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ISSUE REPORT Ready or Not: PROTECTING THE PUBLIC’S FROM , , AND 2021 MARCH 2021 Acknowledgements The National Preparedness Index (NHSPI) is a joint Trust for America’s Health (TFAH) is a nonprofit, nonpartisan initiative of the Robert Wood Johnson Foundation, the University public , research, and advocacy organization that of Kentucky, and the University of Colorado. TFAH wishes to promotes optimal health for every person and community and recognize and thank Glen Mays and Michael Childress of the makes the prevention of illness and injury a national priority. NHSPI for their collaboration and expertise as well as the Robert The Ready or Not report series is supported by generous Wood Johnson Foundation for its continued funding support. grants from the Robert Wood Johnson Foundation, with Ready or Not and the NHSPI are complementary projects that additional support from The California Endowment, W.K. work together to measure and improve the country’s health Kellogg Foundation and The Kresge Foundation. Opinions security and emergency preparedness. TFAH looks forward to a in this report are TFAH’s and do not necessarily reflect the continued partnership. views of its funders.

TFAH BOARD OF DIRECTORS Gail Christopher, D.N. Stephanie Mayfield Gibson, M.D. Eduardo Sanchez, M.D., MPH Chair of the Board Director Chief Medical Office for Prevention Executive Director U.S. COVID-19 Response Initiative American Heart Association National Collaborative for Health Equity Resolve to Save Lives Umair A. Shah, M.D., MPH Former Senior Advisor and Vice President Cynthia M. Harris, Ph.D. Secretary of the Health W.K. Kellogg Foundation Associate Dean for Washington State David Fleming, M.D. Director and Professor Vince Ventimiglia, JD TFAH Distinguished Visiting Fellow and Vice Institute of Public Health President Chair, TFAH Board of Directors Florida A&M University Collaborative Advocates Robert T. Harris, M.D., FACP David Lakey, M.D. Leavitt Partners Treasurer of the Board Chief Medical Officer and Vice Chancellor for Senior Medical Director Health Affairs TRUST FOR AMERICA’S HEALTH General Dynamics Information Technology The University of Texas System LEADERSHIP STAFF Theodore Spencer, M.J. Octavio Martinez Jr., M.D., MPH, MBA, FAPA John Auerbach, MBA Secretary of the Board Executive Director President and CEO Co-Founder Hogg Foundation for Mental Health J. Nadine Gracia, M.D., MSCE Trust for America’s Health The University of Texas at Austin Executive Vice President and Chief Operating Officer John A. Rich, M.D., MPH Co-Director of the Center for Nonviolence and Social Justice Drexel University School of Public Health

REPORT AUTHORS EXTERNAL REVIEWERS Matt McKillop, MPP This report benefited from the insights and expertise of the following external reviewers. Although Senior Health Policy Researcher and Analyst they have reviewed the report, neither they nor their organizations necessarily endorse its findings or recommendations. TFAH is extremely grateful to these reviewers for their time and expertise. Dara Alpert Lieberman, MPP Director of Government Relations James Blumenstock Shelley A. Hearne, DrPH Senior Vice President Deans Sommer and Klag Professor for Public Rhea K. Farberman, APR Pandemic Response and Recovery Health Advocacy Director of Strategic Communications and Policy Association of State and Territorial Health Director, Center for Public Health Advocacy Research Officers (ASTHO) Johns Hopkins University Bloomberg School of Public Health CONTRIBUTING AUTHOR Dr. Oxiris Barbot, M.D. Adjunct Assistant Professor David Fleming, M.D. Kendra May Columbia University Mailman School of Public TFAH Distinguished Visiting Fellow and Vice Consultant Health and Senior Fellow for Public Health and Chair, TFAH Board of Directors Social Justice at the JPB Foundation Former New York City Health Commissioner 2 TFAH • tfah.org TABLE OF CONTENTS Table of Contents Ready or Not Executive Summary ...... 4 Sidebar: COVID-19 and Emergency Preparedness: Tragic Lessons ...... 6 2021  Interview: Earning Confidence in Communities of Color ...... 12

SECTION 1: ASSESSING STATES’ PREPAREDNESS ...... 15 Indicator 1: Nurse Licensure Compact ...... 16 Indicator 2: Hospital Participation in Healthcare Coalitions ...... 18 Indicators 3 and 4: Accreditation ...... 20 Indicator 5: Public Health Funding ...... 22 Indicator 6: Water System Safety ...... 24 Indicator 7: Access to Paid Time Off ...... 26 Indicator 8: Flu Rate ...... 28 Indicator 9: Patient Safety in Hospitals ...... 30 Indicator 10: Public Health Laboratory Surge Capacity ...... 32 Indicators Performance Matrix by State ...... 34

SECTION 2: RECOMMENDATIONS FOR FEDERAL AND STATE POLICY ACTIONS . .36 Priority Area 1: Provide Stable, Sufficient Funding for Domestic and Global Public Health Security ...... 36 Priority Area 2: Prevent Outbreaks and Pandemics ...... 39 Priority Area 3: Build Resilient Communities and Promote Health Equity in Preparedness ...... 41 Priority Area 4: Ensure Effective Leadership, Coordination, and Workforce ...... 43 Priority Area 5: Accelerate Development and Distribution of Medical Countermeasures ...... 45 Priority Area 6: Ready the Healthcare System to Respond and Recover . . . . 47 Priority Area 7: Prepare for Environmental Threats and Extreme Weather . . . . 49

APPENDIXES ...... 50 Year in Review – 2020 Health Threats Incidents and Actions ...... 50 Report Methodology ...... 63

Endnotes ...... 67

Editor’s note: This report was being prepared during a presidential transition. We have included comments in the report where we have noted action on TFAH policy recommendations by the Biden administration. View this report online at www.tfah.org/report-details/readyornot2021 MARCH 2021 EXECUTIVE SUMMARY Ready or Not Executive Summary

2021 The past year, 2020, will long be remembered as the year more than 2 million people lost their lives due to a global pandemic. Not since the 1918 pandemic has a single event so urgently demonstrated the criticality of a strong public . This Ready or Not report has tracked the country’s level of public health emergency preparedness since 2003. For nearly two decades, it has asked the fundamental question: “are we ready?” Unfortunately, the COVID-19 crisis has provided a clear answer: an emphatic “no.”

