Embargoed until Ready or Not: ISSUE REPORT 10:00 am ET on Tuesday, December 19 2019 PROTECTING THE PUBLIC’S HEALTH FROM DISEASES, DISASTERS AND BIOTERRORISM FEBRUARY 2019 Acknowledgements Trust for America’s Health (TFAH) is a nonprofit, nonpartisan The Ready or Not report series is supported by generous grants public health policy, research, and advocacy organization that from the Robert Wood Johnson Foundation. Opinions in this promotes optimal health for every person and community and report are those of TFAH’s and do not necessarily reflect the views makes the prevention of illness and injury a national priority. of the foundation. TFAH BOARD OF DIRECTORS Gail Christopher, DN Stephanie Mayfield Gibson, MD John Rich, MD, MPH Chair of the TFAH Board Senior Physician Advisor and Population Health Co-Director President and Founder, Ntianu Center for Consultant Center for Nonviolence and Social Justice Healing and Nature Drexel University Cynthia M. Harris, PhD, DABT Former Senior Advisor and Vice President Director and Professor Eduardo Sanchez, MD, MPH W.K. Kellogg Foundation Institute of Public Health, Florida A&M University Chief Medical Officer for Prevention and Chief of David Fleming, MD the Center for Health Metrics and Evaluation David Lakey, M.D. Vice Chair of the TFAH Board American Heart Association Chief Medical Officer and Vice Chancellor for Vice President of Global Health Programs Health Affairs Umair A. Shah, MD, MPH PATH The University of Texas System Executive Director Robert T. Harris, MD Harris County, Texas Public Health Octavio Martinez, Jr. MD, DrPH, MBA, FAPA Treasurer of the TFAH Board Executive Director Vince Ventimiglia, JD Senior Medical Director Hogg Foundation for Mental Health Chairman, Board of Managers General Dynamics Information Technology The University of Texas at Austin Leavitt Partners Theodore Spencer Karen Remley, MD, MBA, MPH, FAAP Secretary of the TFAH Board Former CEO and Executive Vice President Senior Advocate, Climate Center American Academy of Pediatrics Natural Resources Defense Council REPORT AUTHORS Rhea K. Farberman, APR TFAH wishes to recognize and thank Glen Mays, PhD, MPH and Michael Childress, Director of Strategic Communications and Policy MS of the University of Kentucky’s National Health Security Preparedness Index Research (NHSPI) for their collaboration and expertise. Ready or Not and the NHSPI, both Dara Alpert Lieberman, MPP supported by the Robert Wood Johnson Foundation, are complementary projects Director of Government Relations working together to measure and improve the country’s health security and Matt McKillop, MPP emergency preparedness. TFAH looks forward to a continued partnership. Senior Health Policy Researcher and Analyst John Auerbach, MBA President and CEO PEER REVIEWERS This report benefited from the insights and expertise of the following external reviewers. Although CONTRIBUTORS they have reviewed the report, neither they nor their organizations necessarily endorse its findings or Kendra May, MPH conclusions. Consultant E. Oscar Alleyne, DrPH, MPH Asha M. George, DrPH Zarah Ghiasuddin Senior Advisor for Public Health Programs Executive Director TFAH Intern National Association of County and City Health Blue Ribbon Study Panel on Biodefense Officials Elizabeth Jungman, MPH, JD This edition of Ready or Not was published in James S. Blumenstock Director, Public Health 2019 based on data available in 2018. Going Chief Program Officer for Health Security Pew Charitable Trusts forwarding Ready or Not will be published Association of State and Territorial Health annually in January. Officials 2 TFAH • tfah.org Executive Summary Ready or Not: EXECUTIVE SUMMARY One lesson from recent events is that emergencies happen. And Protecting the happen often. From disease outbreaks to natural disasters to man-made crises, the stakes are high: Americans face serious Public’s Health health risks and even death with increasing regularity. Therefore, from Diseases, as a nation, it’s critical to ask, “Are we prepared?” Disasters and The public health emergencies of the past year—an unusually severe flu funds, and finally a retrenchment of money once attention wanes. What’s Bioterrorism season, confounding cases of acute more, states are uneven in their levels of flaccid myelitis, two major hurricanes, preparedness. Some—often those that and the deadliest fire season in most frequently face emergencies—have California’s history—reinforce the the personnel, systems, and resources need for every jurisdiction to be vigilant needed to protect the public. But others about preparing for emergencies in are less prepared and less experienced, order to safeguard the public’s health. elevating the likelihood of preventable harms. This unstable funding and The Ready or Not: Protecting the Public’s uneven preparation undermines Health from Diseases, Disasters and America’s health security. Bioterrorism series from Trust for America’s Health (TFAH) has tracked Ready or Not examines the country’s public health emergency preparedness level of public health emergency in the United States since 2003. The preparedness on a state-by-state series has documented significant basis using 10 priority indicators. progress in the nation’s level of (See Table 1.) Taken together, the preparedness as well as those areas still indicators are a checklist of priority in need of improvement. aspects of states’ readiness for public health emergencies. However, these A fundamental role of the public health indicators do not necessarily reflect the community is to protect communities effectiveness of states’ public health from disasters and disease outbreaks. departments. Improvement in these To this end, the nation’s health security priority areas often requires action from infrastructure has made tremendous other agencies, elected officials, or the strides since 2001 by building modern private sector. laboratories, maintaining a pipeline of medical countermeasures, and This edition of the series finds that recruiting and retaining a workforce states have made progress in key areas, trained in emergency operations. Yet, including public health funding and unstable and insufficient funding puts participation in provider compacts and FEBRUARY 2019 this progress at risk, and a familiar coalitions. However, performance in pattern takes shape: underfunding, other areas—such as flu vaccination, followed by a disaster or outbreak, then hospital patient safety, and paid time off an infusion of onetime supplemental for workers—has stalled or lost ground. TABLE 1: Top-Priority Indicators of State Public Health Preparedness INDICATORS 1 Incident Management: Adoption of the Nurse Licensure Compact. 6 Water Security: Percentage of the population who used a community water system that failed to meet all applicable health-based standards. 2 Cross-Sector Community Collaboration: Percentage of hospitals 7 Workforce Resiliency and Infection Control: Percentage of employed participating in healthcare coalitions. population with paid time off. 3 Institutional Quality: Accreditation by the Public Health 8 Countermeasure Utilization: Percentage of people ages 6 months or Accreditation Board. older who received a seasonal flu vaccination. 4 Institutional Quality: Accreditation by the Emergency Management 9 Patient Safety: Percentage of hospitals with a top-quality ranking (Grade Accreditation Program. A) on the Leapfrog Hospital Safety Grade. 5 Institutional Quality: Size of the state public health budget, 10 Health Security Surveillance: The public health laboratory has a plan compared with the past year. for a six- to eight-week surge in testing capacity. Notes: The National Council of State Boards of Nursing organizes the Nurse Licensure Compact. The federal Hospital Preparedness Program of the U.S. Office of the Assistant Secretary for Preparedness and Response supports healthcare coalitions. The U.S. Environmental Protection Agency assesses community water systems. Paid time off includes sick leave, vacation time, or holidays, among other types of leave. The Leapfrog Group is an independent nonprofit organization. Every indicator, and some categorical descriptions, were drawn from the NHSPI, with one exception: public health funding. See “Appendix A: Methodology” for a description of TFAH’s funding data-collection process, including its definition. Source: National Health Security Preparedness Index.1 TFAH’s research found: healthcare coalitions. On average, 89 Hospitals in most states have a l majority of states have made A percent of hospitals were in a coalition high degree of participation in preparations to expand capabilities and 18 states had universal coalition in an emergency, often through participation, meaning every hospital healthcare coalitions. On average, in the state was part of a coalition. collaboration. In 2018, 31 states 89 percent of hospitals were in participated in the Nurse Licensure Such coalitions bring hospitals and Compact,2 which allows registered other healthcare facilities together a coalition and 18 states had with emergency management and nurses and licensed practical or universal coalition participation. vocational nurses to practice in multiple public health officials to plan for, jurisdictions with a single license. In an and respond to, events requiring emergency, this enables health officials extraordinary action. This increases to quickly increase their staffing levels. the likelihood that patients are served For example, nurses may cross state in a coordinated and efficient manner lines to lend their support at evacuation during an emergency. sites or other healthcare facilities. The Finally, 44 states and the District of number of states participating in the Columbia had a plan to surge public compact is up by five from 26 in 2017.3 health laboratory capacity for six to eight In addition, hospitals in most states weeks as necessary during overlapping have a high degree of participation in emergencies or large outbreaks. 4 TFAH • tfah.org The Ready or Not report groups states and the District of Columbia into one of three tiers based on their performance across the 10 indicators. This year, 17 states scored in the top tier, 20 and the District of Columbia placed in the middle tier, and 13 were in the bottom tier. (See Table 2.) TABLE 2: Top-Priority Indicators of State Public Health Preparedness State performance, by scoring tier, 2018 Performance Tier States Number of States Top Tier AL, CO, CT, FL, ID, KS, MA, MD, MO, MS, NC, NE, NJ, RI, VA, WA, WI 17 states Middle Tier CA, DC, GA, HI, IA, IL, LA, ME, MI, MN, MT, ND, NH, NM, NV, OK, OR, SC, TX, VT, WV 20 states and DC Bottom Tier AK, AR, AZ, DE, IN, KY, NY, OH, PA, SD, TN, UT, WY 13 states Note: See “Appendix A: Methodology” for scoring details. Complete data were not available for U.S. territories. l ost residents who got their household M and Wyoming) were accredited by l I n 2018, only 55 percent of employed water through a community water neither. Both programs help ensure that state residents, on average, had system had access to safe water.  On necessary emergency prevention and access to paid time off. Those average, just 6 percent of state response systems are in place and staffed without such leave are more likely residents used a community water by qualified personnel. to work when they are sick and risk system in 2017 that did not meet all spreading infection. In the past, some l easonal flu vaccination rate, already S applicable health-based standards. infectious disease outbreaks have too low, fell further. The seasonal flu Water systems with such violations been linked to or exacerbated by the vaccination rate among Americans increase the chances of water-based absence of paid sick leave.5 ages 6 months or older dropped from emergencies in which contaminated 47 percent in the 2016–2017 season to l nly 28 percent of hospitals, on O water supplies place the public at risk. 42 percent in the 2017–2018 season. average, earned a top-quality patient l ost states are accredited in the areas of M This drop-in coverage may have safety grade. Hospital safety scores public health, emergency management, exacerbated the severity of the 2017- measure performance on such issues or both. In 2018, the Public Health 2018 influenza season and the high as healthcare-associated infection Accreditation Board or the Emergency number of illnesses, hospitalizations rates, intensive-care capacity, nursing Management Accreditation Program and deaths due to flu. Healthy People staff volume, and an overall culture accredited 42 states and the District of 2020, a set of federal 10-year objectives of error prevention. In the absence Columbia; 26 states were accredited and benchmarks for improving the of diligent actions to protect patient by both groups. Eight states (Alaska, health of all Americans by 2020, set safety, deadly infectious diseases can Hawaii, Indiana, New Hampshire, a seasonal influenza vaccination-rate take hold or strengthen. South Dakota, Texas, West Virginia, target of 70 percent annually.4 TFAH • tfah.org 5 There are a host of concrete actions to further protect the public’s health that TFAH recommends be taken by federal, state, and local officials; the healthcare system; academia; and the private or nongovernmental sectors. Those that are of highest priority include: l P roviding stable, dedicated, and l B olstering the Hospital Preparedness sufficient funding for preparedness Program and multisector healthcare activities and a significant funding collaboration as well as adopting increase for core public health state policies to improve healthcare capabilities. delivery during disasters. l E stablishing a complementary l A dopting comprehensive climate emergency response fund to change adaptation plans, including accelerate crisis responses. a public health assessment and response. l M aintaining a long-term investment in the Global Health Security Agenda l I ncreasing public and private framework and global preparedness investments in efforts to combat and response programs to help antimicrobial resistance, including prevent infectious disease threats through diagnostic, stewardship, from becoming global crises. detection, and treatment methods. l F ollowing the National Biodefense l S upporting vaccine infrastructure Strategy (NBS) with transparent goals, and first-dollar coverage of implementation plans, and budgets recommended vaccines. for all relevant agencies. l P romoting health equity in l C losely monitoring the transition of emergency preparedness planning, the Strategic National Stockpile and response, and recovery, including significantly strengthening the “last through the appointment of a chief mile” of distribution and dispensing. equity or resilience officer. l D eveloping a multiyear strategic Taken together, action on TFAH’s vision and fully funding surveillance recommendations would make the infrastructure, for fast, accurate United States safer for all its residents. outbreak detection at all levels of See page 26 for a complete description. government. This report was updated on Mar. 19, 2019, to reflect revised data submitted by the Delaware Department of Health and Social Services pertaining to its change in public health funding from fiscal year 2017 to 2018. The state’s public health funding fell by 1.8 percent in FY 2018, not by 18.1 percent. 