animal husbandry the detection and control of drug resistant to fully implement the priority public practices—such as the age at which outbreaks. National programs to identify health actions identified in the National pigs are weaned or the type of flooring emerging patterns of both resistance and Action Plan for Combating Antibiotic used in animal areas—and adopting antibiotic use will quantify the magnitude Resistant Bacteria, including slowing alternative interventions, such as of antibiotic use in the United States and the emergence of resistant bacteria, vaccines, probiotics, or prebiotics, can inform new interventions. Requirement preventing the spread of infections, and reduce the risk of disease. Additional of data on antibiotic use and resistance strengthening surveillance.284 federal funding is needed to research, will be essential for surveillance (i.e. develop, and adopt husbandry practices NHSN modules for use and resistance). l I ncentivizing the development of and alternative interventions that reduce Sustained funding and continued support new antibiotics and new diagnostic the need for routine antibiotics. to state and local health departments tests for resistant bacteria. There implementing CDC’s Antibiotic Resistance should be investment in antibiotic l R educing over-prescription of Laboratory Network (AR Lab Network) to discovery science, early stage product antibiotics through implementation of provide rapid detection of and response development and research through antibiotic stewardship. The Centers to emerging resistance threats, next BARDA, public-private partnerships for Medicare and Medicaid Services generation surveillance in ARLN/ such as CARB-X and other programs. (CMS) should finalize and implement PulseNet laboratories and whole genome Partners should also work together to requirements for all CMS-enrolled sequencing to rapidly uncover foodborne develop a model of delinking antibiotic facilities to have effective antibiotic drug-resistant bacteria, including reimbursement from sales so drug stewardship programs that align foodborne pathogens, as well as effective developers are incentivized to innovate with CDC’s core elements guidance dissemination of data collected, will be despite efforts to conserve antibiotics.285 and work with public health to track critical for realizing the impacts of this progress in prescribing rates and l R educing overuse of antibiotics in initial federal investment in antibiotic resistance patterns. HHS should help agriculture. The FDA should build on resistance surveillance. There should be develop quality measures that assure this year’s elimination of antibiotic increased coordination between human appropriate prescribing of antibiotics.  use for growth promotion and further health, animal health and agriculture — HHS, CMS, accrediting organizations, increased veterinary oversight by across public health agencies and USDA healthcare facilities, medical schools enforcing requirements for the collection and state departments of agriculture. and others should educate providers and publishing of species-specific use and patients about the harm of l S trengthen global commitments to data, ensuring medically important inappropriate prescribing. antibiotic stewardship and surveillance. antibiotics in food animals meet judicious As part of the Global Health Security use principles, ensuring adherence to l P reventing and stopping the spread of Agenda, participating countries should requirements for veterinary oversight on infections and improve antibiotic use commit to implementing regulations and the farm, promoting antibiotic stewardship in every state. CDC should continue performance targets for reducing overuse programs and tracking the impact of expanding implementation of public of antibiotics in humans and animals, these policies on trends in resistance and health-healthcare prevention networks preventing spread of resistant bacteria antimicrobial use in agriculture. Farmers in every state to improve identification through infection prevention and control, and the food industry should stop using and response to all emerging threats and safely sharing data on resistance patterns medically important antibiotics to promote implement proven strategies in healthcare and detection of threatening pathogens, growth and prevent disease in healthy facilities to prevent infections and and funding less resourced countries for animals, as recommended by the WHO.286 transmission across healthcare settings. stewardship and surveillance. TFAH • healthyamericans.org 93 l P reventing infection by improving l H ealthcare Infection Prevention and • ollaborating on the detection and C vaccination rates for children and Control. Despite years of progress, control of outbreaks. Each healthcare adults. Despite their effectiveness, healthcare providers do not routinely facility working alone cannot prevent, vaccination rates remain low in many adhere to standard infection control track or contain the spread of communities across the United practices that have been shown to