The COVID-19 crisis has illuminated In addition, the pandemic has once the urgent need for federal, state, local, again demonstrated and exacerbated tribal, and territorial leaders to take the impact of structural racism, both aggressive steps to shore up the nation’s historic and current, on the health and preparedness for all types of emergency well-being of communities of color and events. The pandemic put a spotlight Tribal Nations. Acknowledging the on a public health system hollowed- lingering health impacts of slavery and out by years of insufficient funding. the treatment of native peoples and Health departments were overstretched, addressing current day racist policies, responding to the pandemic with systems, and attitudes must be part archaic technologies1 and with of building the nation’s resilience. overworked staff who faced threats In short, equity is not separate from and retribution.2 These gaps were preparedness. Ensuring an equitable all the more critical in 2020 because opportunity for the health and well- the federal government failed to take being of all residents before a an evidence based, leadership role in creates more resilient communities the pandemic response, with many during an emergency. Equity must be an decisions being left to states that would explicit and foundational principle in all ordinarily be federally coordinated. emergency planning. Achieving equity It also demonstrated the harm that in all facets of emergency response can be done when science and public requires including equity accountability health expertise are stifled by political metrics in emergency preparation and interference and misinformation. management. MARCH 2021 Foundational capabilities are necessary throughout the public health system, “A powerful aspect of this report is its long objectively from the Centers for Control measuring states’ preparedness. This year’s recommendations and Prevention (CDC) to state, local, tribal, and territorial health are almost identical to past years. Had the nation paid more departments, including:3 attention to pandemic threats and TFAH’s commonsense and l Health monitoring and assessment, consistent recommendations, this country would be in a very comprising surveillance, different place today.” epidemiology, and laboratory capacity; Shelley A. Hearne, DrPH l All-hazards preparedness and response; Johns Hopkins University Bloomberg School of Public Health l Policy development and support; l Public communications; It is also important to note that the threats. They are not tailored to an l Community outreach and partnership infusion of COVID-19 emergency assessment of a given state’s response to development; funding was onetime funding—critical the COVID-19 pandemic, as widescale to the pandemic response but not political, funding, economic, and social l Organizational and administrative a solution to the system’s longtime factors all influenced the impact competencies (i.e., leadership, underinvestment. and local responses. A state may do well governance, and health equity); and in terms of its ranking in this report but This report is designed to give l Accountability and performance poorly in its response to the COVID-19 policymakers at all levels of government management.4 pandemic—and vice versa. While no actionable data and recommendations state has been spared, what seems to Today, only half of Americans are with which they can target policies have mattered most in the pandemic protected by a comprehensive local and spending to strengthen their response is a state’s socioeconomic and public health system.5 The Public jurisdiction’s emergency preparedness. racial profile, as well as the adherence Health Leadership Forum estimates The report’s 10 key public health of elected leaders and residents to a $4.5 billion annual shortfall in preparedness indicators give state evidence-based public health guidelines. the spending necessary to meet officials benchmarks for progress, point The pandemic has illustrated that the infrastructure needs of public out gaps within their states all-hazards robust and sustained funding, elected health agencies nationwide.6 This preparedness, and provide data to officials’ leadership, and federal-state shortfall was on display throughout compare states’ performance against coordination and planning are key to the COVID-19 pandemic, as decades like jurisdictions. These data points, protecting Americans’ health security. of chronic underfunding hindered or ones similar to them, have been the Moreover, there is no substitute at the communications, , focus of this report for over a decade state or local level for a strong federal , vaccine delivery, and and are meant to measure readiness response. other key health department activities. for a broad set of health security

TFAH • tfah.org 5 COVID-19 AND EMERGENCY PREPAREDNESS: TRAGIC LESSONS

TFAH’s Ready or Not: Protecting the Public’s Health from Diseases, Disasters and Bioterrorism report has tracked the nation’s readiness to respond to a public health emergency for nearly two decades. During that time, no event highlighted the critical importance of this report’s purpose—measuring and promoting readiness to safeguard Americans’ health during an emergency—to the degree the COVID-19 crisis has.

The COVID-19 pandemic is an on- the-ground, real-time measure of the nation’s public health emergency response system—a test the federal government failed according to most public health experts. An October 2020 report by Columbia University Earth Institute’s National Center for Disaster Preparedness estimated that the federal government’s inadequate pandemic response led to between 130,000 and 210,00 avoidable deaths. The report submits that if the had implemented sufficient testing, earlier lockdowns, a accreditation, (4) public health funding, Importance of Federal Leadership national mask-wearing mandate, and (5) access to paid time off, (6) flu Government at multiple levels shares provided federal guidance on social vaccination rates (as a proxy for a responsibility for emergency planning distancing, over 200,000 lives could community’s vaccination infrastructure and response. Under this tiered have been saved.7 and receptivity), and (7) laboratory structure, when an event requires a With a possible single exception (water surge capacity. TFAH will continue to larger response than a local entity system safety), all of the readiness measure states on these indicators, as can provide, government from the tier indicators measured annually by this they play a central role in the standing- above it—typically a tribal, territorial Ready or Not report played a role in ready, public health protection capacity or state agency—provides assistance. jurisdictions’ COVID-19 response. that every state needs. When a state’s response resources Seven were relevant to the effort to The pandemic has also spotlighted a are not enough to meet demands control the pandemic and save lives: number of issues not currently measured during an emergency, the federal (1) nurse licensure compact (allowing by the report but critical and dramatically government provides support. For a jurisdictions to borrow medical apparent if absent during a health public health emergency as significant personnel when they need to surge emergency: federal and state political and contagious as COVID-19, clear capacity), (2) hospital participation leadership, interagency coordination, communication and strong leadership in healthcare coalitions, (3) public consistent and well-executed public and coordination by the federal health and communications, and health equity. government are essential, elements

6 TFAH • tfah.org that were lacking during the initial Overcoming the Legacy of Racism l Developing a White House led strategy months of the pandemic response. The legacy of slavery, genocide, focused on addressing the root Instead, inconsistent messages and centuries of racism, combined causes of disease and on promoting between federal agencies and the White with current day interpersonal and health equity. House; lack of centralized coordination, structural racism, is at the root of the l Creating a social determinants of such as for procurement of personal disproportionate impact COVID-19 has health line item at the Centers for protective equipment (PPE); and had on communities of color and Tribal Disease Control and Prevention political interference with guidance from Nations. These systemic inequities, in (CDC), authorized and fully funded scientific agencies—all led to confusion access to healthcare, housing, education, by Congress, with sufficient funding and contradictory policies among states transportation, and employment, existed to guarantee grant-funded efforts and weakened the emergency response. before the pandemic and have been throughout the nation.