6 TFAH • tfah.org SERIOUS RISKS PERSIST ON CENTENNIAL OF 1918 FLU PANDEMIC Mid-2018 marked the 100th anniversary In 1918, scientists had not yet discovered what made it so lethal.9 However, experts of the deadly 1918 influenza pandemic, viruses. There were no vaccines to believe a future pandemic will likely be which is estimated to have sickened prevent viral infection, no antiviral drugs caused by an influenza subtype for which one-third of the world’s population and to treat illness, and no antibiotics to treat there is little or no preexisting immunity killed at least 50 million people.6 The secondary bacterial infections, such as in humans.10 “The thing that keeps me pandemic killed approximately 675,000 pneumonia.8 While today there is a global up at night is pandemic flu,” Dr. Robert people in the United States alone, influenza surveillance system to detect Redfield, the director of the Centers for lowering U. S. life expectancy by 12 flu viruses with pandemic potential, and Disease Control and Prevention, said. years from 1917 to 1918. Caused by an vaccines and medicines to prevent and “Our best preparation for that pandemic H1N1 virus, the flu took the life of a high treat infections, the world is also now is to optimize our response to seasonal number of otherwise healthy people ages so interconnected that an outbreak flu.”11 To that end, the United States 20 to 40. This outbreak struck during in Boston could trigger an infection in must improve surveillance and be able to World War I, where it spread rapidly Beijing in less than a day. quickly develop—and mass-produce and among troops living in close quarters— distribute—broadly effective vaccines, Despite having successfully reconstructed more American soldiers died from the flu while also creating cheaper and more the virus that was the cause of the 1918 than on that war’s battlefield. 7 effective treatments.12 outbreak, scientists still do not know CLIMATE CHANGE INCREASING LIKELIHOOD AND SEVERITY OF EXTREME WEATHER According to the Center for Climate and Energy Solutions, a nonprofit advocacy group, climate change is expected to increase the frequency, intensity, and consequences of some types of extreme weather events,13 including: l Drought,14 which can contribute to food insecurity and exacerbate wildfires.15 l E xtreme heat, which in a typical year already kills more people in the United States than hurricanes, lightning, tornadoes, earthquakes, and floods In 2017 alone, at least 15 extreme the dangers from floods, and replacing combined.16 Extreme heat is especially weather events across the globe were nonpermeable surfaces with “green dangerous for medically vulnerable made more likely by climate change, infrastructure,” such as rain gardens and people. It also worsens droughts and according to studies published by the bioswales, reduces stormwater runoff increases the risk of wildfires.17 American Meteorological Society.20 and subsequent flooding.23 In drought- l H eavy rains,18 which cause catastrophic prone areas, green infrastructure can On top of possible federal action, states flooding, landslides, and contaminated retain stormwater for later use.24 Cooling and localities can act to mitigate these waterways.19 centers can keep vulnerable populations threats, particularly the dangers they pose l H urricanes, which sometimes have more safe during heat waves, and green roofs to people with health ailments or in poor destructive wind speeds, precipitation, can reduce the urban heat island effect.25 living conditions.21 For example, land- and storm surges. Finally, preserving coastal wetlands, use planning can reduce loss of life and dunes, and reefs can help absorb storm l W ildfires, which can now burn more land property from wildfires.22 Zoning rules that surges from hurricanes.26 and are more difficult to extinguish. limit building in flood-prone areas reduces TFAH • tfah.org 7 Report Purpose and Methodology TFAH’s annual Ready or Not report there are some important differences. on their performances across the 10 series tracks states’ readiness for public The two projects have somewhat indicators. Partial credit, also new, health emergencies based on 10 key different purposes and are meant was provided for some indicators indicators that collectively provide to be complementary, rather than in order to draw finer distinctions a checklist of top-priority issues and duplicative. With its 140 indicators, among states and within states over action items for states and localities the Index paints a broad picture of time. States were placed into the to continuously address. By gathering national health security, allowing users three tiers—top tier, middle tier, and together timely data on all 50 states to zoom out and holistically understand bottom tier—based on their relative and the District of Columbia, the the extent of both individual states’ performance across indicators. report assists states in benchmarking and the entire nation’s preparedness their performance against comparable for large-scale public health threats. State Public Health Funding jurisdictions. This research was In slight contrast, Ready or Not, with TFAH collected data for fiscal year completed after consultation with a its focus on 10 select indicators, 2018 and for earlier years from diverse group of subject-matter experts focuses attention on a subset of the states’ publicly available funding and practitioners. Index and spotlights important areas documents. With assistance from the for stakeholders to prioritize. Going Association of State and Territorial Ready or Not and the forward, TFAH and the NHSPI will Health Officials (ASTHO), data National Health Security work together to help federal, state, were provided to states for review Preparedness Index and local officials use data and findings and verification. Informed by the The indicators included in this report from each project to make Americans Public Health Activities and Services were drawn from, and identified in safer and healthier. Tracking project at the University of partnership with, the National Health Washington, TFAH defines “public Security Preparedness Index (NHSPI), Measuring performance health programming and services” with one exception: a measure of state Ready or Not was first published in to include communicable disease public health funding-level trends, which 2003. Over time, the series has tracked control; chronic disease prevention; reflects how equipped key agencies are significant progress in the nation’s injury prevention; environmental to prepare and respond to emergencies. emergency preparedness, but notable public health; maternal, child, and The NHSPI is a joint initiative of the vulnerabilities remain. To help states family health; and access to and Robert Wood Johnson Foundation and track their own progress, TFAH will linkage with clinical care. the University of Kentucky. strive to maintain continuity among the TFAH excludes from its definition indicators tracked in this edition of the See “Appendix A: Methodology” for a of “public health programming and report for the next several years. detailed description of how indicators services” insurance coverage programs, were selected and scored. New to the series in this edition such as Medicaid or the Children’s is a three-tiered grouping system. Health Insurance Program, and While states’ placements in Ready States are grouped into tiers based inpatient clinical facilities. or Not and the NHSPI largely align, 8 TFAH • tfah.org SECTI O N 1 Health Threats: A Review of 2018 Ready or Not: HEALTH THREATS: A REVIEW OF 2018 From a historic seasonal flu season to extreme weather that Protecting the upended millions of lives, 2018 offered plenty of evidence that much more work must be done to ensure the health and safety Public’s Health of all Americans. Some policy advancements strived to address from Diseases, these challenges, such as the National Biodefense Strategy and the Global Health Strategy Agenda renewal. These represented Disasters and positive steps in an increasingly dangerous world. Bioterrorism This section outlines major public health incidents, actions, research findings, meetings, and federal hearings across three domains: disease outbreaks; severe weather and natural disasters; and biological, chemical, radiological, and nuclear terrorism. Disease Outbreaks Notable incidents since the 1976–1977 season.31 One l epatitis A. In June 2018, the Centers H possible contributing factor: only 42 for Disease Control and Prevention percent of Americans received a flu (CDC) warned of ongoing hepatitis shot in 2017–2018.32 A virus outbreaks,27 primarily among l oodborne outbreaks. Multistate F those who reported drug use and/ foodborne illness outbreaks included or homelessness. The hepatitis A several cases of salmonella infections virus is a highly contagious, short- found in eggs, chicken, raw turkey, term liver infection for which pasta salad, chicken salad, melon, vaccination is the best prevention. cereal, raw sprouts, kratom, tahini, and In October, the Advisory Committee coconut. Other outbreaks included on Immunization Practices, which cyclospora in salad mix and vegetable develops recommendations for the trays, listeria in pork products and CDC, voted unanimously to add deli ham, vibrio parahaemolyticus in people without homes to the list imported fresh crab meat, and E. coli of populations that should receive in romaine lettuce.33 routine hepatitis A vaccinations.28 l cute flaccid myelitis. The CDC A l easonal flu. The 2017–2018 season S confirmed more than 165 cases, across was a “high-severity” flu season,29 with a majority of states, of acute flaccid large numbers of visits to outpatient myelitis in children, which affects the FEBRUARY 2019 clinics and emergency departments, nervous system—especially the spinal record hospitalization rates, and cord—and can lead to temporary or high numbers of influenza-associated permanent paralysis. This followed pediatric deaths.30 There were about weaker outbreaks, starting in 2014.34 80,000 flu-related deaths, the most Notable actions a peer-review with international experts l A ccording to research by the Pew l lobal health security. In November, G from the World Health Organization Charitable Trusts and the CDC, the Global Health Security Agenda (WHO), and resulted in a set of tighter antibiotic stewardship is (GHSA), an initiative that aims to comprehensive scores and specific needed in urgent care settings to accelerate and optimize global health recommendations for the United States. reduce inappropriate prescriptions security, launched GHSA 2024, a plan The National Action Plan consolidates for acute respiratory conditions that to evaluate risks and close gaps.35 information about federal programs are viral or noninfectious, including in a long-term coordination process the common cold, bronchitis, l ntimicrobial resistance. In A to strengthen health emergency influenza, and viral pneumonia.41 September, the U.S. Food and Drug preparedness and response capacities Administration (FDA) announced l T he U.S. Government Accountability for all hazards, specifically addressing a new antimicrobial resistance Office (GAO) examined the U.S. public the 2016 JEE recommendations and strategy based on four pillars: (1) health system’s capacity to respond to aiming to increase the U.S. scores on a developing new antibiotics, diagnostic infectious disease threats, evaluating follow-up JEE in 2021. tests, and vaccines; (2) promoting three preparedness and capacity- stewardship in human and veterinary building programs: Epidemiology and Notable research findings, meetings, settings; (3) improving surveillance Laboratory Capacity for Infectious and federal hearings of antimicrobial use and resistance; Diseases, Hospital Preparedness l B etween 2009–2015, Norovirus was Program, and Public Health Emergency and (4) advancing regulatory science the most common cause of foodborne Preparedness. GAO found uneven to bring about breakthroughs in outbreaks, followed by salmonella.37 performances among these programs’ antibiotic development.36 Antibiotic resistance poses a serious public health l T he number of reported illnesses state and local government grant threat, as illnesses that were once transmitted by ticks, mosquitoes, or awardees in the areas of electronic lab treatable become untreatable, leading fleas more than tripled from 2004– reporting, epidemiological capacity, and to dangerous infections and even 2016.38 Tickborne diseases were most laboratory capacity.42 disability or death. prevalent, especially Lyme disease. l A n assessment by researchers and In addition, a new invasive Tick practitioners of epidemiological capacity l A lso, in September, the CDC and species,39 the Asian Longhorn Tick, was in state health departments found HHS launched the Antimicrobial identified. The Asian Longhorn is able significant understaffing, particularly Resistance (AMR) Challenge, a year- to transmit several diseases to humans. among epidemiologists dedicated long program to accelerate the fight West Nile virus was the most commonly to evaluating personal and public against antimicrobial resistance across transmitted mosquito-borne disease in health services and researching new or the globe. The Challenge is based the continental United States, while improved solutions to health problems.43 on a “one health” approach which dengue, chikungunya, and Zika were recognizes the health connections l T he CDC published Public Health prevalent in the U.S. territories and in between humans, animals and the Surveillance: Preparing for the Future, a other countries. environment. status report on its strategy since 2014 l O ne in seven babies born in the U.S. to streamline and better integrate its l ealth Security National Action Plan. H territories to mothers who contracted systems to regularly collect, analyze, More than 40 federal departments/ Zika virus infection during pregnancy use, and share data to prevent and agencies developed and published had an associated birth defect, a control disease and injury. The report the Health Security National Action neurodevelopmental problem, or both.40 documented faster notification, Plan based on the 2016 Joint External Early interventions have been shown to easier reporting systems, quicker Evaluation (JEE) of the United States. improve cognitive, social, and behavioral understanding of emerging health The JEE, which evolved out of the functioning in these children. threats, and improved disease tracking. Global Health Security Agenda, involved 10 TFAH • tfah.org Severe Weather and Natural Disasters Notable incidents l xtreme weather. Two major E hurricanes pummeled the East Coast in 2018. When Hurricane Florence made landfall in North Carolina in September, it produced days of unyielding rainfall, causing catastrophic flooding and at least 51 deaths.44,45 Weeks later, Hurricane Michael crept through the Gulf of Mexico toward the Florida panhandle, where the warm waters quickly fueled it from a Category 2 storm to a Category 4 within 24 hours.46 Michael leveled entire towns and caused at least 35 deaths.47 To the west, Hurricane Walaka wiped Hawaii’s tiny East Island off the map.48 In October, the Commonwealth of the Northern of the city drifted into the area.59 In Mariana Islands was devastated by November, amid the Camp fire, some Super Typhoon Yutu.49 parts of California had air that ranked among the dirtiest in the world.60 l ildfires. More than 7,000 wildfires W scorched more than 1.6 million acres Notable actions in California in 2018.50 The Camp l I n 2018, the HHS secretary declared Fire was the deadliest in California’s public health emergencies for the history, killing 86 people.51 The California wildfires; for hurricanes Mendocino Complex Fire—the in Florida, Georgia, North Carolina, merging of the Ranch Fire and the South Carolina, and Virginia; for River Fire—was the largest wildfire Typhoon Yutu on the Commonwealth in California history and took nearly of the Northern Mariana Islands; two months to contain.52 The Carr and for an earthquake in Alaska. Fire produced “fire whirls” with wind Declarations were renewed for the speeds equal to an EF-3 tornado—143 continued response to Hurricane miles per hour53—and killed eight Maria in Puerto Rico and the U.S. people.54 Colorado, Nevada, Oregon, Virgin Islands.61 (Nationwide public and Washington also dealt with health emergency declarations for large wildfires.55,56,57,58 Wildfires the opioid crisis were also renewed.62) produce smoke that can affect air Such declarations enable certain quality hundreds of miles away. In flexibilities for each jurisdiction, such August, Seattle’s air quality was rated as waiving or modifying requirements “unhealthy for all,” as smoke from by the Centers for Medicare and wildfires well north, east, and south Medicaid Services. TFAH • tfah.org 11 Notable research findings, meetings, l T he Federal Emergency Management supplies in the Caribbean; and