Superbugs. Public health needs to be States — especially among adult prevent healthcare-associated infections the backbone organization in a state populations — and reducing disease and reduce transmission of highly or region to coordinate prevention rates can lower the need for use of resistant bacteria and resistant fungal among competing or disparate antibiotics. For example, viral respiratory infections like Candida auris. On any healthcare systems and contain infections, such as the flu, that are given day, one in 25 people in the potential outbreaks, such as in the often mistakenly treated with antibiotics, hospital has an HAI, and over the course model supported by CDC’s Antibiotic would be reduced.287 Federal, state and of a year, around 75,000 people with Resistance Solutions Initiative. Private local health officials, in partnership with HAIs die during their hospitalizations. healthcare also needs to be seen medical providers, health care systems as part of a coordinated response, • Every hospital should have minimum and community organizations, should recognizing the importance of public baseline screening practices, including continue to expand assertive campaigns health led efforts in implementing travel history; isolation capabilities to about the importance of vaccines, regional antimicrobial resistance ensure patients and healthcare workers particularly stressing and demonstrating control. Barriers to everyday are safe from a potential threat; regular the safety, benefits and efficacy of coordination in the private healthcare training on infectious control practices immunizations. They also should rely system, such as competition, and use of protective gear; routine on trusteed sources to do outreach should be addressed and managed monitoring of adherence to important to high-risk groups and to racial and for emergency preparedness and prevention practices, like environmental ethnic minority populations where the response — which is one of the roles cleaning and hand hygiene; and misperceptions and mistrust about and values that HCC provides through procedures for removal and disposal of vaccines are particularly high. 288 regional coordination. protective gear and waste. HEALTHCARE-ASSOCIATED INFECTIONS Approximately 1 out of every 25 hospitalized patients will HAIs cost the country $28 billion to $33 billion in preventable contract a healthcare-associated infection, which is an infection healthcare expenditures each year.291 Prevention and education patients can get while receiving medical treatment in a efforts have been helping to decrease the rates of HAIs. CDC, healthcare facility. 289 Healthcare-associated infections not only the Centers for Medicare and Medicaid Services (CMS), states happen in hospitals but can also occur in outpatient surgery and medical providers have launched a series of provider centers, nursing homes and other long-term care facilities, education and prevention initiatives.292 Many states are rehabilitation centers, community clinics or physicians’ offices. seeing decreases in HAIs. For instance, between 2008 and 2014, there were 50 percent fewer central line-associated A person’s risk for an HAI, which includes a range of drug- bloodstream infections and 17 percent fewer surgical site resistant infections, increases if they are having invasive infections related to 10 surgical procedures in in-patient surgery, if they have a catheter in a vein or their bladder, or if healthcare settings.293 they are on a ventilator or a prolonged course of antibiotics as part of their care.290 94 TFAH • healthyamericans.org K. Improving Vaccination Rates — for Children, Teens and Adults Vaccines are the safest and most effective way to prevent many infectious diseases. 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.294 A model estimated that from 1994-2013 the Vaccines for Children program in the United States will have prevented as many as 322 million illnesses, 21 million hospitalizations and 732,000 deaths at a net savings of $1.38 trillion in societal costs.295 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.296 Millions of Americans are not receiving the recommended vaccinations. For instance, more than 2 million preschoolers do not receive recommended vaccinations; there have been outbreaks of measles, mumps and whooping cough around the country; vaccination gaps put teens and young adults at risk for HPV and bacterial meningitis; and more than 38 percent of seniors have not received setting. Significant numbers of adults do the recommended pneumococcal not have regular well care exams, switch vaccination.297, 298, 299 doctors or health plans often or only seek care from specialists who do not While many efforts focus on vaccines traditionally screen for immunization for children, it is also important to histories or offer vaccines. This makes address the fact that currently, there is it extremely difficult to establish ways no real system or structure in place to for people to know what vaccinations ensure adults have access to or receive they need and for clinicians to track