TFAH has made a number of policy exacerbated by it. Health inequities due l Requiring all agencies to collect, recommendations designed to ensure to disadvantages experienced by racial, disaggregate, and report health robust and nonpartisan federal ethnic, or other population groups are data in such a way that the impact leadership during future public health preventable differences in the burden of of health conditions, policies, or emergencies, including: disease, injury, and health emergencies interventions on specific population and to opportunities to achieve good l Create a White House Health groups are known, including health health.8 Addressing issues at the Security Directorate, including senior status data by race, ethnicity, sexual root of health inequity is imperative to advisors to the president with public orientation, gender identity, primary ensuring all people, regardless of their health expertise on health security language, and disability status. race or ethnicity or where they live, have issues. This directorate would the opportunity for good health and are The tragedy of the COVID-19 oversee the national biodefense protected during a health emergency. pandemic, including over 500,000 strategy and all interagency deaths in the United States (as this emergency responses. TFAH has called on the administration publication was being prepared) and l Ensure full transparency and and Congress to make advancing unprecedented harm to the economic consistency in federal messaging health equity and eliminating health security of millions of American from the White House, CDC, ASPR, disparities a national priority by: families, will forever be a painful FDA, and National Institutes of Health l Ensuring that all COVID-19 response reminder of the critical importance (NIH) concerning public health issues actions prioritize advancing health of pre-event public health emergency to ensure message clarity, avoid equity, including access to COVID-19 preparations, investments in public confusion, and build trust. testing and . health infrastructure, and evidence- l Ensure that federal public health l Creating a Truth, Racial Healing, and based policy and communications. The officials are fully empowered to make Transformation Commission, and pandemic has undeniably demonstrated decisions based on science and provide funding to communities to begin that historical discrimination coupled without undue political influence. the process of acknowledging a history with current-day racism impacts a Efforts to infuse politics into public of racism and working to dismantle the community’s health status and ability health decision-making puts the myth of hierarchy based on race. to weather a disaster. The COVID-19 crisis has also painfully reinforced public’s health at risk. l Expanding funding for initiatives that national leadership must be l HHS should strengthen leadership serving communities that have been grounded in science and committed by working with states and suppliers marginalized by disinvestment, and to addressing structural racism, both to ensure adequate stockpiling ensure that federal funding supports of which are imperative to saving lives and distribution of medical processes that meaningfully engage during an emergency. countermeasures and ancillary the most affected communities in emergency response products, such the planning and implementation of as personnel protective equipment. such initiatives.

TFAH • tfah.org 7 This edition of the Ready or Not series other areas—such as paid time off for compared with last year, while eight fell finds that states have made progress workers and hospital patient safety—has behind. Three states improved by one in most of the report’s measured stalled. In this 2021 report, Trust for tier, six states dropped one tier, and two areas, especially rates of seasonal flu America’s Health (TFAH) found that dropped two tiers. vaccination. However, improvement in three states improved their standing

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 that 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 Control: Percentage of employed participating in healthcare coalitions. population that used 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 (“A” Accreditation Program. grade) 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 commu- nity 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. TFAH drew every indicator, and some categorical descriptions, from the National Health Security Preparedness Index, with one exception: pub- lic 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 9

The Ready or Not report groups states a greater share of its hospitals receive that received an “A” rating—one of and the District of Columbia into one high marks on patient safety. Montana, the highest in the nation—rose by of three tiers (high, middle, low) based which elevated from the low tier to the slightly less than the national average. on their performances across the 10 middle tier, increased its public health Other steps it could take to improve indicators. This year, 20 states and funding level in fiscal year 2020. And its standing include joining the Nurse the District of Columbia scored in the Rhode Island, which rose from the Licensure Compact or increasing its high-performance tier, 15 placed in the middle tier to the high tier, did so by below-average share of residents who middle-performance tier, and 15 were dramatically increasing its community take paid time off from work. in the low-performance tier (see Table drinking-water security. Five states fell from the high tier to the 2). (See “Appendix A: Methodology” Two states fell from the high tier to the middle tier: Alabama, Illinois, Iowa, for more information on the scoring low tier: Missouri and Pennsylvania. New Jersey, and Tennessee. These process.) Missouri cut its public health funding in states did not experience significant Three states showed notable FY 2020 and saw an increase in the share backsliding overall, but they lost ground, improvement, moving up a tier: of its residents that used a community as a number of other states took greater Georgia, Montana, and Rhode Island. water system with one or more health- steps that increased their standing. Georgia, which rose from the middle based violations. Its flu vaccination One state fell from the middle tier to tier to the high tier, improved its rate ticked up marginally, but by less the low tier: Arizona. Arizona’s below- standing by achieving accreditation than the nation as a whole. Likewise, average flu vaccination rate rose, but by by the Emergency Management Pennsylvania also cut its public health less than the nation overall, so its overall Accreditation Program and by having funding level, and its share of hospitals standing fell back.

8 TFAH • tfah.org TABLE 2: State Public Health Emergency Preparedness State performance, by scoring tier, 2020 Performance Number of States Tier States

CO, CT, DC, DE, GA, ID, KS, MA, MD, ME, MS, High Tier 20 states and DC NC, NE, NM, OK, RI, UT, VA, VT, WA, WI

AL, CA, FL, IA, IL, KY, LA, MI, MN, MT, ND, NJ, Middle Tier 15 states OR, TN, TX

AK, AR, AZ, HI, IN, MO, NH, NV, NY, OH, PA, Low Tier 15 states SC, SD, WV, WY Note: See “Appendix A: Methodology” for scoring details. Complete data were not available for U.S. territories.

TFAH’s Analysis Found: during an emergency. What’s more, A majority of states have made every state had public health laboratories preparations to expand healthcare that had plans for how to manage a and public health capabilities in an large influx of testing needs. States had emergency, often through collaboration. a plan to surge public health laboratory Thirty-four states participated in the capacity for six to eight weeks as necessary Nurse Licensure Compact, up from 26 during overlapping emergencies or large in 2017,10 with Indiana and New Jersey outbreaks, an increase of six states since being the most recent adopters.11 The 2017. compact allows registered nurses and Most states are accredited in the licensed practical or vocational nurses areas of public health, emergency to practice in multiple jurisdictions management, or both. As of December with a single license. In an emergency, 2020, the Public Health Accreditation this enables health officials to quickly Board (PHAB) or the Emergency increase their staffing levels. For example, Management Accreditation Program nurses may cross state lines to work at (EMAP) accredited 42 states and the evacuation sites or other healthcare District of Columbia; 29 states and the facilities. In addition, hospitals in most District of Columbia were accredited states have a high degree of participation by both groups, a net increase of in healthcare coalitions. On average, 89 one since November 2019. (EMAP percent of hospitals were in a coalition, has now accredited Delaware and and 17 states and the District of Columbia Georgia; Maryland transitioned from had universal participation, meaning being accredited by both bodies to the every hospital in the jurisdiction was PHAB only, with the EMAP providing part of a coalition. Such coalitions bring conditional accreditation.) Eight states hospitals and other healthcare facilities (Alaska, , Indiana, New Hampshire, together with emergency management South Dakota, Texas, West Virginia, and and public health officials to plan for and Wyoming) were not accredited by either respond to incidents or events requiring group. Both programs help ensure that extraordinary action. This increases the necessary emergency prevention and likelihood that providers serve patients response systems are in place and staffed in a coordinated and efficient manner by qualified personnel.