to add and federal hearings Agency (FEMA) released its 300 new emergency generators to its l T hree major reports authored 2017 Hurricane Season After-Action inventory.68 by the United Nations,63 13 U.S. Report, which analyzes the agency’s l T he GAO released 2017 Hurricanes federal agencies,64 and 24 academic preparation for, immediate response and Wildfires: Initial Observations institutions and the United Nations,65 to, and initial recovery operations on the Federal Response and Key respectively, warned about the current for the three major hurricanes that Recovery Challenges, which examines and future risks of a changing climate. occurred in quick succession in the challenges that slowed and The reports left no doubt about the 2017—Harvey, Irma, and Maria—while complicated FEMA’s responses to urgency of the situation. simultaneously responding to historic hurricane and wildfire disasters, wildfires in California. FEMA found its l T he American Public Health including staffing shortages, logistical major challenges involved mounting Association (APHA) and the Public obstacles, and the incapacitation of a sufficient response for concurrent, Health Institute released Climate Change, local responders, on top of limited complex incidents; sustaining whole Health, and Equity: A Guide for Local local preparedness in Puerto Rico and community logistics support (including Health Departments, which summarizes the U.S. Virgin Islands.69 collaboration among individuals, the science of climate change and businesses, faith-based and community l A n independent assessment of deaths its impact on health, particularly organizations, nonprofits, schools and resulting from Hurricane Maria, among low-income communities and academia, media outlets, and all levels commissioned by the governor of communities of color. The report of government67); responding during Puerto Rico and performed by the connects what is known about climate long-term infrastructure outages; and George Washington University’s impacts and related solutions with supporting food, shelter, and housing Milken Institute School of Public the work of local health departments. activities at unprecedented levels. Health, estimates that 2,975 people The authors recommend that climate Among the actions FEMA took to died between September 2017 and change be integrated into public improve its operations, based on its February 2018 due to the storm or health emergency preparedness efforts, findings, were to update its hurricane its aftermath.70 Risk of death was emphasizing surveillance, health plans and procedures; to improve persistently highest for seniors and system and community resilience, and staffing processes during incidents; to those living in low-income areas. preparations for the displacement of dramatically increase meal and water vulnerable populations.66 12 TFAH • tfah.org All-Hazards Policy Actions Notable actions use during a major disease outbreak, Notable research findings, meetings, l I n July, the FDA approved TPOXX bioterror or chemical attack, or other and federal hearings (tecovirimat) as a treatment for public health emergency.75 The move, l I n February, the Blue Ribbon Study smallpox—the first drug of its kind.71 intended to streamline and align Panel on Biodefense released Budget While smallpox was eradicated in medical countermeasure operations Reform for Biodefense: Integrated Budget 1980, it still exists in small quantities under ASPR, generated questions Needed to Increase Return on Investment, at two research labs in the United from some in Congress and the public which recommends moving toward States and Russia,72 and perhaps health community about the potential a strategic, well-informed, and other locations, and there are impact on existing countermeasure coordinated biodefense spending longstanding concerns that it could capabilities and on the provision of approach that will support more be used as a bioweapon. support and technical assistance to sound investments, close capability state and local jurisdictions. gaps, and reduce inefficiencies.77 l I n September, the White House released its National Biodefense l I n October, the CDC updated l I n May, the Johns Hopkins Center for Strategy. Among other actions, the its framework of public health Health Security convened U.S. national strategy calls for the creation of a emergency preparedness and security and epidemic response experts Cabinet-level steering committee, response capabilities,76 which to participate in a mock pandemic to be chaired by the HHS secretary, through the Public Health tabletop exercise involving a novel to provide strategic guidance in Emergency Preparedness (PHEP) and deadly influenza virus that is preparing for, countering, and cooperative agreement, provides released by bioterrorists and that kills responding to biological threats. standards for states and localities, 150 million people worldwide within The strategy also outlines how helping them to plan, operationalize, one year—15 million in the United the United States can better and evaluate their public health States alone.78 At the completion of the coordinate with international emergency preparedness. “Clade X” exercise, the center issued partners, industry, academia, l I n September, December and six policy recommendations, two of nongovernmental entities, and the again in January 2019, the House which were (1) to maintain a national private sector on all elements of a passed the Pandemic and All- public health system that can manage national biodefense strategy.73 Hazards Preparedness and the challenges of pandemic response, Advancing Innovation Act of 2018. and (2) to build the capacity to develop l I n October, responsibility for the The legislation, if enacted, would new vaccines and drugs quickly. management of the Strategic National Stockpile moved from the CDC to the reauthorize the U.S. Department of l I n October, the Blue Ribbon Study U.S. Office of the Assistant Secretary Health and Human Services (HHS) Panel on Biodefense released Holding for Preparedness and Response, the emergency preparedness and response the Line on Biodefense: State, Local, Tribal, office within the HHS that was created programs, including programs And Territorial Reinforcements Needed. in 2006 to coordinate the federal to research and develop medical The report recommends several steps responses to health emergencies.74 countermeasures for biological to increase the capability of state, local, The stockpile is a national repository, threats. However, the legislation did tribal, and territorial governments to distributed throughout the country not pass the Senate before Congress share with the federal government the in secure locations, of medical adjourned for the year and many burden of large-scale biological event countermeasures and supplies for authorities expired. preparedness, response, and recovery.79  TFAH • tfah.org 13 S EC T I ON 2 Ready or Not: Assessing State Preparedness ASSESSING STATE PREPAREDNESS Protecting the While it is important that every state be ready to handle public Public’s Health health emergencies, each faces its own mix of threats, and some are more prepared than others. To help states assess their from Diseases, readiness, and to highlight a checklist of top-priority concerns Disasters and and action areas, this report examines a set of 10 select indicators. The indicators, drawn heavily from the National Health Security Bioterrorism Preparedness Index (NHSPI), a joint initiative of the Robert Wood Johnson Foundation and the University of Kentucky, capture core elements of preparedness. Based on states’ standing across the 10 indicators (see “Appendix A: Methodology” for scoring details), states were placed into three tiers. (See Table 3.) TABLE 3: Top-Priority Indicators of State Public Health Preparedness State performance, by scoring tier, 2018 Performance Tier States Number of States AL, CO, CT, FL, ID, KS, MA, MD, MO, MS, NC, NE, Top Tier 17 states NJ, RI, VA, WA, WI CA, DC, GA, HI, IA, IL, LA, ME, MI, MN, MT, ND, Middle Tier 20 states and DC NH, NM, NV, OK, OR, SC, TX, VT, WV Bottom Tier AK, AR, AZ, DE, IN, KY, NY, OH, PA, SD, TN, UT, WY 13 states Note: See “Appendix A: Methodology” for scoring details. Complete data were not available for U.S. territories. Importantly, the implications of this Moreover, some indicators (for example, assessment, and responsibility for public health funding) are under the continuously improving, extend beyond direct control of public officials, whereas any one state or local agency. Indeed, improvement in other indicators (for most require sustained engagement example, seasonal flu vaccination) will and coordination by a broad range require multisector, statewide efforts, of policymakers and administrators. including by residents. FEBRUARY 2019 INDICATOR 1: ADOPTION Workforce shortages can impair a state’s The NLC has been crucial to response ability to effectively manage disasters or efforts after several recent disasters.81 OF NURSE LICENSURE disease outbreaks, potentially resulting In 2017, when Hurricane Harvey COMPACT in poorer health outcomes for those struck Texas, healthcare systems were affected. Therefore, the capacity to overwhelmed, and nurses from many quickly increase the availability of member states were able to immediately KEY FINDING: 31 states qualified medical personnel is critical. assist those in need. In 2018, when participated in the Nurse Hurricane Florence left severe damage This indicator examines whether states Licensure Compact in 2018. in South Carolina from rain, flooding, have adopted legislation to participate and high winds, DaVita Renal Dialysis in the Nurse Licensure Compact (NLC). Centers were in dire need of nurses. Launched in 2000 by the National Thanks to South Carolina’s membership Council of State Boards of Nursing, in the compact, DaVita was able to the NLC permits registered nurses and recruit nurses from other NLC states licensed practical nurses to practice with without delay. A few weeks later, when a single multistate license—physically or flooding from Hurricane Michael remotely—in any state that has joined forced at least one hospital in the state the compact. The NLC provides standing to evacuate, nurses from other member reciprocity, with no requirement that an states were able to assist. emergency be formally declared. As of November 2018, 31 states had To help make participation in the adopted the NLC.82 (See Table 4.) Five compact more viable for states, the states (Florida, Georgia, Oklahoma, National Council of State Boards of West Virginia, and Wyoming) began Nursing enhanced its requirements in to formally implement the compact 2017–2018, adding a requirement for in January 2018, and two (Kansas and state and federal criminal background Louisiana) are scheduled to do so in checks, and standardizing licensure July 2019. In contrast, Rhode Island requirements among participating exited the NLC in July 2018. states, among other changes.80 TABLE 4: 31 States Participated in the Nurse Licensure Compact Participants and nonparticipants, 2018 Participants Nonparticipants Arizona Maine South Carolina Alabama Minnesota Arkansas Maryland South Dakota Alaska Nevada Colorado Mississippi Tennessee California New Jersey Delaware Missouri Texas Connecticut New York Florida Montana Utah D.C. Ohio Georgia Nebraska Virginia Hawaii Oregon Idaho New Hampshire West Virginia Illinois Pennsylvania Iowa New Mexico Wisconsin Indiana Rhode Island Kansas North Carolina Wyoming Massachusetts Vermont Kentucky North Dakota Michigan Washington Louisiana Oklahoma Note: Kansas and Louisiana are scheduled to begin implementing the NLC in July 2019. Source: National Council of State Boards of Nursing.83 TFAH • tfah.org 15 INDICATOR 2: HOSPITAL PARTICIPATION IN HEALTHCARE COALITIONS KEY FINDING: Widespread hospital participation in healthcare coalitions was common in 2017; only four states (California, New Hampshire, Ohio, and South Carolina) reported that 70 percent or fewer of their hospitals participated in Lowe Llaguno / Shutterstock.com coalitions supported by the HHS The federal Hospital Preparedness reunification.86 The Houston area’s Hospital Preparedness Program. Program, which is managed by the coalition, which comprises 25 counties HHS’s Office of the Assistant Secretary that are home to 9.3 million people and for Preparedness and Response, 180 hospitals, coordinated activities, provides grants to states, localities, such as evacuations and patient and territories to develop regional transfers, during and after Hurricane coalitions of healthcare organizations Harvey in 2017.87 More recently, after that collaborate to prepare for, and Hurricane Florence knocked out respond to, medical surge events.84 communication capabilities at a major Coalitions prepare members with critical regional hospital in North Carolina, tools, including medical equipment the area coalition established a backup and supplies, real-time information, system within eight hours.88 enhanced communication systems, and On average, 89 percent of hospitals in well-trained healthcare personnel.85 states belonged to a healthcare coalition Broad participation by hospitals in in 2017, with universal participation, healthcare coalitions means that when meaning every hospital in the state was disaster strikes, systems are in place part of a coalition, in 17 states (Alaska, to coordinate the response, freeing Colorado, Connecticut, Delaware, hospitals to focus on clinical care. Hawaii, Louisiana, Minnesota, Mississippi, For example, when a train derailed Nevada, North Dakota, Oregon, Rhode on the border of two counties and Island, South Dakota, Utah, Vermont, two coalitions in Washington state in Virginia, and Washington) and the December 2017, nine participating District of Columbia. (See Table 5.) hospitals across three counties used a However, some states, such as Ohio shared tracking system to streamline (25 percent) and New Hampshire (47 the documentation and distribution percent) lagged behind. of 69 patients, and to aid family 16 TFAH • tfah.org TABLE 5: Widespread Participation of Hospitals in Healthcare Coalitions Percent of hospitals participating in healthcare coalitions, 2017 States Percent of Participating Hospitals AK, CO, CT, DC, DE, HI, LA, MN, MS, NV, ND, 100% OR, RI, SD, UT, VT, VA, WA ID, WI 98% GA, WV 97% KS 96% AL, NE, NC, OK 95% ME 94% KY 93% WY 92% TN 91% MI 90% MD 89% IL 88% MO 87% NY, PA 86% MT 83% MA, NJ 82% AR 81% IA, TX 80% IN 75% FL 73% AZ 72% NM 71% CA 70% SC 56% NH 47% OH 25% Note: This indicator measures participation by hospitals in healthcare coalitions supported through the federal Hospital Preparedness Program of the Office of the Assistant Secretary for Preparedness and Response. Source: NHSPI analysis of data from the Office of the Assistant Secretary for Preparedness and Re- sponse, U.S. Department of Health and Human Services. TFAH • tfah.org 17 INDICATORS 3 AND 4: The Public Health Accreditation Board that they meet national standards for (PHAB), a nonprofit organization that emergency response capabilities.91 ACCREDITATION administers the national public health The PHAB and the EMAP each provide accreditation program, advances quality important mechanisms for improving KEY FINDING: Most states are within public health departments by evaluation and accountability. Accredita- providing a framework and a set of evi- accredited by one or both of tion by these entities demonstrates that dence-based standards against which they a state’s public health and emergency two well-regarded bodies—the can measure their performance. Among management systems are capable of ef- standards with direct relevance to emer- Public Health Accreditation fectively responding to a range of health gency preparedness are assurances of labo- Board and the Emergency threats. Priority capabilities that are ratory, epidemiologic, and environmental tested include identification, investiga- Management Accreditation expertise to investigate and contain serious tion, and mitigation of health hazards; public health problems, policies and pro- Program—but eight are not. a robust and competent workforce; cedures