and the vaccines they need unless they are recommend vaccines to patients. part of institutions that have vaccine requirements, such as being enrolled Improving the nation’s vaccination rates in colleges or universities, serving in would help prevent disease, mitigate the military or working in a healthcare suffering and reduce healthcare costs. TFAH • healthyamericans.org 95 RECOMMENDATIONS: l M inimizing vaccine exemptions immunizations or refer their patients for school children. States should to providers who can administer these enact and provide universal childhood needed immunizations; and document vaccinations to ensure children receive administration of adult immunizations required vaccinations to help protect using an Immunization Information themselves, their classmates and System. Training is also needed for educators from diseases (except providers to ensure they are able to where immunization is medically effectively educate patients and make contraindicated). Non-medical vaccine a strong recommendation for vaccines exemptions, including personal belief across the lifespan. exemptions (PBE), enable higher l M aking adult vaccinations routine, rates of exemptions — and reduce including regular screenings and vaccination coverage — in those states referrals. Private providers and health that allow them. School exemption systems should have standing orders for rates should also be made publicly vaccinations so every provider of care available so parents and educators for adults can to assess the need for understand the risks. The National vaccinations, to recommend and directly Vaccine Advisory Committee (NVAC) administer and either provide directly or recommends states with existing PBE refer to another provider for vaccination. policies should strengthen policies Vaccine locator systems should be so that exemptions are only available enhanced to be integrated with other after appropriate parent education and electronic health records to build a acknowledgement of risks to their child comprehensive vaccine referral system and the community.300 where providers can identify quantities l B oosting demand for vaccines. Federal, of available vaccine and track whether state and local health officials, in the patient received the vaccine. A partnership with medical providers routine adult vaccination schedule and community organizations, should should be established, where healthcare continue to expand assertive campaigns providers are expected to purchase, about the importance of vaccines, educate, advise about and administer particularly stressing and demonstrating immunizations to patients. the safety and efficacy of immunizations. l E xpand access to vaccinations to Targeted outreach should be made reduced missed opportunities. School- to high-risk groups and to racial and located vaccination clinics can be used ethnic minority populations where to provide catch-up immunizations for the misperceptions about vaccines school-entry, reach adolescents and are particularly high.301, 302 The NVAC young adults, and deliver seasonal adopted Adult Immunization Practice influenza vaccination. An increasing Standards should be adopted by all number of adults receive vaccination healthcare providers and systems through alternate locations including to ensure all providers, including to pharmacies and in the workplace. assess immunization needs of their Obstetricians and midwives play adult patients; strongly recommend a critical role in providing credible needed immunizations to adults; information to pregnant women and properly administer these needed adult administering recommended vaccines. 96 TFAH • healthyamericans.org l B olstering immunization registries and tracking. Federal and state policymakers should take steps to facilitate reporting of immunization encounters and interoperability and data use between immunization registries and EHRs as well as between state and jurisdictional immunization registries. This will help track when patients receive vaccines, improve information sharing and data integrity across providers, remind providers to routinely provide recommended vaccinations, remind patients of needed vaccinations and address gaps. State health information exchanges or hub models that have supportive policies and procedures to encourage bi- directional data exchange may make this process simpler by encouraging integration of registry data with EHRs. Resources should be available to build capacity of Immunization Information Systems (IIS) and conduct outreach to encourage providers to participate in registries — and IIS systems should be linked to school vaccination reporting. States should also review and adapt statutes to require reporting or enable opting-out of adult registries. l I ncreasing provider education. Parents and patients frequently identify healthcare providers as their trusted source for information about immunizations. Training is needed for healthcare providers to ensure they are able to effectively educate patients and make a strong recommendation for vaccination across the lifespan. Scientific