TFAH • tfah.org 9 Seasonal flu vaccination rates, while still Most residents who received their too low, have risen significantly. The household water through a community seasonal flu vaccination rate among water system had access to safe water. On Americans ages 6 months or older rose average, just 5 percent of state residents from 42 percent during the 2017–2018 used a community water system in 2019 season to 52 percent during the 2019– (latest available data) that did not meet 2020 season.12 However, Healthy People all applicable health-based standards, 2030, a set of federal 10-year objectives down slightly from 7 percent in 2018. and benchmarks for improving the Water systems with such violations health of all Americans by 2030, set increase the chances of water-based a seasonal influenza vaccination-rate emergencies in which contaminated target of 70 percent annually.13 water supplies place the public at risk.

In 2019, only 55 percent of employed state Based on its policy research and residents, on average, used paid time off, analysis, consultation with experts, the same percentage as in 2018. Those and review of progress and gaps in without paid leave are more likely to work federal and state preparedness—with when they are sick and risk spreading a particular focus on the preparation infection. In the past, the absence of gaps and shortfalls identified by dedicated paid sick leave has been linked the COVID-19 pandemic—TFAH is to or has exacerbated some infectious recommending policy action in seven disease outbreaks.14 This became priority areas: particularly relevant during the COVID- 1. Provide stable, sufficient funding 19 pandemic, as isolation and for domestic and global public were important tools for controlling the health security. outbreak. The Families First Response Act helped address this issue 2. Strengthen policies and systems to during the early stages of the pandemic for prevent and respond to outbreaks employers with fewer than 500 employees and pandemics. and certain public employers, temporarily 3. Build resilient communities and requiring employees to be paid up to 80 promote health equity generally and hours of sick leave benefits under certain in preparedness. conditions.15 In January 2021, the Biden administration economic stimulus package 4. Ensure effective public health proposal included extending paid sick leadership, coordination, and leave to over 100 million U.S. workers. workforce.

Only 31 percent of hospitals, on 5. Accelerate development and average, earned a top-quality patient distribution, including last- safety grade, up slightly from 30 mile distribution, of medical percent in 2019. Hospital safety scores countermeasures. measure performance on such issues as 6. Strengthen the healthcare system’s healthcare-associated infection rates, ability to respond to and recovery intensive-care capacity, and an overall from health emergencies. culture of error prevention. In January 2021, the Biden administration’s 7. Prepare for environmental threats economic aid package included and extreme weather. extending paid sick leave to over 100 million U.S. workers.

10 TFAH • tfah.org Report Purpose and Methodology

TFAH’s annual Ready or Not report series Foundation, the University of Kentucky, tracks states’ readiness for public health and the University of Colorado. (See emergencies based on 10 key indicators “Appendix A: Methodology” for a that collectively provide a checklist of detailed description of how TFAH top-priority issues and action items for selected and scored the indicators.) states and localities to continuously While state placements in Ready or address. By gathering together timely Not and the NHSPI largely align, data on all 50 states and the District there are some important differences. of Columbia, the report assists states The two projects have somewhat in benchmarking their performance different purposes and are meant to be against comparable jurisdictions. complementary, rather than duplicative. TFAH completed this research after With more than 100 indicators, the consultation with a diverse group of Index paints a broad picture of national subject-matter experts and practitioners. health security, allowing users to zoom out and holistically understand the Ready or Not and the National Health extent of both individual states’ and the Security Preparedness Index entire nation’s preparedness for large- The indicators included in this report scale public health threats. In slight were drawn from, and identified in contrast, Ready or Not, with its focus on partnership with, the National Health 10 select indicators, focuses attention on 16 Security Preparedness Index (NHSPI), state performances on a subset of the with one exception: a measure of state Index and spotlights important areas public health funding-level trends, for stakeholders to prioritize. TFAH which reflects how well-resourced key and the NHSPI work together to help agencies are to prepare and respond federal, state, and local officials use data to emergencies. The NHSPI is a joint and findings from each project to make initiative of the Robert Wood Johnson Americans safer and healthier.

TFAH • tfah.org 11 Earning Vaccine Confidence in Communities of Color

Interview with Claude A. Jacob, Dr.PH(c), MPH, the chief public health officer at the Cambridge, Massachusetts, Public Health Department, and Maria Lemus, the executive director of Visión y Compromiso, about barriers—both historic and contemporary— to COVID-19 vaccinations within communities of color. This interview was conducted in December 2020.

TFAH: As this report is being finalized, voice on COVID-19. Given this finding, the United States is nearing a time when we plan to work closely with our hospitals, many Americans, particularly those ambulatory sites, and healthcare at the highest risk of infection or the providers to help spread the message. most serious impact if infected, can be Ms. Lemus: There are many barriers. vaccinated. What are the barriers to high The ones I’m most concerned about are rates of vaccination in communities of myths and misinformation, including color and among Tribal nations? crazy social media propaganda, fear of Dr. Jacob: We are fortunate in adverse reactions, and problems with Cambridge. Flu vaccine participation is vaccine accessibility. High rates of the strong and childhood vaccine compliance uninsured among some populations is also very high, which we view as rough groups and misconceptions about who is proxies for COVID-19 vaccine acceptance. at risk are additional concerns. That being said, there is a long and TFAH: The pace of COVID-19 sordid history of abuse and mistreatment development has been quicker than of these communities by the U.S. many people expected. In some government and healthcare system. That communities this may mean that many Black and Brown people continue the vaccine will be available before to feel deep mistrust of the healthcare communications programs about system is understandable. All of us in the vaccine’s safety and availability healthcare and public health must have fully taken root. What do those understand that this mistrust goes back responsible for vaccine distribution to slavery for Black Americans and the need to do when distributing the vaccine genocide perpetuated against indigenous under these circumstances? people that lasted for centuries. Dr. Jacob: First of all, we need to We have strong relationships with celebrate the news that, so far, community organizations, leaders in the two vaccines have received FDA faith community, and others who are well emergency use authorization. That known and trusted among communities two vaccines were developed, tested, of color, and we will partner with them and manufactured in less than 12 to overcome these barriers to vaccine months is a breathtaking achievement. uptake. Recent national and state surveys While we can’t let down our guard on have told us that Americans view their physical distancing, wearing masks, personal physician as the most trusted

12 TFAH • tfah.org and continuing to practice good hand hygiene, the COVID-19 vaccine marks a watershed moment in the pandemic. We now see the light at the end of the tunnel. At the same time, it’s understandable that people have many questions and deep concerns given how quickly the vaccine was developed and approved. For communities of color, the concern over safety comes with a long- standing, entrenched, and well-placed mistrust of the healthcare system.