for urgent communications and incident, resource, and logistics manage- maintenance of an all-hazards emergency ment; and communications and com- operations plan.89 Through the process of munity-engagement plans.92,93 (States accreditation, health departments identify sometimes aim to meet applicable stan- their strengths and weaknesses, increase dards, but do not pursue accreditation.) their accountability and transparency, and improve their management processes, As of October 2018, both the PHAB and which all promote continuous quality im- the EMAP accredited 26 states and the provement.90 District of Columbia and an additional 16 states were accredited by one or the Emergency management, as defined other. (See Table 6.) Just eight states by the Emergency Management (Alaska, Hawaii, Indiana, New Hampshire, Accreditation Program (EMAP), South Dakota, Texas, West Virginia, encompasses all organizations in a given and Wyoming) were not accredited by jurisdiction with emergency or disaster either body. This analysis includes state functions, which may include prevention, level accreditations only, it does not mitigation, preparedness, response, and include accredited local or tribal health recovery. The EMAP helps applicants departments. In some instances, local ensure—though self-assessment, public health departments are accredited documentation, and peer review— in states that may not be. TABLE 6: 42 States and the District of Columbia Accredited by PHAB and/or EMAP Accreditation status by state, October 2018 PHAB and EMAP PHAB only EMAP only No Accreditation Alabama Illinois New York Delaware Georgia North Carolina Alaska Arizona Kansas North Dakota Maine Iowa Pennsylvania Hawaii Arkansas Maryland Ohio Minnesota Kentucky South Carolina Indiana California Massachusetts Oklahoma Montana Louisiana Tennessee New Hampshire Colorado Mississippi Rhode Island Oregon Michigan Virginia South Dakota Connecticut Missouri Utah Washington Nevada Texas District of Columbia Nebraska Vermont West Virginia Florida New Jersey Wisconsin Wyoming Idaho New Mexico Note: These indicators track accreditation by the PHAB and the EMAP. States with conditional or pending accreditation at the time of data collection were classified as having no accreditation. States sometimes aim to meet applicable standards but do not pursue accreditation. Sources: NHSPI analysis of data from the PHAB and the EMAP. 18 TFAH • tfah.org INDICATOR 5: STATE Healthier communities are more 4) nvironmental public health. Public E resilient. Funding for public health services related to air and PUBLIC HEALTH health programs that support the water quality, fish and shellfish, FUNDING TRENDS infrastructure and workforce needed food safety, hazardous substances to protect health—including the ability and sites, lead, onsite wastewater, to detect, prevent, and control disease solid and hazardous waste, zoonotic KEY FINDING: A majority of outbreaks and mitigate the health diseases, etc. states held their public health consequences of disasters—is a critical 5) Maternal, child, and family health. funding steady or increased it in ingredient of preparedness. General Public health services related to public health competences—such fiscal year 2018, but 17 states the coordination of services; direct as those pertaining to epidemiology, service; family planning; newborn and the District of Columbia environmental hazard detection and screening; population-based control, infectious disease prevention had reduced funding. maternal, child, and family health; and control, and risk communications— supplemental nutrition, etc. and targeted emergency response resources are needed to ensure that 6) ccess to and linkage with clinical A routine capabilities are maintained, and care. Public health services that surge capacity is readily available related to beneficiary eligibility for emergencies. Skilled public health determination, provider or facility employees are often redeployed during licensing, etc. emergencies to provide surge capacity, The overall infrastructure of public so health departments must maintain health programming supports adequate numbers of trained personnel. states’ ability to carry out emergency According to the Public Health Activities responsibilities. But public health and Services Tracking project at the funding is typically discretionary, University of Washington, state public making it vulnerable to neglect or health programming and services span retrenchment, especially when times are six core areas: tight. This can undermine emergency preparedness activities and weaken 1) ommunicable disease control. Public C response and recovery efforts. health services related to communicable disease epidemiology, hepatitis, Fortunately, a majority of states (32) HIV/AIDS, immunization, sexually increased public health funding and transmitted diseases, tuberculosis, etc. one state (Wyoming) held it steady in fiscal year 2018. (See Table 7.) But 2) hronic disease prevention. Public C 17 states and the District of Columbia health services related to asthma, reduced the money they directed cancer, cardiovascular disease, to these vital activities, increasing diabetes, obesity, tobacco, etc. the likelihood that they will be less 3) njury prevention. Public health I prepared and less responsive in the services related to firearms, motor moments that matter most. It is worth vehicles, occupational injuries, noting that this indicator does not senior fall prevention, substance-use assess the adequacy of states’ public disorder, other intentional injuries, health funding. and other unintentional injuries. TFAH • tfah.org 19 TABLE 7: State Public Health Funding Held Stable or Increased in 33 states Public health funding, by state, fiscal 2017–2018 State Percentage Change Alabama 1.7% Alaska -13.8% Arizona -0.1% Arkansas -2.8% California 2.8% Colorado 1.5% Connecticut 6.5% Delaware -1.8% D.C. -1.1% Florida 0.8% Georgia 6.4% Hawaii 10.5% Idaho 1.3% Illinois 1.6% Indiana 9.7% Iowa -0.5% Kansas 16.8% Jonathan Weiss / Shutterstock.com Kentucky -6.3% Louisiana 16.4% Maine -17.1% Maryland 5.0% Massachusetts 1.1% Michigan 18.0% Minnesota -0.1% Mississippi -9.9% Missouri 3.7% Montana -5.9% Nebraska 4.1% Nevada 30.2% New Hampshire 2.9% New Jersey 5.2% New Mexico* -1.8% New York -4.5% North Carolina 6.0% North Dakota 12.2% Ohio 5.8% Oklahoma -5.4% Oregon 2.7% Pennsylvania 7.5% Rhode Island 0.4% South Carolina 9.4% South Dakota -3.5% Tennessee -1.2% Texas -12.1% Utah 3.9% Vermont -1.3% Virginia 0.5% Washington 13.5% West Virginia 3.4% Wisconsin 1.0% Wyoming 0% Note: Owing to differences in organizational responsibilities and budgeting, funding data are not necessarily comparable state to state. See “Appendix A: Methodology” for a description of TFAH’s data-collection process, including its definition of public health funding. 20 TFAH • tfah.org Source: TFAH analysis of states’ public funding data. INDICATOR 6: Nothing is more critical to human levels, and failing to meet customer- life than safe drinking water. It is notification requirements.96 COMMUNITY WATER essential for consumption, sanitation, SYSTEM SAFETY and the efficient operation of the The United States has one of the safest public drinking-water supplies healthcare system. In the United in the world, but some communities, KEY FINDING: Few Americans States, 90 percent of the population particularly low-income communities, gets water from a public water drink from community water struggle to maintain constant access to system, and the U.S. Environmental safe water. The most prominent water- systems that are in violation Protection Agency (EPA) sets legal contamination crisis in recent years limits on contaminants in drinking of applicable health-based water, including microorganisms, occurred in Flint, Michigan, where a 2014 change in water supply caused standards required by the Safe disinfectants and their by-products, distribution pipes to corrode and to chemicals, and radionuclides;94 the Drinking Water Act. But room leach lead and other contaminants into EPA also requires states to periodically the drinking water. Tens of thousands for improvement remains. report drinking-water quality of residents, including young children, information.95 Water systems must have been exposed to high levels of report any violations, such as failing lead and other toxins.97 In children, to follow established monitoring and even low levels of exposure can damage reporting schedules, failing to comply the nervous system and contribute to with mandated treatment techniques, learning disabilities, shorter stature, violating any maximum contaminant impaired hearing, and impaired formation and function of blood cells.98 TABLE 8: Few Americans Used Contaminated Yet, across the nation, on average, Community Water Systems only 6 percent of state residents used a Percent of state populations who used a community water system in community water system in 2017 that violation of health-based standards, 2017 failed to meet all applicable health- States Percent of Population based standards, according to the HI, VT 0% EPA. What’s more, that share was 0 to AL, CT, IL, IN, ME, MD, MI, MT, NV, OR, WA 1% 1 percent in Alabama, Connecticut, CA, MN, NH, SD 2% Hawaii, Illinois, Indiana, Maine, FL, MA, MS, MO, SC, VA, WI 3% Maryland, Michigan, Montana, Nevada, ID, KS, NE, NJ, OH, WY 4% Oregon, Vermont, and Washington. DC, NC, TN, TX 5% (See Table 8.) But in five states (New AK, LA 6% York, North Dakota, Oklahoma, AR, RI 7% Pennsylvania, and Utah), more than 15 AZ, CO, GA, WV 8% percent of residents used a community IA 9% water system with health-based violations DE 11% at some time during the year. New KY, NM 12% York’s share was 46 percent, a sharp ND, OK 16% increase from earlier years, after a PA, UT 20% violation at the massive New York City NY 46% water supply system. In years prior to Note: Some state residents use private drinking-water supplies, rather than community water systems. Private supplies are not captured by these data. Only regulated contaminants are measured. 2017, New York state’s water quality was Source: NHSPI analysis of data from the EPA. more comparable to that of other states. TFAH • tfah.org 21 INDICATOR 7: ACCESS TO When workers without paid leave get This is particularly important for sick, they face the choice of going to industries and occupations that require PAID TIME OFF work and potentially infecting others frequent contact with the public. or staying home and losing pay—or For example, people working in the KEY FINDING: Just over half of even their jobs. Similarly, when workers food service and childcare industries without paid leave have children commonly have no paid sick leave.99 workers in states, on average, who get sick, they face the choice of This often leads service employees to had some type of paid time sending their sick child to school and work throughout a bout of the flu, or potentially infecting others or, again, return to work before their symptoms off (for example, sick leave, staying home with their child and losing have fully subsided, when one or vacation, holidays) in 2018. Most pay or even their jobs. Therefore, paid two days off could have dramatically states were closely clustered to time off, especially dedicated sick leave, reduced workplace infections.100,101 At a can strengthen infection control and societal level, flu rates have been shown that midpoint, with few outliers. resilience in communities by reducing to be lower in cities and states that the spread of contagious diseases and mandate paid sick leave.102,103 bolstering workers’ financial security. Paid time off also increases access to preventive care among workers and their families, including TABLE 9: 55 Percent of Workers, On Average, routine checkups, screenings, and Received Paid Time Off immunizations. Delaying or skipping Percent of employed population with paid time off, 2018 such care can result in poor health States Percent of Workers outcomes and can ultimately lead to TX 68% costlier treatments. Workers without CT, DC 65% paid sick days are less likely to get a flu OR 63% GA 62% shot, and their children are less likely to MS 61% receive routine checkups, dental care, AL, MD, IA, NY, WA 60% and flu shots.104 HI, MA 59% NE, VA 58% In 2018, 55 percent of workers in NH, RI, VT, WI 57% states, on average, had some type of CA, FL, WV 56% paid time off, according to the Current AL, CO, MO, MT, NV 55% Population Survey, which is sponsored IL, NM, OK 54% jointly by the U.S. Census Bureau and KS, LA, ME, NC, TN 53% NJ 52% the U.S. Bureau of Labor Statistics.105 MN, PA 51% Connecticut (65 percent), the District AZ, DE, ND 50% of Columbia (65 percent), and Texas ID 49% (68 percent) stood out as states where AR, IN, KY, MI, OH 48% relatively high percentages of workers SC, SD, UT 46% had such benefits, whereas fewer WY 45% workers had them in South Carolina (46 Note: Paid time off includes sick leave, vacations, and holidays. The measure’s data are estimated based on a survey of a sample of the general population. percent), South Dakota (46 percent), Source: NHSPI analysis of data from the Annual Social and Economic Supplement of the Current Utah (46 percent), and Wyoming (45 Population Survey. percent).106 (See Table 9.) 22 TFAH • tfah.org TABLE 10: Less than Half of Americans INDICATOR 8: FLU VACCINATION RATE Received a Seasonal Flu Vaccination States seasonal flu vaccination rates for people ages 6 months or older, 2017 – 2018 KEY FINDING: Flu vaccination coverage fell for the Vaccination Rate, State Ages 6 Months or Older 2017–2018 season, with a smaller share of every Rhode Island 50.1% age group analyzed receiving a vaccine. On average, Massachusetts 49.7% Maryland 49.3% 43 percent of state residents ages 6 months or older Washington 48.5% Minnesota 48.4% were vaccinated—well below the recommended level. New Jersey 48.1% Virginia 48.1% South Dakota 47.7% Delaware 47.6% Vaccination is the best prevention against the seasonal flu. West Virginia 47.6% The CDC recommends that everyone ages 6 months or older Iowa 47.1% get vaccinated annually, yet, year after year, even with a steady Nebraska 47.0% increase among adults over the past three decades,107 less than Connecticut 46.3% North Carolina 46.0% half of Americans do. The 2017–2018 flu season in the United Pennsylvania 46.0% States was the deadliest in nearly 40 years; it is estimated that Colorado 45.2% more than 900,000 people were hospitalized, and about 80,000 North Dakota 44.9% Oklahoma 44.9% people died108—tragically underscoring the importance of Mississippi 44.3% annual vaccination. Kentucky 44.1% South Carolina 44.1% Vaccination is particularly important for people at high risk of New Hampshire 43.7% severe flu-related illnesses, including young children, pregnant New Mexico 43.7% women, people with certain chronic health conditions, and Vermont 43.6% Hawaii 43.2% older adults. In addition to protecting Americans from the Ohio 42.8% seasonal flu, establishing a cultural norm of vaccination, building Alabama 42.4% vaccination infrastructure, and establishing policies that support Missouri 42.4% vaccinations can help prepare the country to vaccinate all Montana 42.1% Arkansas 41.7% Americans quickly during a pandemic or disease outbreak. Maine 41.2% Kansas 41.1% Under the Affordable Care Act, all routine vaccines Oregon 40.5% recommended by the Advisory Committee on Immunization New York 40.4% Practices, including flu shots, are fully covered when provided Wisconsin 40.4% by in-network providers, except in states that have not Alaska 40.2% California 40.0% expanded their Medicaid programs in accordance with the act. Illinois 39.9% Michigan 39.5% During the 2017–2018 flu season, 43 percent of state residents Nevada 39.1% ages 6 months or older were vaccinated on average, according Arizona 38.9% to the CDC.109 Only Rhode Island succeeded in vaccinating a Georgia 38.7% majority (50.1 percent), followed Maryland (49.3 percent) and Utah 38.5% Texas 37.6% Massachusetts (49.7 percent). (See Table 10.) Vaccination rates Idaho 37.0% were lowest in Louisiana and Wyoming (35.3 percent each), Indiana 37.0% Florida (35.6 percent), and Tennessee (36.4 