improvements in vaccine manufacturing can quickly change the landscape of recommended immunizations. Professional healthcare associations should provide ongoing education and routine communication to their members. Medical, nursing, pharmacy and allied health schools Source: CDC TFAH • healthyamericans.org 97 should expand their training curricula will likely face a co-payment that can has led to a surge of acute hepatitis on vaccines and vaccine-preventable vary by plan and vaccine, presenting a B cases — a vaccine-preventable diseases to strengthen a provider’s significant barrier for seniors. disease — with an increase of 20.7 ability to reduce missed opportunities by percent in 2015 alone.305 Public health l R equiring on-time immunizations — routinely assessing, recommending and and healthcare providers must include based on the medically-recommended administering immunizations. vaccination, testing and linkages to vaccines for a person’s age and care for hepatitis B, hepatitis C and l S upporting expanded research health status — as a quality measure HIV as part of the response to the and use of alternatives to syringe for all health plans. opioid epidemic. administration of vaccination. l C ontinuing support for vaccine Alternative delivery methods, such as l R equiring universal immunization of programs: The Vaccines for Children intradermal patches, could help address healthcare personnel for all ACIP (VFC) and CDC’s Section 317 issues around vaccine shortages, recommended vaccinations. The immunization programs provide a storage and stability, particularly for Infectious Diseases Society of safety net for individuals who are global vaccination efforts.303, 304 American (IDSA), the Society for uninsured or remain outside of the Healthcare Epidemiology of American l E nsuring first dollar coverage and traditional healthcare system, such (SHEA) and the Pediatric Infectious access to all recommended vaccines as children who are eligible but not Diseases Society (PIDS) support under Medicaid, Medicare and private enrolled in Medicaid/State Children’s universal immunization of healthcare insurance. All public and private Health Insurance Program (CHIP). The personnel (HCP) by healthcare payers should ensure that all ACIP- CDC immunization program’s grants to employers (HCE) as recommended recommended vaccines are covered states have also been key to building by ACIP According to a joint policy . without cost sharing requirements. the immunization infrastructure, statement by the three Societies, All insurance plans should consider including enhancing registries, mandatory immunization programs are pharmacies and other complimentary monitoring the safety and effectiveness the most effective way to increase HCP providers as important immunizers of vaccines, responding to outbreaks vaccination rates.306 The Societies and should be considered in-network and conducting surveillance, outreach also support requiring comprehensive and receive equal payment for vaccine and service delivery. educational efforts to inform HCP about administration services for their adult l M aking outbreak prevention part of the benefits of immunization and risks and pediatric populations. State the public health response to the of not maintaining immunizations. Medicaid programs are not currently opioid epidemic. The opioid epidemic required to offer all recommended adult vaccinations without co-payments. While some states offer coverage of all recommended vaccines, some do EXAMPLES OF VACCINE PREVENTABLE DISEASES not. And, many have co-payments, Anthrax, Sequelae of Hepatitis B Measles, Meningococcal disease, which present a significant cost barrier. Infection (including Liver Cancer), Mumps, Pertussis (Whooping cough), Medicare also does not consistently Diphtheria, Haemophilus influenza Pneumococcal disease, Polio, Rabies, provide first dollar coverage for all type b (Hib), Hepatitis A, Hepatitis B, Rotavirus, Rubella, Smallpox, Tetanus, vaccines, and the different policies Sequelae of Human Papillomavirus Typhoid Fever, Varicella (Chickenpox), dictate what is covered under Part (including Cervical Cancer), Influenza Yellow Fever and Zoster (Shingles). B and Part D, leaving many seniors (flu), Japanese Encephalitis, with gaps in coverage. Those who do 98 TFAH • healthyamericans.org L. Protecting Food and Water Safety Every year, an estimated one in six Americans suffer from a foodborne illness.307 Of those, around one million will suffer from long-term chronic complications, such as kidney failure or brain and nerve damage.308 Foodborne illnesses are responsible for around 128,000 hospital visits and kill approximately 3,000 persons each year.309 Young children, older adults, and people with compromised immune systems are most at risk for serious illness. Norovirus is the most common cause of foodborne illnesses and outbreaks, causing an estimated 5.5 million illnesses and about 37 percent of outbreaks.310 Foodborne norovirus outbreaks are most commonly due to the handling of ready-to-eat foods by infected persons who did not wash their