Communication will be pivotal in educating everyone, especially communities of color, about the safety and importance of this vaccine. To start, we need to have communities of color and physicians of color at the TFAH: A woeful history of mistreatment speak to these injustices; they must decision-making table to inform and of people of color by government and denounce them and support remedies. ensure a vaccine rollout that is equitable the healthcare system is at the root of They need to give real-time examples for all members of our community. much of the lack of trust in the COVID- of the efforts being made to engage Messaging around the vaccine also 19 vaccine within those communities with and empower communities and needs to be informed by, and tested but there are other barriers to vaccine to correct past wrongs. Only then will with, communities of color to make access. What are they and how can they government be able to be heard and sure that these communication efforts be overcome? only by using trusted messengers and resonate. We have a superb opportunity community navigators. to work with those on the front line Ms. Lemus: The understandable of this pandemic, especially doctors, distrust of government is going to It’s also important to remember that nurses, and physicians’ assistants, be a huge barrier to the vaccine. A the reasons for distrust of government to help amplify the message in core specific example for my community is within underrepresented communities communities. By all accounts, frontline the Bracero Program, which between is not only about historical legacies; medical workers are the most trusted 1942 and 1964, based on a series of it is based on current-day events and source of health information and they bilateral agreements between the U.S. climates. However, it can be corrected. are the first to be vaccinated, starting and Mexican governments, brought My organization, Visión y Compromiso, this past December. We should use their nearly 4.6 million Mexican citizens has as its mission providing leadership- voices of trust and reason to speak to to work on U.S. farms, railroads, and development and capacity-building communities of color about the safety factories. Those workers experienced opportunities for promotores and and critical importance of getting this racial and wage discrimination and were community health workers in over vaccine. forced to live and work in substandard 4,000 communities. These community- conditions. More recently, there based promotores will have a critical role Ms. Lemus: It will be imperative to have been allegations of unnecessary to play in reducing share data about the vaccine without hysterectomies being performed in ICE in communities of color. Messaging to jargon and to have trusted messengers detention centers. convince people to be vaccinated has to deliver the information. I heard a quote feature their heroes, their community recently in response to the question, The only way to overcome these leaders, their voices. “Do you know what’s in Tylenol?”: “No, will be to first acknowledge but I trust it will help me.” them. Leaders must acknowledge and

TFAH • tfah.org 13 Dr. Jacob: Communities of color have TFAH: What is the importance of where uptake in your community? What historically had difficulty accessing the COVID-19 vaccine is available in resources do you need to be successful? healthcare. Lack of transportation, your community? Dr. Jacob: Local public health has work schedules, childcare needs, and Ms. Lemus: Where the vaccine will be an important role and responsibility competing financial interests—such as available is another critical issue. The in educating communities about the paying rent and bills—pose significant credibility, location, hours, accessibility, safety and importance of the COVID-19 barriers to healthcare, as do other social relationship to community, their vaccine, as it does with all vaccinations. determinants of health, such as poverty staff, and emissaries are important to Once the vaccine is made available and lack of education. Even with the individual and families’ decision to be to the general public, the Cambridge Affordable Care Act—which greatly vaccinated. Promotores are important Public Health Department, through its expanded access to health insurance also in gathering information to partnership with city agencies and the for everyone—Hispanic, Black, and contribute to the vaccine distribution private sector, will be ready to provide some Asian communities have lower and administration, planning vaccines to residents. Throughout the insurance coverage rates than any other implementation, and communications. pandemic, our department has worked population. Many of them remain Community-based organizations hand in hand with city partners, especially uninsured altogether. must be included in all planning and first-responders, to provide testing and The cost of the vaccine is being covered execution; they are a big part of the flu shots, and we will rely on this strong, by the federal government through solution. Partnering with community- successful relationship to provide the tax dollars, but providers can charge based organizations allows local officials COVID vaccine. It is critically important to administer the vaccine, if they to scale means and resources. to note that we could not do our work choose. We need to do everything without strong financial support. Our city Dr. Jacob: As I have already we can and work with providers to manager, Louis A. DePasquale, and the mentioned, the Cambridge Public eliminate fees they may charge in the Cambridge City Council have provided Health Department has had enormous interest of overcoming this public financial resources to fight this pandemic success with COVID-19 testing and flu health emergency. When it is available, and keep our residents and those who vaccinations by bringing these services we need to bring the vaccine to the work in Cambridge safe. They have long to people in the communities where public rather than making people been committed to the important work they live and work. We have taken come to the vaccine. In Cambridge, of the public health department, which a traditional grassroots approach— the public health department, through is enhanced by the Cambridge Health going door to door in harder-hit its partnership with the city’s first- Alliance led by Dr. Assaad Sayah, who is neighborhoods and providing responders and others, have made the commissioner of public health for the information in eight languages—to build free COVID-19 testing available to all city of Cambridge. trust and understanding. We need to residents (regardless of symptoms) use this same approach with the COVID- Dr. Claude A. Jacob is the chief public health since July 2020. Starting in November officer for the City of Cambridge, Massachusetts. 19 vaccine and build on these robust 2020, this “no-barrier,” city-funded He served as the president of the National community linkages, which are anchored Association of City and County Health Officials in testing program expanded to seven to the long-standing relationships that we 2016–2017. days a week (from two days/week) and have with partners on the ground. Maria Lemus is the executive director of Visión from two neighborhood sites to four. y Compromiso, headquartered in San Francisco, These testing sites are geographically TFAH: As the chief public health California. Visión y Compromiso provides dispersed, and all but one are located in officer for the city of Cambridge, leadership, advocacy, and capacity-development neighborhoods with disproportionately Massachusetts, what is your training to community health workers. high rates of new COVID-19 . department’s role in increasing vaccine

14 TFAH • tfah.org SECTION 1: SECTION 1: ASSESSING STATE PREPAREDNESS Assessing State Preparedness Ready or Not Every state needs to be prepared to respond to a variety of 2021 potential public health emergencies; such readiness requires understanding an individual state’s preparedness strengths, risks, and vulnerabilities. To help states assess their readiness, and to highlight a checklist of top-priority concerns and action areas, this report examines a set of 10 select indicators. The indicators, used consistently year to year, draw heavily from the National Health Security Preparedness Index (NHSPI), a joint initiative of the Robert Wood Johnson Foundation, the University of Kentucky, and the University of Colorado. They capture core elements of emergency preparedness.

Based on states’ standing across the 10 indicators (see “Appendix A: Methodology” for scoring details), TFAH placed states into three performance tiers: high, middle, and low. (See Table 3.)