percent). (Adult Tennessee 36.4% Florida 35.6% data were not available for the District of Columbia.) Louisiana 35.3% Children, particularly young children, were more likely to be Wyoming 35.3% vaccinated than were adults. Nearly 58 percent of Americans District of Columbia Data incomplete Note: These data are calculated from a survey sample, with a corresponding ages 6 months to 17 years were vaccinated in 2017–2018,110 sampling error. Adult data were not publicly reported for the District of Columbia. compared with just 37 percent of adults.111 ­ Source: Centers for Disease Control and Prevention.112 TFAH • tfah.org 23 INDICATOR 9: PATIENT SAFETY IN TABLE 11: Hospital Patient Safety Scores HOSPITALS Vary Significantly by State States percentage of hospitals with “A” grade, fall 2018 State Percent of Hospitals KEY FINDING: On average, roughly a quarter of New Jersey 57% Oregon 55% hospitals received an “A” grade in the fall 2018 Virginia 52% Massachusetts 44% hospital safety assessment administered by the Texas 43% Leapfrog Group, a nonprofit advocate for safety, North Carolina 43% Rhode Island 43% quality, and transparency in hospitals. Ohio 43% Colorado 41% Maine 40% Michigan 40% Hospitals can be dangerous places for patients. Every year, Louisiana 39% as many as 440,000 people die from hospital errors, injuries, Illinois 39% accidents, and infections, collectively making such incidents the Pennsylvania 38% third leading cause of death in the United States.113,114 Keeping Utah 36% Nevada 35% hospital patients safe from preventable harm is an important Georgia 35% element of preparedness; those hospitals that excel in safety are Mississippi 34% less likely to cause or contribute to a public health emergency Florida 34% and are better positioned to handle any public health Hawaii 33% Montana 33% emergencies that put routine quality standards to the test. Wisconsin 33% California 32% The Hospital Safety Score is calculated by the Leapfrog Group Kansas 32% using 27 evidence-based metrics that measure the success of New Hampshire 31% healthcare processes and outcomes. The measures track such South Carolina 30% issues as healthcare-associated infection rates, the number of Idaho 30% Wyoming 30% available beds and qualified staff in intensive-care units, nursing Oklahoma 26% staff volume, patients’ assessments of staff communications Alaska 25% and responsiveness, and a hospital’s overall culture of error Minnesota 25% prevention.115 These measures are especially critical for health Washington 24% system readiness for emergencies and outbreak prevention Kentucky 24% Missouri 23% and control, which includes workforce training and availability, Tennessee 23% surge capacity, and infection-control practices. Indiana 23% Arizona 22% In the Leapfrog Group’s fall 2018 assessment, 28 percent Maryland 20% of general acute-care hospitals across the United States, on Alabama 19% average, met the requirements for an “A” grade. But results Vermont 17% West Virginia 17% varied widely state to state, from no hospitals in Delaware, New Mexico 14% North Dakota, or the District of Columbia receiving the top Arkansas 10% score, to a majority of hospitals doing so in New Jersey (57 South Dakota 10% percent), Oregon (55 percent), and Virginia (52 percent). Iowa 9% New York 8% (See Table 11.) Hospitals with “F” grades were in California, Connecticut 8% Florida, Illinois, Indiana, Louisiana, Mississippi, New York, New Nebraska 7% Jersey, New Mexico, and South Carolina. These states also had Delaware 0% hospitals with higher scores. District of Columbia 0% North Dakota 0% Note: This measure captures only general acute-care hospitals. Source: The Leapfrog Group.116 24 TFAH • tfah.org INDICATOR 10: STATE Public health laboratories are essential situation, implementing substantial to emergency response. They help operational changes as defined in PUBLIC HEALTH detect and diagnose health threats as laboratory emergency response plans LABORATORY SURGE they emerge, and they track and monitor and using all resources available CAPACITY the spread of those threats, which can within the laboratory.”118 Surging help public health officials learn how capacity can require staff movement to control them. Public health labs or reassignment, extra shifts, and KEY FINDING: Virtually every state exist in every state and territory and hiring. Labs also have to plan for reported having a plan in 2017 are the backbone of the Laboratory infrastructure factors, such as sufficient Response Network (LRN), a national biological safety cabinets and chemical for a six- to eight-week surge in network of laboratories that provide the fume hoods; amount and type of laboratory testing capacity to infrastructure and capacity to respond to supplies; space for intake, processing, public health emergencies.117 and storage of samples; versatility respond to an outbreak or other and capacity of analytical equipment public health event. When a disaster or disease outbreak and instruments; personal protective strikes, public health laboratories must equipment; and power supply.119 be able to surge to meet increased demand, just like hospitals and other In 2017, the District of Columbia and responders. The Association of Public all states except Arkansas, Georgia, New Health Laboratories defines internal Jersey, Oregon, Utah, and Vermont surge capacity as a “sudden and reported to the Association of Public sustained increase in the volume of Health Laboratories that they had a testing that a LRN reference laboratory plan for a six- to eight-week surge in can perform in an emergency testing capacity. (See Table 12.) TABLE 12: Nearly Every State Planned for a Laboratory Surge State public health laboratories had a plan for a six- to eight-week surge in testing capacity, 2017 Had a Plan No Plan Alabama Iowa Nevada Texas Arkansas Alaska Kansas New Hampshire Virginia Georgia Arizona Kentucky New Mexico Washington New Jersey California Louisiana New York West Virginia Oregon Colorado Maine North Carolina Wisconsin Utah Connecticut Maryland North Dakota Wyoming Vermont Delaware Massachusetts Ohio District of Michigan Oklahoma Columbia Florida Minnesota Pennsylvania Hawaii Mississippi Rhode Island Idaho Missouri South Carolina Illinois Montana South Dakota Indiana Nebraska Tennessee Note: This indicator tracks only the existence of a plan, not its quality or comprehensiveness, or the frequency in which it is used or tested. Georgia and New Jersey reported that they had a plan for a six- to eight-week surge in 2018; Montana and West Virginia reported that they did not have a plan in 2018. Source: NHSPI analysis of data from the Association of Public Health Laboratories. TFAH • tfah.org 25 S EC T I ON 3 : Ready or Not: Recommendations RECOMMENDATIONS Protecting the Securing a nation against major public health threats requires action Public’s Health by policymakers at all levels, public health practitioners, the healthcare delivery system, academia, and the private or nongovernmental from Diseases, sectors. What follows is a description of actions these stakeholders Disasters and should take to improve the country’s health security. Cutting across these recommendations are three common themes: Bioterrorism 1) ufficient resource allocation. There is S and improve emergency preparedness a need for both a stable and dedicated as materials and tools improve and budget as well as a readily available lessons are learned. supplemental funding process for 3) killed multisector leadership and S emergency preparedness and response collaboration. Multiple organizations, and for health security programs. agencies, and sectors must be involved 2) Modern technologies and innovations. in planning to ensure adequate There are continual needs to update response and minimal harm. TFAH supports the following recommendations across 11 high-priority areas: Priority Area 1: Funding a Modern Public Health and Emergency Preparedness Infrastructure Every person deserves the protection of disaster or outbreak, then an infusion of a modern public health system equipped onetime supplemental funds, and finally to surmount 21st-century threats. Indeed, an erosion of money once attention protecting communities from disasters wanes. This pattern undermines health and disease outbreaks is a fundamental security. A modern health security responsibility of the public health infrastructure requires reliable funding community. Public health departments, to support preparedness capabilities healthcare providers, and emergency and staffing, emergency funds for major management officials must work together crises, and flexibility to recover and to prevent and respond to threats. rebuild resilient communities. The U.S. health security infrastructure Since 2001, federal funds to support and has made tremendous progress since the maintain state and local public health 9/11 terrorist attacks by building modern preparedness have been cut by about FEBRUARY 2019 laboratories, maintaining a pipeline of 28 percent (from $940 million in fiscal medical countermeasures, and recruiting 2002 to $675 million in fiscal 2019), and retaining a workforce trained in and funding for healthcare emergency emergency operations. Yet, unstable and preparedness has been cut nearly in insufficient funding puts this progress at half (from $515 million in fiscal 2004 to risk. Too often, there has been a chronic $265 million in fiscal 2019). Researchers cycle of stagnant funding, followed by a estimate that state and local public health agencies face a $13 per-capita shortfall,120 preparedness, assessment and surveillance, Hospital Preparedness Program, have on average, to achieve full foundational communications, and partnership helped communities respond to many capabilities—“the cross-cutting skills development, are critical to protecting emergencies without additional federal that need to be present in state and communities from emergencies. support. But larger or more demanding local health departments everywhere emergencies and outbreaks necessitate Long-term investments, such as Public for the system to work anywhere.”121 both base preparedness funding and a Health Emergency Preparedness These capabilities, such as all-hazards surge of resources. cooperative agreements and the RECOMMENDATIONS: l P rovide stable, dedicated, and sufficient century threats. Members of the Public the rapid hiring of emergency response funding for preparedness activities and Health Leadership Forum, which found workers when a disaster strikes. In a significant funding increase for core that only 51 percent of Americans are addition, policymakers should streamline public health capabilities. Continued served by a comprehensive public health the traditional procurement processes investment is crucial in specialized system, recommends the creation of and create mechanisms for the rapid programs that support health security, a Public Health Infrastructure Fund to release of emergency supplemental including Public Health Emergency assure protection for all communities. 123 funding. Advance planning and testing Preparedness, the Hospital Preparedness of accelerated personnel, procurement, l E stablish a standing public health Program, and medical countermeasures and other administrative processes, emergency response fund to accelerate programs. Congress should also including the consideration of contingency crisis responses. In addition to stable significantly increase overall funding for contracting (as is done with indefinite core funding, governments need readily the CDC, which supports national, state, delivery, indefinite quantity contracts), will available funds on hand to respond to local, tribal, and territorial health security avoid dangerous delays in emergencies crises. When the Zika outbreak began capabilities, as well as more generalized when every minute counts. in 2016, it took nearly nine months for core public health capabilities, such Congress to appropriate funds, and even l T he federal government should permit as epidemiology, communications, and more time for states to access them. states and grantees to braid or blend information technology. As the 2017 Congress should place sufficient money emergency funding streams that hurricane season demonstrated, public into a public health emergency response support response and recovery. health and healthcare systems must fund to serve as a temporary bridge Emergency funding for an event may be be strong and collaborative to reduce between preparedness and supplemental allocated to multiple federal agencies. the health impacts of emergencies. emergency funds. It should be used for However, the coordination of funding Following Hurricane Maria in Puerto acute emergencies that require a rapid across agencies can be impeded by Rico, the provision of healthcare and response to save lives and protect the differing agency policies and practices. behavioral health services, assessment public. Such funding should not come This can lead to disconnected and less and mitigation of environmental health from existing emergency preparedness effective emergency responses on the threats, prevention of outbreaks, and resources, nor should it supplant other ground. To prevent this inefficiency, surveillance of ongoing health effects cuts made to such resources. policymakers should adopt practices that were all severely curtailed. Such allow for braiding funding from various foundational capabilities cannot be built l F ederal agencies and state policymakers sources to support a single initiative or rebuilt overnight in an emergency. should update policies to allow for or strategy at the state, community, or expedited emergency responses. The 22 by 22 campaign, led by the program level. Braided funds remain in Usual—sometimes time-consuming— Association of State and Territorial separate and distinguishable strands administrative policies and practices Health Officials122 and joined by over 70 for tracking purposes but can have can become impediments to a quick partners, urges Congress to increase coordinated application processes and response during an emergency. Federal funding for the CDC by 22 percent by funding cycles, jointly funded line items, and state policymakers should review federal fiscal year 2022 in order to equip and uniform reporting mechanisms. and update personnel laws to facilitate the public health system to face 21st TFAH • tfah.org 27 Priority Area 2: Bolstering Global Health Security Disease can spread from an isolated, when they occur.126 America’s 2018 rural village to any major city in just National Biodefense Strategy shares this 36 hours.124 Food, people, and supply objective, setting a goal to “strengthen chains move across the globe, and global health security capacities to America’s economy and security depend prevent local bio-incidents from on the safety of those movements. becoming epidemics.” However, many nations are still not U.S. investment in global health security prepared to detect and respond to received a onetime increase of $909 disease threats, as the outbreak of Ebola million in the 2015 Ebola supplemental in the Democratic Republic of the funding appropriation,127 but significant Congo demonstrates. annual funds are needed to help build The Global Health Security Agenda and maintain the domestic capacity in (GHSA) is an international, multisector GHSA-target nations. The United States commitment by more than 64 nations, reaffirmed support for the GHSA in international organizations, and November 2018 when HHS Secretary nongovernmental stakeholders to build Alex Azar announced a commitment countries’ capacity to protect against of $150 million.128 However that infectious disease threats before they announcement involved funding that become severe.125 Its goal is to build had already been appropriated, rather health systems that prevent and detect than ongoing or new investments.129 outbreaks and respond effectively RECOMMENDATION: l T he United States should maintain key partner in the GHSA and must a significant long-term investment maintain its leadership in the effort. in the GHSA framework and The U.S. commitment requires robust global preparedness