hands after using the toilet. Salmonella is the leading cause of hospitalizations and deaths from foodborne disease in the David Litman / Shutterstock.com United States, causing an estimated 19,000 hospitalizations and 378 deaths to significant economic losses in the l F oreign Supplier Verification annually.311 According to CDC data, the agriculture and food-related industries, Program for food importers to assure food categories responsible for the most which contribute $985 billion to the U.S. that imported food meets U.S. safety outbreak-associated illnesses during 2015 gross domestic product (GDP) in 2014, a standards.317 were seeded vegetables (e.g. cucumbers), 5.7 percent share.315 A 2011 CDC study The FY 2016 appropriations bills pork, and vegetable row crops (e.g. found that Salmonella infections alone are included an additional $104.5 million in lettuce and spinach). Salmonella caused responsible for an estimated $365 million new budget authority for implementing most of the illnesses in each of these in direct medical costs annually, and the FDA food safety rules.318 three food categories. In 2017, Cyclospora number of infections had not decreased cayetanensi, a microscopic parasite, in the 15 years prior to the study.316 In 2017, the Interagency Food Safety has caused outbreaks of diarrheal Analytics Collaboration (IFSAC) — a Most foodborne illnesses could be illness linked to fecal contamination of partnership created in 2011 between avoided with a stronger U.S. food safety imported produce items — 1,065 cases as CDC, FDA and USDA — issued a new oversight system. In 2015, FDA finalized of October 4th.312 Food Safety Analytics Strategic Plan several major rules implementing for 2017-2021. Its efforts focus on According to the U.S. Department portions of the FDA Food Safety four priority pathogens: Salmonella, of Agriculture’s (USDA) Economic Modernization Act (FSMA): E. coli O157:H7, Listeria monocytogenes, Research Service, E. coli costs the United l P reventive Controls for Human and Campylobacter, which CDC estimates States over $271 million a year, and a Foods and Preventive Controls for together cause 1.9 million cases of 2015 study found that 15 foodborne Animal Foods, which require covered foodborne illness in the United States pathogens alone are estimated to cost facilities to analyze potential hazards each year. The three goals of the new the country $15.5 billion in per year.313 and implement risk-based preventive strategic plan are to improve the use This estimate includes medical costs controls in their production processes; and quality of new and existing data (doctor visits and hospitalizations) sources; improve analytic methods and and productivity loss due to premature l P roduce Safety, which establishes models; and enhance communication death and time lost from work.314 standards for growing, harvesting, about IFSAC progress.319 Major outbreaks can also contribute packing and holding of produce; and the TFAH • healthyamericans.org 99 WATER SAFETY AND SECURITY Waterborne illnesses also pose serious threats to America’s health each year. While water-related illnesses are underreported, studies have reported estimates of nearly 82,000 annual hospitalizations, 477,000 annual emergency department visits, and nearly 7,000 deaths each year from diseases that can be transmitted by water.320 From 2013-2014, 42 drinking-water associated outbreaks were reported to CDC, resulting in at least 1,006 cases of illness and 13 deaths. There have been a number of recent major water crises that demonstrate the harmful impact that unsafe water can have on health and for communities when they do not have access to safe water. Some of these have required coordinated multisector emergency supply for around 300,000 people, water; nearly all healthcare functions are responses. For instance: where many were unable to use their degraded within two hours.327 l I n Puerto Rico, following Hurricane tap water for weeks to months.324, 325 According to CDC, lead exposure remains Maria, millions of residents lost In their annual Infrastructure Report a health concern for young children in access to clean drinking water, some Card, the American Society for Civil the United States. Risk varies across for many weeks. Unclean water led to Engineers gave U.S. drinking water the country, but because there are often widespread acute medical problems, infrastructure a Grade D+ based on no obvious symptoms, the exposure including vomiting, diarrhea, scabies identified need to repair and maintain frequently goes unrecognized. In addition, and asthma.321 There were at least 76 aging drinking water distribution only around 10 percent of schools with suspected cases of leptospirosis, a pipes and water systems, and reduce their own water systems are required to bacteria, including several deaths.322 the estimated 240,000 water main test for lead (350 of which failed lead l I n Flint, Michigan, a change in the breaks that occur each year. 326 Security tests from 2012 to 2015), and federal law water supply in 2014 led to tens professionals