TABLE 3: State Public Health Emergency Preparedness State performance, by scoring tier, 2020 Performance Number of States Tier States

CO, CT, DC, DE, GA, ID, KS, MA, MD, ME, MS, High Tier 20 states and DC NC, NE, NM, OK, RI, UT, VA, VT, WA, WI

AL, CA, FL, IA, IL, KY, LA, MI, MN, MT, ND, NJ, Middle Tier 15 states OR, TN, TX

AK, AR, AZ, HI, IN, MO, NH, NV, NY, OH, PA, Low Tier 15 states SC, SD, WV, WY Note: See “Appendix A: Methodology” for scoring details. Complete data were not available for U.S. territories.

Importantly, the implications of and administrators. Moreover, some this assessment, and responsibility indicators are under the direct control for continuously improving, extend of federal and state lawmakers, whereas beyond any one state or local agency. improvement in other indicators

Such improvement typically requires requires multisector, statewide efforts, MARCH 2021 sustained engagement and coordination including by residents. by a broad range of policymakers

TFAH • tfah.org 15 INDICATOR 1: ADOPTION Workforce shortages can impair a state’s in nurses from other member states, OF NURSE LICENSURE ability to effectively manage disasters without harmful delays, or to send or disease outbreaks, potentially nurses to other member states that COMPACT resulting in poorer health outcomes for were experiencing acute shortages. For those affected. This reality was starkly example, New Jersey, which experienced KEY FINDING: 34 states illuminated by the COVID-19 pandemic one of the most severe outbreaks in as healthcare capacity in some parts of spring 2020, began implementing the participate in the Nurse the country was overwhelmed by the NLC, immediately qualifying out-of- Licensure Compact. number of people needing care. In state nurses with a multistate license an event like a pandemic, the ability to practice.17 “I think the COVID-19 to quickly surge qualified medical outbreak is going to cause the states personnel by bringing healthcare that are not in the compact now to workers from out of state is a key really take a second look at it,” says NLC component of healthcare readiness. Director Jim Puente. “If the NLC was expanded to all 50 states, none of the This indicator examines whether states guesswork with emergency orders would have adopted legislation to participate be necessary because nurses could travel in the Nurse Licensure Compact to other states where they are needed. (NLC). Launched in 2000 by the No applications, fees, or background National Council of State Boards of checks would be necessary.” Nursing, the NLC permits registered nurses and licensed practical nurses As of December 2020, 34 states had to practice with a single multistate adopted the NLC, with Indiana and New license—physically or remotely—in any Jersey being the most recent adopters.18 state that has joined the compact. The This was a net increase of two since 2019 NLC provides standing reciprocity, with and eight since 2017. Toni Herron, the no requirement that an emergency be education compliance officer of the formally declared. Indiana State Board of Nursing, which joined the compact on July 1, 2020, Throughout much of 2020, the COVID- said that the NLC “presents innovative 19 pandemic placed extraordinary ways for our Indiana nurses to improve pressure on hospitals across the country both access to care for patients, while as surging infections sent admissions simultaneously reducing the regulatory soaring. States that were members of burden on licensees.” 19 the NLC were well positioned to bring

16 TFAH • tfah.org TABLE 4: 34 States Participate in the Nurse Licensure Compact Participants and nonparticipants, 2020 Participants Nonparticipants Alabama Louisiana North Dakota Alaska Nevada Arizona Maine Oklahoma California New York Arkansas Maryland South Carolina Connecticut Ohio Colorado Mississippi South Dakota District of Columbia Oregon Delaware Missouri Tennessee Hawaii Pennsylvania Florida Montana Texas Illinois Rhode Island Georgia Nebraska Utah Massachusetts Vermont Idaho New Hampshire Virginia Michigan Washington Indiana New Jersey West Virginia Minnesota Iowa New Wisconsin North Carolina Wyoming Kentucky Note: Indiana and New Jersey joined the NLC in 2020. Source: National Council of State Boards of Nursing.20

TFAH • tfah.org 17 INDICATOR 2: HOSPITAL The federal Hospital Preparedness information about available beds and PARTICIPATION IN Program (HPP), which is managed ICU capacity, and training healthcare by the HHS Office of the Assistant workers on PPE use, treatments, HEALTHCARE COALITIONS Secretary for Preparedness and and testing guidelines.25 During a Response, provides cooperative pandemic, coordination across a region KEY FINDING: Widespread agreements to states, localities, is essential to alleviate pressure on any and territories to develop regional single facility, to promote cooperation hospital participation in coalitions of healthcare organizations and information sharing for supplies healthcare coalitions was that collaborate to prepare for, and and bed availability, and to facilitate in many cases respond to, medical training of healthcare personnel.26 common in 2017*; only surge events.21 Coalitions prepare The extent to which healthcare systems four states (California, New members with critical tools, including leveraged the resources of their medical equipment and supplies, coalitions during the pandemic is a Hampshire, Ohio, and South real-time information, enhanced subject that requires further research. Carolina) reported 70 percent communication systems, and exercises On average, 89 percent of hospitals and training for healthcare personnel.22 or less of their hospitals in states belonged to a healthcare A healthcare coalition must contain a coalition in 2017, with universal participated in coalitions minimum of two acute-care hospitals, participation, meaning every hospital emergency medical services, emergency supported by the HHS Hospital in the state was part of a coalition, in 17 management, and public health states (Alaska, Colorado, Connecticut, Preparedness Program. agencies.23 Healthcare coalitions Delaware, Hawaii, Louisiana, invest in local capacity to prepare Minnesota, Mississippi, Nevada, North for and respond to events, reducing Dakota, Oregon, Rhode Island, South jurisdictions’ reliance on federal Dakota, Utah, Vermont, Virginia, medical assets during disasters. and Washington) and the District of Broad and meaningful participation by Columbia. (See Table 5.) However, hospitals in healthcare coalitions means some states, such as Ohio (25 percent) that when disaster strikes, systems are and New Hampshire (47 percent) in place to coordinate the response, lagged behind. freeing hospitals to focus on clinical The pandemic exposed major gaps in care. In the past, healthcare coalitions healthcare preparedness, mentioned have assisted in patient transfer, in TFAH’s 2020 report, including evacuations, and information sharing coordinating surge capacity across in events such as Hurricane Harvey the healthcare system;27 building and in 2017. 24 More recently, the COVID- maintaining preparedness for high- 19 pandemic presented the most consequence infectious diseases;28 intense, widespread, and prolonged preparedness of facilities that serve test of U.S. hospital systems in a people at higher risk, such as long-term century, threatening at several points care facilities; and lack of training and to overwhelm facilities’ capacities. preparedness for events in healthcare.29 Healthcare coalitions performed Experts have also identified additional roles such as facilitating the transport gaps, such as pediatric surge capacity,30 of equipment and supplies, sharing burn capacity and other specialty

18 TFAH • tfah.org care needed for emerging threats, *This summary reflects the latest available and ongoing stress on the healthcare data (2017). Because these data are no system’s ability to provide emergency longer being updated, TFAH will consider care. While healthcare coalitions replacing this measure in future assessments. can help address some of these vulnerabilities, systemwide approaches to preparedness are needed.