and response annual funding to maintain and programs. The United States is a improve these programs.130 28 TFAH • tfah.org La Zona / Shutterstock.com Priority Area 3: Improving Leadership and Coordination Every recent crisis illustrates strengths and weaknesses in coordination, leadership, and collaboration across governmental and nongovernmental organizations. For example, the Federal Emergency Management Agency’s (FEMA) after-action report on the 2017 hurricane season found that the agency had inadequate plans for michelmond / Shutterstock.com a devastating disaster, underestimated resources needed, lacked staff and Many 21st-century threats will not be health injuries and illnesses. The HHS, clarity of roles with partner entities, addressed by a single agency. During FEMA, the State Department, the U.S. and failed to leverage information— the devastating 2017 hurricane season, Agency for International Development, all of which contributed to delays in for instance, public health officials in the Defense Department, and the response and recovery.131 (As of this Florida, Texas, Puerto Rico, and the U.S. Environmental Protection Agency, writing, a similar after-action report Virgin Islands identified critical public among others, all play a part in modern has not been made publicly available health needs that would not be addressed health security. Therefore, specialized for agencies within the HHS or other by FEMA funding, such as post- efforts to ensure coordination and federal departments.) emergency trauma and environmental skillful, timely leadership are crucial. RECOMMENDATIONS: l C ongress should quickly pass and fully stakeholder engagement and continue to and response activities, including fund the Pandemic and All-Hazards align with and advance the U.S. Health private-sector and volunteer-organization Preparedness and Advancing Innovation Security National Action Plan and other engagement, taking care to maintain Act. This legislation authorizes most national security strategies. systems and policies that are working federal public health security programs well, to avoid duplicative efforts, and to l H HS, the CDC, and the Office of the and proposes strategies to improve their keep experts connected to key functions. Assistant Secretary for Preparedness effectiveness. and Response (ASPR), and FEMA l P olicymakers and public health l T he National Biodefense Strategy (NBS) should clarify roles and address gaps officials should develop, in advance should be followed by transparent within the government’s Emergency of an event, a framework for decision goals, implementation plans, and Support Functions. Disaster survivors, making related to isolation, quarantine, budgets for all relevant agencies. The especially those with disabilities or in movement, and monitoring decisions strategy—which directs biodefense need of ongoing care, can fall through during extraordinary outbreaks. priorities for multiple agencies—sets the cracks between federal agencies’ Federal, state, and local public health goals around risk awareness, prevention, response functions. 132 FEMA’s after-action and infectious disease experts should preparedness, rapid response, and report for the 2017 hurricanes called convene to agree on a framework that recovery. The National Biodefense for cross-sector Emergency Support helps states make movement and Strategy will only be successful if it Functions to integrate FEMA capabilities monitoring decisions that are based is backed by adequate funding and with the public, the private sector, and on scientific and medical evidence; programmatic support and involvement volunteer actions to ensure the right that preserves social and economic of relevant public health agencies. capability reaches the survivor at the right continuity to the greatest extent Implementation of the strategy should be time.133 The ASPR and the CDC should possible; and that is in the best interest transparent and should allow for routine coordinate and align their preparedness of the public’s health. TFAH • tfah.org 29 Priority Area 4: ccelerating Development and Distribution of Medical Countermeasures A Medical countermeasures (MCMs), deployment. Many small companies in the FDA-regulated biologics, drugs, the CBRN sector depend on government and devices used in public health investment, so stable funding and emergencies, represent one of the best transparency are important. defenses against natural and man-made The United States is not adequately health threats. With effective and timely prepared for a flu pandemic, as vaccines, diagnostics, and treatments, existing vaccines are only partially diseases can be prevented or contained effective and still take too long to before becoming global crises—but produce. Too few new antibiotics are only if they reach the right people at the being produced to meet the threat of right time. The United States has made antimicrobial resistance, and companies tremendous progress in improving the continue to move away from antibiotic pipeline of medical countermeasures development. As the Zika and Ebola to protect against chemical, biological, outbreaks demonstrated, the next radiological, and nuclear (CBRN) threats. health security crisis could be an But this progress could be undermined unanticipated disease with few, if any, by unstable funding and insufficient MCM options in development. support for MCM development and RECOMMENDATIONS: l P rovide significant funding over the long ASPR. Oversight of the SNS moved l S trengthen the last mile of distribution term for the entire MCM enterprise, from the CDC to the ASPR in 2018. The and dispensing. While transitioning including new funding models and HHS must ensure that this significant SNS functions to the ASPR, state and promising technologies. Long-term transition does not negatively affect local health departments must continue funding that is coordinated and readiness by separating the CDC’s to be key partners in coordinating transparent would offer more certainty expertise and its well-established distribution and dispensing to targeted to the biotechnology industry and relationships with states and localities populations. Funding, planning, training, researchers and would strengthen public- from SNS operations, or through and engagement of health departments private partnerships. Public and private duplicative systems and procedures for this purpose should be improved, and investors should support innovative that complicate responses. HHS should private-sector distributors and supply- funding models for biodefense, similar to also ensure proper procedures for chain partners should be integrated into the Coalition for Epidemic Preparedness purchase decisions, including regular planning, exercises, and responses. Innovations or the Combating Antibiotic input of the Public Health Emergency Investments in new technologies should Resistant Bacteria Biopharmaceutical Countermeasures Enterprise (PHEMCE), also consider last-mile delivery needs Accelerator (CARB-X) and the BARDA an interagency coordinating body. Officials by investing in innovative delivery and Division of Research Innovation and should continue supporting state and distribution methods. HHS, including Ventures (DRIVe) acceleration program local MCM distribution capabilities, the CDC, should work with healthcare models. The United States should clarify roles between the CDC and the professionals and state and local partners invest in innovative, flexible technologies ASPR in day-to-day activities and incident to develop standardized guidance for and capabilities that will enable faster response, avoid administrative duplication distributing and dispensing MCMs to production of products.134,135 and delay, and restore necessary funding children, people who are homebound, and and staff for the CDC. The HHS should other target groups. Finally, the CDC and l C losely monitor the impacts of the also measure and evaluate the success FDA must monitor and assess MCM use transition of the Strategic National of the leadership transfer. nationally during emergencies.136 Stockpile (SNS) from the CDC to the 30 TFAH • tfah.org Priority Area 5: Improving Disease Surveillance Health security requires efficient As new technologies enable earlier a reporting burden and duplication and effective disease detection. and more accurate identification of effort for partners, discrepancies Disease surveillance is a multisectoral, of pathogens and outbreaks, public among the data elements, and the need multilayered system that requires accurate health surveillance must adapt. to use multiple information technology diagnostics; fast communication between For example, culture-independent systems.” The CDC has made progress clinicians, clinical laboratories, and their diagnostic tests of enteric diseases in addressing the reduction of state, local, tribal, and territorial (SLTT) speed up diagnosis but may redundant surveillance systems and the public health counterparts; efficient complicate the detection of outbreaks faster reporting of data, but significant reporting between SLTT and federal by forgoing the submission of cultures effort is still needed to support agencies; and a well-trained workforce to public health laboratories.137,138 And effective disease surveillance. Some at all levels. The CDC is investing in earlier detection of pathogens—the remaining challenges for public health Advanced Molecular Detection capacity result of innovation—necessitates include recruiting and retaining health to enable state and local public health more boots on the ground to informatics specialists, data scientists laboratories to study the genetic makeup investigate sources of pathogens. and other qualified staff; upgrading of pathogens, to examine vaccine laboratory and IT technologies; In 2018, the CDC released a progress effectiveness, to detect outbreaks and adapting surveillance systems to newer report on the implementation of its their sources faster, to develop better diagnostics; and building into reporting public health surveillance strategy.139 diagnostics, and to understand the spread systems electronic case reporting, two- The progress report found that the of transmission. However, due to funding way communication with clinicians, and “CDC maintains more than 100 constraints, these advancements are being interoperability. surveillance systems, which creates implemented in a piecemeal fashion. RECOMMENDATIONS: l D evelop a strategic budget plan and fully fund surveillance and data infrastructure for fast, accurate outbreak detection at all levels of government. The CDC, in consultation with public health and nongovernmental partners, should submit to Congress a multiyear strategic vision and professional judgment budget estimate for what is needed to upgrade bio- surveillance capacity and interoperability at all levels of government. The estimate should account for workforce needs, public health laboratory and epidemiological capacity, and technological upgrades. of siloed systems and requiring all streamlined data exchange mechanisms l T he CDC should be sufficiently funded grants and cooperative agreements and should actively participate in to fully implement its internal strategic that have a surveillance element to national syndromic surveillance. plan for improving surveillance and meet updated data standards. More Public health officials must also have public health data. 140 Implementation states should use electronic messaging a coherent strategy for incorporating should include reducing the number for notifiable diseases and other nongovernmental data into surveillance. TFAH • tfah.org 31 Priority Area 6: Ensuring a Qualified Public Health Workforce laboratories, educate and train first responders and other key agencies and organizations, organize incident commands, communicate with the public, and provide life-saving medical countermeasures. These capabilities require training and experience. Unfortunately, the public health workforce continues to dwindle. While layoffs and attrition in local health departments appeared to slow in 2017 after many years of decline,141 the local public health workforce fell by 56,360 jobs from 2008 to 2017,142 and the state public health workforce for the United States fell by 9 percent from 2010 to 2016.143 A 2017 survey of the governmental public health workforce found nearly half could leave their organizations within the next five years, including many who may leave the public health field Even as technology allows health security is done by people. Public altogether.144 These reductions could agencies to identify pathogens more health professionals investigate and threaten health security by eroding quickly, or to respond to disasters respond to potential infectious disease leadership, scientific expertise, and more effectively, much of the work outbreaks and/or environmental core capabilities. of protecting the public’s health risk factors, operate specialized RECOMMENDATIONS: l S upport and fund the recruitment a focus on health equity opportunities l E ase hiring at the federal, state, and and training of experienced public in emergency preparedness. Health local level. In an emergency, it can be health professionals. A highly trained departments should prioritize these difficult to hire people quickly. Each health security workforce cannot simply skills when making hiring decisions. state has its own rules for staffing be hired after a disaster occurs and Student-loan repayment programs, and contracting, which may not align cannot be supported long-term by leadership training, addressing barriers with priorities during an emergency supplemental or emergency funding. to hiring, and other incentives could help response. The HHS should offer Federal, state, and local policymakers attract medical, science, management, guidance to states in effectively hiring must prioritize stable funding for public communications, and informatics and contracting during emergencies. health departments to ensure that they experts into the sector. Federal grants HHS agencies should also have have a pipeline of skilled workers in should require staff to receive public authorities to make immediate offers such pressing areas as vector control health emergency strategic skills and competitive salaries to a range and public health informatics. Public training. Health agencies should also of emergency response staff, such as health curricula should emphasize have plans and capacity to protect their epidemiologists and logisticians. cultural and linguistic competency, with workers during emergencies. 