also raise concerns about does not require schools using local public of thousands of residents exposed protecting water systems from potential water suppliers to test the water.328 Even to high levels of lead and other biological and chemical terrorism low levels of lead in children’s blood have toxins that are harmful to health, attacks, including of agricultural water been shown to affect intelligence, ability to particularly the health of young supplies and emphasize the importance pay attention and academic achievement. children and babies during pregnancy. of water for other community systems. The CDC found that young children Security professionals also raise A National Infrastructure Advisory who drank the water had significantly concerns about protecting from potential Council report highlighted that nearly high blood lead levels. 323 biological and chemical terrorism all critical infrastructure depends on attacks on water supplies, including of l I n Charleston, West Virginia in 2014, a water. Services are severely degraded agricultural water supplies. chemical spill contaminated the water within eight hours after loss of drinking 100 TFAH • healthyamericans.org RECOMMENDATIONS: l F ully funding and implementing the of Salmonella infection, there are 29 • niform standards for retail food U FDA Food Safety Modernization Act. unreported cases, and for every E.coli safety that reduce complexity and Sufficient funding should be devoted O157-H7 case there are an estimated better ensure compliance. at the federal and state levels to be 26 unreported cases.329 New standards • he elimination of redundant processes T able to implement and enforce the law. and requirements should be put in place for establishing food safety criteria. FDA should ensure public health is to incentivize states to improve reporting. the top priority as it implements FSMA Surveillance for foodborne illness • he establishment of a more T prevention-based rules. FDA should also outbreaks should be fully integrated standardized approach to inspections track implementation of these rules to with other HIT systems, which will help and audits of food establishments. ensure that proposed exemptions do not improve tracking and identification of the l A ssuring clean water for all Americans, increase risk from foodborne illness. scope of problems as well as sources especially after disasters. All states of outbreaks. As public health moves l M oving toward a more unified should include water preparedness and toward genome sequencing of foodborne government food safety approach. The sewage removal in their preparedness pathogens, federal and state policymakers federal government currently does not plans, including building relationships should ensure adequate workforce and have a coordinated, cross-governmental between health departments and local infrastructure investment for the transition approach to food safety.  Right now, food environmental and water agencies to modern detection systems. FDA and safety activities are siloed across a range that oversee water security and safety. CDC should also have a plan for requiring of agencies, and many priorities and CDC should include national guidance clinics to send cultures and/or specimens practices are outdated and inconsistent.  and metrics for planning for a range of from rapid culture-independent response Better organization and coordination water-related crises. Measures should tests showing positive results to public within and between federal food safety be taken to protect a safe water supply health labs to allow for subtype pathogen agencies would improve public health.  for all Americans, including addressing testing.330 In the longer term, the Administration the ongoing problem of lead and other should develop a plan with a set timeline l A dopting FDA’s Food Code toxins in the drinking water in some for how to restructure food safety recommendations — a uniform system communities, and taking measures, functions across the federal government of food safety provisions for food service, such as those in the Environmental — potentially consolidating them within retail food stores, or food vending Protection Agency (EPA)’s Clean Water a single, unified food safety agency — to operations in local, state and federal Rule, to reduce the potential for better carry out a prevention-focused, jurisdictions. Data consistently identify waterborne illnesses and increase integrated strategy.  