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. The latest available data is from 2017. Source: NHSPI analysis of data from the Office of the Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services.31

TFAH • tfah.org 19 INDICATORS 3 AND 4: The Public Health Accreditation Board threats. The priority capabilities that ACCREDITATION (PHAB), a nonprofit organization that the PHAB and the EMAP test include administers the national public health identification, investigation, and accreditation program, advances quality mitigation of health hazards; a robust KEY FINDING: Most states are within public health departments by and competent workforce; incident, providing a framework and a set of resource, and logistics management; accredited by one or both of evidence-based standards against which and communications and community- two well-regarded bodies—the they can measure their performance. engagement plans.35,36 States sometimes Public Health Accreditation Among standards with direct relevance aim to meet applicable standards but do to emergency preparedness are not pursue accreditation. Board and the Emergency assurances of laboratory, epidemiologic, As of December 2020, 29 states and the and environmental expertise to Management Accreditation District of Columbia were accredited investigate and contain serious by both the PHAB and the EMAP—a Program—but eight are not public health problems, policies, and net increase of one (Delaware and accredited by either. procedures for urgent communications Georgia are now accredited by the and maintenance of an all-hazards EMAP; Maryland transitioned from emergency operations plan.32 Through being accredited by both bodies to the the process of accreditation, health PHAB only, with the EMAP providing departments identify their strengths conditional accreditation) since and weaknesses, increase their November 2019. Nevada is once again accountability and transparency, and accredited by the EMAP, alongside an improve their management processes, additional 12 states that have received which all promote continuous quality accreditation from one or the other. improvement.33 (See Table 6.) “Over the last eighteen Emergency management, as defined months we have worked diligently by the Emergency Management to review our processes, plans, and Accreditation Program (EMAP), relationships,” said the director of encompasses all organizations in a Delaware’s Emergency Management given jurisdiction with emergency or Agency, A.J. Schall. “Over that time, disaster functions, which may include we learned a tremendous amount and prevention, mitigation, preparedness, modernized procedures.”37 response, and recovery. The EMAP Just eight states (Alaska, Hawaii, helps applicants ensure—through Indiana, New Hampshire, South Dakota, self-assessment, documentation, and Texas, West Virginia, and Wyoming) peer review—that they meet national received no accreditation from either standards for emergency response body. A state without an accreditation capabilities.34 has not necessarily been denied The PHAB and the EMAP each provide accreditation; the state may not have important mechanisms for improving pursued accreditation. This analysis evaluation and accountability. includes state-level accreditations Accreditation by these entities only, it does not include accredited demonstrates that a state’s public local or tribal health departments. In health and emergency management some instances, local public health systems are capable of effectively departments have an accreditation in responding to a range of health states that do not.

20 TFAH • tfah.org TABLE 6: 42 States and the District of Columbia Accredited by the PHAB and/or EMAP Accreditation status by state, December 2020 PHAB and EMAP PHAB only EMAP only No Accreditation

Alabama Idaho New Mexico Maine Kentucky Alaska

Arizona Illinois New York Maryland Michigan Hawaii

Arkansas Iowa North Dakota Minnesota Nevada Indiana

California Kansas Ohio Montana North Carolina New Hampshire

Colorado Louisiana Oklahoma Oregon South Carolina South Dakota

Connecticut Massachusetts Pennsylvania Washington Tennessee Texas

Delaware Mississippi Rhode Island Virginia West Virginia

District of Columbia Missouri Utah Wyoming

Florida Nebraska Vermont

Georgia New Jersey Wisconsin

29 states + DC 6 states 7 states 8 states Note: These indicators track accreditation by the PHAB and the EMAP. TFAH classified states with conditional or pending accreditation at the time of data collection 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.38

TFAH • tfah.org 21 INDICATOR 5: STATE The COVID-19 pandemic showed how 5. Maternal, child, and family health. PUBLIC HEALTH sufficient and sustained funding for a Public health services related to comprehensive public health system is the coordination of services; direct FUNDING TRENDS integral to preparedness and response, service; family planning; newborn including the ability to detect, prevent, and screening; population-based Key Finding: Most states held control disease outbreaks and mitigate the maternal, child, and family health; health consequences of disasters. General supplemental nutrition; etc. their public health funding public health capabilities—such as those 6. Access to and linkage with clinical steady or increased it in FY pertaining to epidemiology, environmental care. Public health services related to hazard detection and control, infectious 2020, but seven reduced beneficiary eligibility determination, disease prevention and control, and risk provider or facility licensing, etc. funding. communications—and targeted emergency response resources are necessary to ensure The overall infrastructure of public that officials maintain routine capabilities health supports states’ ability to promote and that surge capacity is readily available health equity, build resilience in the for emergencies. A trained and standing population, and carry out emergency public health workforce, and one that response activities. But public health knows its community, is critical to the surge funding is typically discretionary, making capacity that is so often necessary during it vulnerable to neglect or retrenchment, an emergency. especially when times are tight. This can undermine emergency preparedness According to the Public Health Activities activities and weaken response and and Services Tracking project at the recovery efforts. State investment in public University of Washington, state public health is important for the operations of health programming and services span health agencies: about 28 percent of state 39 six core areas: and territorial health department revenues 1. Communicable disease control. Public are from state sources,40 while 21 percent health services related to communicable of local health department revenue is from disease epidemiology, hepatitis, state sources, on average.41 HIV/AIDS, , sexually Fortunately, 43 states and the District transmitted diseases, , etc. of Columbia maintained or increased 2. Chronic disease prevention. Public public health funding in FY 2020. (See health services related to asthma, Table 7.) But seven states reduced , cardiovascular disease, the money they directed to these vital diabetes, obesity, tobacco, etc. activities, increasing the likelihood 3. Injury prevention. Public health that they will be less prepared and services related to firearms, motor less responsive in the moments that vehicles, occupational injuries, matter most. (This indicator does not senior fall prevention, substance- assess the adequacy of states’ public use disorder, other intentional and health funding. It should also be noted unintentional injuries, etc. that due to inflation and population 4. Environmental public health. Public growth, stable funding is in some cases health services related to air and water a funding reduction.) The COVID-19 quality, fish and shellfish, food safety, economic has already had a 42 hazardous substances and sites, lead, severe impact on state revenue, which onsite wastewater, solid and hazardous could constrain state public health waste, zoonotic diseases, etc. funding levels over the coming years. 22 TFAH • tfah.org TABLE 7: State Public Health Funding Held Stable or Increased in 43 states and DC Public Health Funding, by state FY 2019 – 2020 State Percentage Change Alabama -4% Alaska 118% Arizona 52% Arkansas -2% California 40% Colorado 9% Connecticut 8% Delaware 8% District of Columbia 2% Florida 8% Georgia 3% Hawaii -2% Idaho 2% Illinois 7% Indiana 0% Iowa -3% Kansas 13% Kentucky 1% Louisiana 3% Maine 24% Maryland 4% Massachusetts 4% Michigan 14% Minnesota 78% Mississippi 2% floridastock Missouri -1% Montana 2% Nebraska 7% Nevada 15% New Hampshire 11% New Jersey 2% New Mexico 8% New York 0.3% North Carolina 2% North Dakota 31% Ohio 13% Oklahoma 29% Oregon 0.5% Pennsylvania -0.4% Rhode Island 3% Note: While states received federal one-time COVID response funding, those South Carolina 3% funds are not included in these tallies, as all federal funds are excluded South Dakota 2% from this measure. However, in some cases, state funding for pandemic Tennessee 9% response may have been included in the data reported to TFAH. For some Texas 28% states, COVID response funding may have resulted in an increase in the state’s overall public health expenditure for the year. Other states may have Utah 9% reallocated money from one line to another with little impact on the overall Vermont 7% funding level. Virginia -6% Owing to differences in organizational responsibilities and budgeting, Washington 6% funding data are not necessarily comparable across states. See “Appendix West Virginia 6% A: Methodology” for a description of TFAH’s data-collection process, Wisconsin 2% including its definition of public health funding. Wyoming 8% Source: TFAH analysis of states’ publicly available funding data.