32 TFAH • tfah.org Priority Area 7: Readying the Healthcare System to Respond and Recover The healthcare delivery system plays a critical role in emergency response. It can be the focal point for widespread vaccination, as it was for the H1N1 pandemic in 2009. It can screen those at elevated risk to determine current health status and provide preventive counseling, as it did in response to the Zika outbreak in 2015–2016. And it can provide urgent care to those with injuries or illnesses in a disaster. It has a special role in protecting and treating those who may be most vulnerable in a crisis, such as frail older adults, young children, pregnant women, people with chronic conditions or disabilities, and those already being cared for in acute- Preparedness Program, administered by Regional Disaster Health Response care and long-term-care facilities. the ASPR, provides funding to states to System intended to create a more develop healthcare coalitions— within comprehensive disaster health Sometimes healthcare facilities are state or regional collaborations between system.146 The nascent program ill-prepared for major emergencies. hospitals, public health, emergency provides grants to hospital-led For example, in 2017, after Hurricane management, and other healthcare partnerships to build a disaster health Irma struck Florida, 12 residents of a organizations—to collaborate in response network, align policies for Florida nursing facility died when the meeting the healthcare preparedness clinical excellence in disaster response, building lost air conditioning for several needs of their communities. increase statewide medical surge days.145 This tragedy called into focus capacity, improve situational awareness, the remaining challenges in preparing In 2018, the HHS initiated a and evaluate capabilities.147 facilities for disasters. The Hospital demonstration program called the RECOMMENDATIONS: l B olster the Hospital Preparedness into regional emergency response. Program and multisector healthcare Multisector collaboration from across collaboration. The Hospital the healthcare spectrum is integral to Preparedness Program needs robust major responses, especially by helping annual funding to ensure every state with managing surges of patients has strong healthcare coalitions that at acute-care facilities. Congress meet the program’s objectives, and should provide additional funding— the program must strive for quality not supplanting existing hospital improvement and the ability to meet preparedness funds—for tiered, regional the needs of the healthcare delivery disaster healthcare systems. These system. Healthcare coalitions must entities should coordinate and leverage continue to build and diversify their existing coalitions to address statewide memberships and fully integrate and regional preparedness challenges. TFAH • tfah.org 33 protective measures, such as vaccines and personal protective equipment, for healthcare workers at all levels, including for those who work outside of clinics. l M eet health needs of populations at risk for a disproportionate impact during disasters. Healthcare providers, policymakers, and emergency personnel need to ensure that planning and response efforts include attention to the special needs of populations that are particularly at-risk. Examples of the need for such attention include older adults Lowe Llaguno / Shutterstock.com who have had high death and injury rates in weather-related emergencies, such as in Hurricane Katrina in New Orleans and in the recent fires in California. People with chronic conditions that require medication or regular treatment, such as dialysis, may be at greater risk in disasters due to power outages, inability l C larify and strengthen policies regarding l P repare every healthcare facility to evacuate safely, and lack of access disaster healthcare delivery. States have for outbreaks and disasters. Every to specialized care. Health systems, varied policies and practices governing healthcare facility—from private payers, providers and other community- the delivery of healthcare during practices to major hospitals—should be serving organizations should ensure emergencies, including those pertaining prepared for a range of potential events. continuity of care and services for such to contracting and hiring, licensure and The Centers for Medicare and Medicaid individuals during disasters or other credentialing, use of telehealth, liability Services (CMS) should strengthen, health emergencies. for healthcare providers and volunteers, implement, and ensure compliance and adoption of crisis standards of care with the emergency preparedness rule The American Academy of Pediatrics in the context of scarce resources. The for participating healthcare facilities. recommends that both the Hospital ASPR should review barriers to healthcare Healthcare facilities should start with the Preparedness Program and the Public response and recovery and should requirements of the CMS preparedness Health Emergency Preparedness provide guidance for states to clarify rule148 and CDC’s antibiotic stewardship program address the needs of children laws and policies regarding healthcare core elements, 149 but healthcare and incorporate the needs of children disaster readiness and volunteer facilities should also have clear, well- into their programs’ performance management. State policymakers should communicated plans for infectious measures.150 According to Save the adopt best practices and policies that disease screening and containment, Children, the United States still lacks a promote healthcare readiness, such as incident command, capacity to deal coordinated national strategy to improve the Nurse Licensure Compact, the EMS with a surge of patients and healthcare pediatric emergency transport and care Personnel Licensure Interstate CompAct, volunteers, continuity of operations, in disasters, and no federal agency the Uniform Emergency Volunteer Health evacuation, and crisis communications. has been designated as the lead on Practitioners Act, and crisis standards of All healthcare systems should offer prehospital emergency medical services care guidelines. appropriate training and provide preparedness.151 34 TFAH • tfah.org Priority Area 8: Preparing for Environmental Threats and Extreme Weather Health departments have an important prevent millions of premature deaths.156 role to play in helping communities The frequency and severity of storms adapt for, and mitigate, the adverse and flooding, as well as wildfires, is effects of climate change and extreme forcing many health departments to weather. Climate change may affect regularly respond to natural disasters, health, including by exacerbating which detracts from their ongoing cardiovascular and respiratory diseases, prevention and health-protection waterborne outbreaks, vector-borne work. Other environmental health diseases, and heat-related deaths.152,153 threats, such as algal blooms and Large-scale droughts and floods are lead in drinking water, have required leading to food and water insecurity multisector responses in several states. in some regions of the globe.154,155 The Every health department should 2018 U.N. climate change report stated prepare for these growing threats to that reducing global warming could human and animal health. RECOMMENDATIONS: l E very state should have a the public about ways to avoid potential detect vector-borne diseases, such as comprehensive climate change threats. State and local public health Zika, West Nile Virus, and Lyme disease. adaptation plan that includes a public officials should ensure that environmental l G uarantee clean water for all U.S. health assessment and response. health is incorporated into emergency residents, including after disasters. Public health and environmental operations planning and incident All states should include water agencies should work together to track command. In addition, funding for security and sewage removal in their concerns, coordinate risk management programs at the CDC’s National Center preparedness plans, and they should and communications, and prioritize for Environmental Health and Agency for build relationships between health the necessary capabilities to reduce Toxic Substances and Disease Registry departments and local environmental and address threats. States and is essential for tracking and mitigating and water agencies. The CDC should localities should investigate what environmental health risks, such as include national guidance and metrics additional capacities are needed and contaminants, heat, and unsafe water. for planning for a range of water-related identify vulnerable populations and l D evelop sustainable state and local crises. Measures that should be taken communities. vector-control programs. A 2017 to protect a safe water supply include l I mprove coordination and alignment assessment of local vector-control addressing the ongoing problem of lead of public health and environmental organizations found that 84 percent and other toxins in drinking water, and agencies. Public health agencies at all of respondents were in need of taking steps, such as those in the EPA’s levels must work with environmental, improvement in core competencies.157 Clean Water Rule, to reduce the potential homeland security, and other agencies The vector-borne disease program at the for waterborne illnesses and to increase to undertake initiatives to reduce known CDC should be broadly expanded and protection against potential acts of health threats from extreme weather. should receive robust funding to support biological and chemical terrorism on Public health agencies must educate state and local capacity to prevent and America’s drinking and agricultural water. TFAH • tfah.org 35 Priority Area 9: Building Resilient Communities and Promoting Health Equity Health disparities, underlying inequities and after an event. Individuals with relocation to a shelter. Those with in access to care and services, and limited English proficiency may not behavioral health diagnoses may find the effects of social determinants of receive timely messages in their primary their symptoms worsened by stress health are exacerbated during health language in the period leading up to and lack of access to regular services emergencies. People with low incomes and during an emergency. Residents during emergencies. Community are often at risk of increased impact who are concerned about their resilience and preparedness planning of a health emergency because they immigration status may be reluctant must recognize health inequities to may have fewer resources to draw on to to accept government assistance. Frail address systemic barriers to services secure their safety during an evacuation. older adults and individuals with serious and must ensure inclusive planning, Many communities of color can suffer chronic illnesses or with access and especially for populations that may face disproportionately during a disaster functional needs may also face serious a disproportionate impact of disasters.158 due to unequal access to services before challenges during an evacuation and RECOMMENDATIONS: l I mprove social determinants of health. resilience officer positions to work in planning. For example, emergency Public health leaders should serve as across programs and agencies managers should establish relationships the chief health strategists for their to advance equity in community- with local independent-living centers communities, working with partners to resilience work and to ensure that it is and assess the accessibility of their address social and economic factors incorporated into preparedness policies sheltering facilities to ensure they meet that influence the health and well-being and plans.160 Innovative partnerships the needs of individuals with access and of communities. 159 Health departments and funding models can also be used to functional needs.162 should use community partnerships and build equity and resilience. The Public l A ddress behavioral health resource data to understand systemic barriers to Health 3.0 model (a 21st century public gaps and incorporate mental health services for traditionally underserved health model) promotes initiatives first-aid and long-term mental health communities that could be addressed to foster shared funding, services, treatment into disaster response before a disaster. Improving the health governance, and collective action and recovery strategies. Emergency of communities helps them prepare between diverse sectors to advance preparedness plans and funding for, respond to, and recover from equity.161 These types of organizational should address immediate- and long- emergencies. This may include working structures can enable the blending and term behavioral health needs.163 on economic policies that reduce braiding of funding from disparate public Services and supports provided to poverty and improve health, such as and private sources to promote a long- disaster survivors should also be low-income tax credits, and that improve term strategy for health equity. trauma-informed, should build on working and living conditions, such as l P lan with communities, not for them. the best evidence available, should paid sick leave and affordable housing. Officials from emergency management empower survivors, and should work Attention to social determinants also and public health agencies should collaboratively with individuals and involves reducing racism and other meaningfully engage community their families.164 Communities can also forms of discrimination, which can lead members and organizations that might create “resilience hubs,” which are to poorer health and uneven responses be disproportionately impacted by a community-serving facilities meant to to community-wide emergencies. disaster—such as people with functional both support residents and coordinate l P ublic health departments should build and access needs, people with limited resource distribution and services strong cross-sector partnerships that English proficiency, people who live before, during and after a natural advance health equity. Communities in poverty, and racially and ethnically hazard event.165 should create chief equity officer or diverse communities—and involve them 36 TFAH • tfah.org Priority Area 10: Stopping Outbreaks and Superbugs Emerging infectious diseases and remote places of the world—could infection each year, and at least 23,000 antimicrobial-resistant superbugs spread rapidly across oceans and people in the U.S. die from such present growing national security continents, directly impacting the U.S. infections.167 Preventing, detecting, threats. The 2018 National Biodefense population and its health, security and responding to outbreaks requires Strategy centered on infectious and prosperity.”166 The CDC estimates cross-sectoral collaboration between disease threats, stating, “An infectious that at least two million people in healthcare, public health, academic, disease outbreak—even in the most the United States get a drug-resistant and private-sector stakeholders. RECOMMENDATIONS: l S ignificantly increase public and private promote growth and prevent disease in devoted to implementing and enforcing investments in innovative initiatives healthy animals, as recommended by the FDA Food Safety Modernization to combat antimicrobial resistance. the World Health Organization,169 and Act (FSMA). The FDA should ensure Federal policymakers should increase they should invest in research to develop public health is the top priority as it funding for priorities of the National and adopt husbandry practices that implements the FSMA’s prevention- Action Plan for Combating Antibiotic reduce the need for routine antibiotics. based rules to ensure that proposed Resistant Bacteria, including innovative exemptions do not increase risk from l D ecrease overprescription of methods of detecting and containing foodborne illnesses. Lawmakers should antibiotics through implementation of outbreaks, such as the Antibiotic also modernize meat and poultry laws antibiotic stewardship and antibiotic- Resistance Solutions Initiative at the so that they are more risk-based, use reporting. CMS should finalize, CDC. There should be robust public- science-based, and protective of public implement, and enforce requirements private investment in antibiotic discovery health. In the near term, HHS and for all CMS-enrolled facilities to science, diagnostics, early stage product the U.S. Department of Agriculture have effective antibiotic stewardship development, and research through the should take the lead in providing better programs that align with the CDC’s Core Biomedical Advanced Research and organization and coordination across Elements of Antibiotic Stewardship Development Authority, CARB-X, and the federal government agencies with guidance and that work with public other programs. Partners should also food safety roles. health stakeholders to track progress work together to decouple antibiotic in prescribing rates and resistance l P rovide job-protected paid sick leave. reimbursement from drug sales so that patterns. All relevant facilities must Approximately 40 percent of private- drug developers are incentivized to drastically improve their reporting of sector employees—more than 41 innovate, despite efforts to conserve antibiotic use and resistance through million workers—cannot earn paid antibiotics.168 the National Healthcare Safety sick days to care for themselves or l E liminate overuse of antibiotics in Network and should adopt stewardship an ill family member.170 When workers agriculture. The FDA and partner programs that meet the CDC’s core without paid sick leave get