One part of this five major risk factors that contribute to protection against potential acts of plan, which is the logical next step foodborne illness: 1) improper holding drinking and agricultural water-related after FSMA, should be to modernize the temperatures; 2) inadequate cooking, biological and chemical terrorism. meat and poultry laws so that they are such as undercooking raw shell eggs; 3) l S trengthening environmental health more risk-based and science-based and contaminated equipment; 4) food from and integrating into preparedness protective of public health. This same unsafe sources; and 5) poor personal and response. Environmental health type of coordinated, cross-governmental hygiene.331 FDA describes the benefits professionals work at local level approach to food safety is also needed associated with the 2013 Food Code’s to ensure safe water, food and within each state. complete and widespread adoption to environments before and after disasters, include:332 l I mproving surveillance of foodborne and mitigate hazards such as mold, illnesses. Currently, foodborne illnesses • Reduction of the risk of foodborne mosquitos, and contaminated food and are radically underreported in the United illnesses within food establishments, water. State and local public health States and the quality of reporting varies thus protecting consumers and industry should ensure environmental health is dramatically by state. For example, from potentially devastating health incorporated into emergency operations CDC estimates for every reported case consequences and financial losses. planning and incident command. TFAH • healthyamericans.org 101 A P P E NDIX Ready or Not? APPENDIX APPENDIX A: State Public Protecting the Health Budget Methodology Public’s Health TFAH conducted an analysis of state or other state funds (e.g. dedicated spending on public health for the last revenue, fee revenue, etc.), was used. from Diseases, budget cycle, fiscal year 2016-2017. Because each state allocates and reports Several states only report their budgets Disasters and in biennium cycles; in those cases, its budget in a unique way, comparisons across states are difficult. This an average year from the budget that Bioterrorism includes FY 2016-2017 was used (for methodology may include programs that, in some cases, the state may North Dakota, Oregon and Washington consider a public health function, but that was the 2015-2017 biennium budget the methodology used was selected to and for Wyoming that was the 2017-2018 maximize the ability to be consistent budget). The percent change in budget across states. As a result, there may be for these four states was calculated from programs or items states may wish to be the last biennium budget. considered “public health” that may not This analysis was conducted September- be included in order to maintain the October of 2017 using publicly comparative value of the data. available budget documents through Finally, to improve the comparability state government web sites. Based of the budget data between FY 2015- on what was made publicly available, 2016 and FY 2016-2017 (or between budget documents used included biennium), TFAH adjusted the FY 2016- either executive budget document that 2017 numbers for inflation (using a listed actual expenditures, estimated 0.976 conversion factor based on the U.S. expenditures, or final appropriations; Dept. of Labor Bureau of Labor Statistics; appropriations bills enacted by the Consumer Price Index Inflation state’s legislature; or documents from Calculator at http://www.bls.gov/cpi/).   legislative analysis offices. After compiling the results from this “Public health” is defined to broadly online review of state budget documents, include all health spending with TFAH coordinated with the Association the exception of Medicaid, CHIP, of State and Territorial Health Officials or comparable health coverage (ASTHO) to confirm the findings with programs for low-income residents. each state health official.  ASTHO sent Federal funds, mental health funds, out emails on October 21, 2017 and state addiction or substance abuse-related health officials were asked to confirm funds, WIC funds, services related to or correct the data with TFAH staff by developmental disabilities or severely November 10, 2017.  TFAH and ASTHO disabled persons, and state-sponsored followed up via email with those state DECEMBER 2017 pharmaceutical programs also were not health officials who did not respond by included as best as possible in order the November 10, 2017 deadline. New to make the state-by-state comparison Mexico did not respond by December 6, more accurate since many states receive 2017 when the report went to print and federal money for these particular the most recent publicly available data programs. For most states, all state was used.  funding, regardless of general revenue Endnotes 1 adrigal A. “The Houston Flooding M 9 ice D. Sergent J. Petras G. Loehrke J. R 17 Rasmussen, S.A. et al. Zika Virus and Pushed the Earth’s Crust Down 2 Centi- “2017 could tie record for billion-dollar Birth Defects — Reviewing the Evidence meters”. The Atlantic September 5, 2017. disasters in a year. Here’s why”. USA Today. for Causality. N Engl J Med 2016; 374:1981- https://www.theatlantic.com/technology/ https://www.usatoday.com/story/weath- 1987. 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TFAH • healthyamericans.org 107 139 Institute for Women’s Policy Research. 