sick, agencies should enforce rules regarding elements. Finally, HHS, CMS, accrediting they face the choice of working and veterinary oversight and the judicious organizations, healthcare facilities, potentially infecting others or staying use of antibiotics in food animals, medical schools, and others should home and risking the loss of income or should ensure data collection and educate providers and patients about even unemployment. Some industries publication, should promote antibiotic the harm of inappropriate prescribing. and occupations that require frequent stewardship programs, and should contact with the public are least likely l M odernize food safety practices track the impact of these policies to provide paid sick leave, enabling and policies and work toward better on resistance patterns. Farmers and diseases to spread through contact with coordination across agencies. Sufficient the food industry should stop using food, coworkers, and the public. federal and state funding should be medically important antibiotics to TFAH • tfah.org 37 Priority Area 11: Improving Vaccination Rates Across the Lifespan Despite the effectiveness of vaccines, adult vaccination rates remain far vaccination rates remain low in many below targets in Healthy People 2020, communities across the United States, including for hepatitis B, seasonal flu, placing people of all ages at risk for pneumococcal, and shingles.172 outbreaks and disease. In 2018, the These gaps have serious consequences CDC reported that the percentage across the lifespan. An estimated of children under age 2 who had 80,000 people died—among them, 185 not received any recommended children173—from seasonal flu in 2017– vaccinations quadrupled since 2018, nearly twice what is considered 2001.171 While overall childhood typical during an average flu year.174 vaccination rates remain relatively Up to 1.4 million people suffer from high, there are pockets of the chronic hepatitis B, which can cause United States with much higher liver cancer and death, and human rates of unvaccinated children, papillomavirus which causes more than placing those communities at risk 27,000 cancers each year.175 for deadly outbreaks. In addition, RECOMMENDATIONS: l R aise awareness about the importance l E nsure first-dollar coverage for of vaccination. Government, healthcare recommended vaccines under systems, and other partners should use Medicaid, Medicare, and commercial varied and targeted media channels to insurance. Public and private payers educate people about the importance, should ensure that ACIP-recommended effectiveness, and safety of vaccinations. vaccines are fully covered, as cost- sharing can be a significant barrier l M inimize vaccine exemptions for to vaccination.177 All insurance plans schoolchildren and healthcare workers. should consider pharmacies and other States should enact and provide universal complimentary providers as in-network childhood vaccinations to ensure children, and receive equal payment for vaccine their classmates, and educators are administration services for their adult protected from diseases (except where and pediatric populations. immunization is medically contraindicated). The National Vaccine Advisory Committee l S upport the vaccine infrastructure. recommends that states with existing The Vaccines for Children program, Personal Belief Exemptions should the CDC’s immunization program (also strengthen policies so that exemptions called the Section 317 Program), and are only available after appropriate parent state immunization information systems education and acknowledgement of risks provide the infrastructure and systems to to their child and to the community.176 states to fill immunization gaps among Healthcare personnel should also be the uninsured and underinsured, and to required to receive all Advisory Committee track usage, safety, and effectiveness of on Immunization Practices (ACIP)– vaccines. These systems are especially recommended vaccinations to protect vital during outbreaks for conducting staff and continuity of operations, support surveillance and targeting vaccines to healthcare infection control, and improve relevant individuals. overall patient safety. 38 TFAH • tfah.org APPEN DIX Appendix: Methodology Ready or Not: APPENDIX: METHODOLOGY To assess the strengths and weaknesses of past editions of Ready Protecting the or Not, including the indicators of public health emergency preparedness that they tracked, Trust for America’s Health Public’s Health (TFAH) conducted listening sessions with state stakeholders from Diseases, (health officers, directors of public health preparedness, and the Association of State and Territorial Health Officials), national Disasters and stakeholders (staff from the executive and legislative branches, Bioterrorism academia, and other policy leaders), and a cross-cutting panel of advisors. Taking into account the guidance of these groups, TFAH established criteria for selecting indicators. Each needed to be: l ignificant. The indicator needed to be S U.S. territories.) TFAH will strive to a meaningful measure of states’ public retain all or most of these indicators for health emergency preparedness. multiple years in response to feedback Significance was first measured by from the reports’ end users that such NHSPI using a multi-stage Delphi stability would help focus attention on process with a panel of experts, making concrete improvements. and then again by TFAH through In response to feedback that alignment interviews with additional experts. between indicators tracked by TFAH and l roadly relevant and accessible. The B the NHSPI would assist state policymakers indicator needed to be relevant—and in the assessment of their readiness, timely data needed to be accessible— TFAH sought measures that were already for every state and the District of incorporated into the NHSPI and that Columbia. most closely met TFAH’s criteria. (There was one exception: a measure of state l imely. Data for the indicator needed T public health funding-level trends, to be updated regularly. which the NHSPI does not track.) TFAH l cientifically valid. Data supporting S then scrutinized the candidates, in the indicator needed to be credible consultation with relevant experts, by and rigorously constructed. examining sources, fidelity to the criteria, amenability to scoring, and limitations. l onpartisan. The indicator, and data N supporting the indicator, needed to TFAH searched for a suitable measure be seen as objective and not rooted in of states’ readiness for extreme weather, any political goals. which nearly all experts expect to worsen FEBRUARY 2019 and become more frequent due to Using these criteria, TFAH aimed global climate change. However, none of to select a broad set of actionable the relevant indicators within the NHSPI indicators with which it—and met TFAH’s requirements. Therefore, other stakeholders, including states such a measure was not included in themselves—could continue to track Ready or Not this year. TFAH will work states’ progress for several years. with the NHSPI and others to identify (Complete data were not available for such a measure for future editions. Indicator data collection disorder, other intentional injuries, Data for every indicator except four and other unintentional injuries. (those data tied to the Nurse Licensure l nvironmental public health. Public E Compact, public health funding, flu health services related to air and water vaccination, and hospital patient safety) quality, fish and shellfish, food safety, were provided to TFAH by the NHSPI. hazardous substances and sites, lead, For three of the four (all except public onsite wastewater, solid and hazardous health funding), newer data were waste, zoonotic diseases, etc. available than those that were modeled in the 2018 edition of the NHSPI, so l aternal, child, and family health. M TFAH collected and verified figures Public health services related to from their original sources. the coordination of services; direct service; family planning; newborn Public health funding data collection screening; population-based and verification maternal, child, and family health; supplemental nutrition, etc. To collect public health funding data for this report, TFAH used states’ l ccess to and linkage with clinical A publicly available funding documents. care. Public health services related to With assistance from the Association of beneficiary eligibility determination, State and Territorial Health Officials, provider or facility licensing, etc. data were provided to states for review TFAH excludes from its definition and verification. Informed by the insurance coverage programs, such Public Health Activities and Services as Medicaid or the Children’s Health Tracking project at the University of Insurance Program, as well as inpatient Washington, TFAH defines public health clinical facilities. programming and services as inclusive of communicable disease control; chronic TFAH, under the guidance of state disease prevention; injury prevention; respondents, revised data for the base environmental public health; maternal, year. (In this report, that was fiscal year child, and family health; and access 2017.) For some states, this was necessary to and linkage with clinical care. to improve comparability between Specifically, this definition includes: the two years when a reorganization of departmental responsibilities had l ommunicable disease control. Public C occurred over the period. health services related to communicable disease epidemiology, hepatitis, All states and the District of Columbia HIV/AIDS, immunization, sexually verified their funding data. transmitted diseases, tuberculosis, etc. Scoring and tier placements l hronic disease prevention. Public C health services related to asthma, New to the Ready or Not series in this cancer, cardiovascular disease, edition is a three-tiered grouping system. diabetes, obesity, tobacco, etc. States are grouped based on their performance across the 10 indicators, l njury prevention. Public health I and partial credit, also new, was provided services related to firearms, motor for some indicators to draw finer vehicles, occupational injuries, distinctions between states and within senior falls prevention, substance-use states over time. States were placed into 40 TFAH • tfah.org the three tiers—top tier, middle tier, • ithin one standard deviation below W and bottom tier—based on their relative the mean (and states with 0 percent performance across the indicators. of residents who used a noncompliant community system): 1 point. Specifically, each indicator was scored as follows: • ithin one standard deviation above W the mean: 0.75 point. l A doption of the Nurse Licensure • etween one and two standard B Compact: 0.5 point. No adoption: 0 deviations above the mean: 0.5 point. points. • etween two and three standard B l P ercent of hospitals participating deviations above the mean: 0.25 point. in healthcare coalitions: States were • ore than three standard deviations M scored according to the number of above the mean: 0 points. standard deviations above or below the mean of state results. l P ercent of employed population • ithin one standard deviation above W with paid time off: States were scored the mean (and states with universal according to the number of standard participation): 1 point. deviations above or below the mean of state results. • ithin one standard deviation below W the mean: 0.75 point. • ore than one standard deviation M above the mean: 1 point. • etween one and two standard B deviations below the mean: 0.5 point. • ithin one standard deviation above W the mean: 0.75 point. • etween two and three standard B deviations below the mean: 0.25 point. • ithin one standard deviation below W the mean: 0.5 point. • ore than three standard deviations M below the mean: 0 points. • etween one and two standard B deviations below the mean: 0.25 point. l A ccreditation by the Public Health • ore than two standard deviations M Accreditation Board: 0.5 point. Not below the mean: 0 points. accredited: 0 points. l P ercent of people ages 6 months l A ccreditation by the Emergency or older who received a seasonal Management Accreditation Program: flu vaccination: States were scored 0.5 point. Not accredited: 0 points. according to the number of standard l S ize of state public health budget deviations above or below the mean compared with the past year of state results. (nominally, not inflation-adjusted). • ore than one standard deviation M • o change or funding increase: 0.5 N above the mean: 1 point. point. • ithin one standard deviation above W • unding decrease: 0 points. F the mean: 0.75 point. l ercent of population who used a P • ithin one standard deviation below W community water system that failed the mean: 0.5 point. to meet all applicable health-based • etween one and two standard B standards: States were scored according deviations below the mean: 0.25 point. to the number of standard deviations • ore than two standard deviations M above or below the mean of state results. below the mean: 0 points. TFAH • tfah.org 41 A P P E NDIX • ositive number, more than one P standard deviation below the mean: 0.25 point. • o hospitals with a top-quality N ranking (Grade A): 0 points. l P ublic health laboratory has a plan for a six- to eight-week surge in testing capacity: 0.5 point. Did not report having a plan: 0 points. In total, the highest possible score a state could receive was 7.5 points. States whose scores ranked among the top 17 were placed in the top tier. States whose scores ranked between 18th- highest and 34th-highest were placed in the middle tier. States whose scores ranked between 35th-highest and 51st- highest were placed in the bottom tier. (Ties in states’ scores prevented an even distribution across the tiers.) This year, Adult flu vaccination data for the states in the top tier had scores ranging 2017–2018 season were not available from 5.75 to 6.75; states in the middle for the District of Columba. TFAH tier had scores ranging from 5 to 5.5; imputed its score by comparing its and states in the bottom tier had scores average rate from 2010–2011 to 2016– ranking from 3.75 to 4.75. 2017 with the U.S. average vaccination rate over that period as well as the Assuring data quality aggregate rate of the 50 states and the Several rigorous phases of quality District of Columbia. assurance were conducted to l P ercent of hospitals with a top-quality strengthen the integrity of the data ranking (Grade A) on the Leapfrog and to improve and deepen TFAH’s Hospital Safety Grade. States were understanding of states’ performance. scored according to the number of During collection of state public health standard deviations above or below funding data, researchers systematically the mean of state results. inspected every verified data file to identify incomplete responses, • More than one standard deviation inconsistencies, and apparent data- above the mean: 1 point. entry errors. Following this inspection, • Within one standard deviation above respondents were contacted and given the mean: 0.75 point. the opportunity to complete or correct • Within one standard deviation below their submissions. the mean: 0.5 point. 42 TFAH • tfah.org Endnotes 1 ational Health Security Health N 9 enters for Disease Control and Preven- C 20 Kaplan S. and Fritz A. “Climate Change Preparedness Index. “National Trend tion. “Reconstruction of the 1918 Influenza Was Behind 15 Weather Disasters in Data and By State.” https://nhspi.org/ Pandemic Virus.” National Center for Im- 2017.” The Washington Post, December 10, (accessed December 12, 2018). munizations and Respiratory Diseases, last 2018. https://www.washingtonpost.com/ updated July 17, 2014. https://www.cdc. science/2018/12/10/climate-change- 2 he National Council of State Boards T gov/flu/about/qa/1918flupandemic.htm was-behind-weather-disasters/?utm_ of Nursing. “Nurse Licensure Compact (accessed December 6, 2018). term=.6d09f73accdb (accessed December Member States.” 2018. https://www.ncsbn. 11, 2018). org/listofmemberstatesanddates111618.pdf 10 Ibid. 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