148 ountermeasure management includes C 154 We base our estimate and analysis on the Paid Sick Days Access and Usage Rates Vary several measures that account for pro- U.S. Census, Current Population Survey, by Race/Ethnicity, Occupation, and Earn- grams, products, and systems necessary July 2015, Computer and Internet Use ings. February 2016. https://iwpr.org/ to be prepared for, protected from, and File. We limit our analysis to heads of wp-content/uploads/wpallimport/files/ resilient against chemical, biological, household between 25 and 54 years old, iwpr-export/publications/B356.pdf (ac- radiological, nuclear, and explosives the prime working age population. cessed November 2017). (CBRNE) agents and emerging infec- 155 We use two different, but similar, models tious disease threats. 140 Drago R and Miller K. Sick at Work: In- for PTO, household broadband, and fected Employees in the Workplace During the 149 usan Cutter, et al., “The geographies of S telecommuting. Both models include H1N1 Pandemic. Washington, D.C.: Insti- community disaster resilience,” Global En- dichotomous variables for income quar- tute for Women’s Policy Research, 2010. vironmental Change 29 (2014), pp. 65-77. tiles, educational attainment, race, resi- http://www.iwpr.org/pdf/B284sick-at- dence, age, and gender. The PTO model 150 ncident & Information Management I work.pdf (accessed November 2015). also include dichotomous variables for reflects the ability to: mobilize all critical 14 industrial sectors, ranging from agri- 141 Kumar S, Grefenstette JJ, Galloway D, resources from any source; establish and culture to public administration. Albert SM, Burke DS. Policies to Reduce maintain command, control, and coor- Influenza in the Workplace: Impact As- dination structures within the affected 156 lonzo L. Plough, “The Impact of Cli- A sessments Using an Agent-Based Model. community; provide necessary legal, ad- mate Change on Health and Equity,” American Journal of Public Health, 103(8): ministrative, and logistical support; and June 22, 2016, Robert Wood Johnson 1406-1411, 2013. exchange multijurisdictional, multidis- Foundation http://www.rwjf.org/en/ ciplinary public health and medical-re- culture-of-health/2016/06/what_does_ 142 Mao et al, Annual economic impacts lated information, intelligence, plans, climatech.html. of seasonal influenza on US counties: and situational awareness. Spatial heterogeneity and patterns. In- 157 amila Taylor, “What the Media and J ternational Journal of Health Geographics, 151 ew Research Center, Pathways P Congress Are Missing on Zika and Pov- 11(16), 2012. to news, http://www.journalism. erty,” May 24, 2016, https://talkpoverty. org/2016/07/07/pathways-to-news/. org/2016/05/24/media-congress-miss- 143 eipins LA, Soman A, Berkowitz Z, White P ing-zika-poverty/. MC. The lack of paid sick leave as a 152 e pool five years of U.S. Census, Cur- W barrier to cancer screening and medical rent Population Survey, Annual Social 158 lue Ribbon Study Panel on Biodefense. B care-seeking: results from the National and Economic (ASEC) Supplement data A National Blueprint for Biodefense: Health Interview Survey. BMC Public (2012-2016) and limit our sample to prime Leadership and Major Reform Needed Health, 12(1):520, 2012. working age adults, 25 to 54 years old. Our to Optimize Efforts. Washington, DC: estimate of 62 percent is similar to another Hudson Institute, 2015, pg. vii. https:// 144 Paid Family and Medical Leave: An Over- that uses a different method and data s3.amazonaws.com/media.hudson. view. National Partnership for Women set—the March 2016 Bureau of Labor org/20151028ANATIONALBLUE- and Families. http://www.national- Statistics National Compensation Survey PRINTFORBIODEFENSE.pdf (accessed partnership.org/research-library/ (NCS). The 2016 NCS data estimates 68 August 2016). work-family/paid-leave/paid-fami- percent of workers have paid sick leave, ly-and-medical-leave.pdf (accessed No- 159 Ziemer, T. “Securing Global Health 73 percent have paid vacation, and 75 per- vember 2017). through U.S. Leadership.” In White cent have paid holidays. For more infor- House. https://www.whitehouse.gov/ 145 Preemptions Watch: Paid Sick Days. Grass- mation on the NCS see Employee Benefits blog/2017/10/23/securing-glob- roots Change. https://grassrootschange. Survey http://www.bls.gov/ncs/ebs/. al-health-through-us-leadership (accessed net/preemption-watch/#/category/ 153 These estimates are derived from the U.S. November 2017) paid-sick-days (accessed November Census, Current Population Survey, July 2017). 160 ublic Health Preparedness Capabilities: P 2015, Computer and Internet Use File, National Standards for State and Local 146 Robert Drago and Kevin Miller, “Sick at and is estimated from the variable PE- Planning. U.S. Centers for Disease Work: Infected Employees in the Work- TELEWK: What about telecommuting, or Control and Prevention. March 2011. place During the H1N1 Pandemic,” Insti- working while away from (you/his/her) http://www.cdc.gov/phpr/capabilities/ tute For Women’s Policy Research Briefing usual workplace? (Do you/Does NAME) DSLR_capabilities_July.pdf (accessed Paper, IWPR No. B264, February 2010. use the Internet to telecommute or work November 2016). while away from (your/his/her) usual 147 See Anne M. 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