TFAH • tfah.org 23 INDICATOR 6: Access to safe water is essential for water.48 In children, even low levels of COMMUNITY WATER consumption, sanitation, and the lead exposure can damage the nervous efficient operation of the healthcare system and contribute to developmental SYSTEM SAFETY system. In the United States, the vast delays, learning disabilities, weight majority of the population gets water and hearing loss.49 These incidents KEY FINDING: Few Americans from a public water system,43 and could have long-term consequences on the U.S. Environmental Protection the health and brain development of drink from community water Agency (EPA) sets legal limits on children, as well as the mental health systems that are in violation contaminants in drinking water, and trust of the community. including microorganisms, disinfectants, of applicable health-based As contributes to more and their byproducts, chemicals, and frequent , a residual danger standards required by the Safe radionuclides;44 the EPA also requires is the release of toxic chemicals into states to periodically report drinking- Drinking Water Act. But room community water systems. For example, water quality information.45 Water months after the deadly Camp Fire in for improvement remains. systems must report any violations, Paradise, California, in 2018, experts still such as failing to follow established advised residents not to drink or cook monitoring and reporting schedules, with the water due to concerns about failing to comply with mandated benzene contamination.50,51 Among the treatment techniques, violating any health effects of long-term exposure to maximum contaminant levels, and unsafe levels of benzene is a decrease in failing to meet customer-notification red blood cells, which can lead to anemia. requirements.46 It can also cause excessive bleeding and The United States has one of the can affect the immune system, increasing safest public drinking-water supplies the chance for infection.52 in the world, but some communities, Other water-related emergencies and particularly low-income communities, concerns in the United States include struggle to maintain constant access harmful algal blooms,53 which can to safe water. When water safety issues impact human and animal health, occur, it can require a multisector the safety of seafood, damage the emergency response, as well as a long- economies of affected communities, term public health response. The increase the presence of toxic chemicals most prominent water-contamination like per- and polyfluoroalkyl substances crisis in recent years occurred in Flint, (PFAS), and reduce the availability of Michigan, where a 2014 change in clean water during power outages,54 a water supply caused distribution pipes particular concern in rural areas where to corrode and to leach lead and smaller utilities may not have enough other contaminants into the drinking backup power to meet the demands of water. Tens of thousands of residents, the water and sewage services. Water including young children, were exposed shortages can have a particularly dire to high levels of lead and other toxins.47 impact on healthcare systems, which In 2019, residents of Newark, New rely on clean water for many procedures Jersey, had to rely on bottled water and hygiene practices. due to high levels of lead in their tap

24 TFAH • tfah.org New CDC data indicate waterborne older buildings are more vulnerable to pathogens cause nearly 7,000 deaths, waterborne pathogens in their pipes.55 seven million illnesses and more According to the EPA, across the nation, than $3 billion in healthcare costs 5 percent of state residents on average each year. The risks around drinking used a community water system in water disproportionately threaten 2019 that failed to meet all applicable communities of color, highlighting the health-based standards, down from 7 impact historical structural racism and percent in 2018. That share was 0 to 1 continued institutional bias can have on percent in Hawaii, Maryland, Minnesota, a critical resource most Americans take Nevada, North Dakota, Vermont, and for granted. In some areas, redlining has Washington. (See Table 8.) But in four kept peri-urban communities of color, states (New Jersey, New York, Oregon, tribal lands and rural agricultural areas and West Virginia), more than 15 out of municipal water systems, thereby percent of residents used a community increasing their potential exposure water system with health-based violations. to waterborne illness. In addition,

TABLE 8: Few Americans Used Contaminated Community Water Systems Percent of state populations who used a community water system in violation of health-based standards, 2019 States Percent of Population HI, MD, MN, ND, NV, VT, WA 0% CA, ID, IL, IN, ME, OH 1% AL, CO, DE, MI, NC, NE, NH, WY 2% CT, FL, SC, VA 3% AK, IA, KY, RI, SD, TN, TX, 4% AZ, DC, KS, UT, WI 5% NM 6% GA, MA 7% AR, MS, MT 8% MO, PA 9% LA 13% OK 15% NJ, OR, WV 16% NY 45% Note: The EPA estimates that more than 13 million American households get their drinking water from private wells.56 The data reported by this indicator do not reflect the water quality of those households. Only regulated contaminants are measured. These data do not include water safety on Indian reservations. According to health officials in New York, a drinking water system in New York City is in violation because of an uncovered reservoir, but it has no current violations with respect to contaminants. Source: NHSPI analysis of data from the EPA.57

TFAH • tfah.org 25 INDICATOR 7: USE OF Note: The specification of this indicator has shown to be lower in cities and states 64,65 PAID TIME OFF been adjusted slightly from a measure of those that mandate paid sick leave. When who received paid time off to a measure of employees who previously did not have those who used it. access are granted paid or unpaid sick KEY FINDING: Just over half of leave, rates of flu infections decrease.66 The need for paid time off was obvious workers in states, on average, during the pandemic, when frontline During the COVID-19 pandemic, studies used some type of paid time and essential workers—people who consistently showed that access to paid could not work from home during the sick leave helped slow the spread of the off—sick leave, vacation, outbreak—were often compelled to work virus.67 The Families First Coronavirus holidays—in 2019. Most states when sick themselves or caring for a Response Act helped temporarily sick family member. Black and Hispanic address this issue for employers were closely clustered to that workers typically have less access to paid with fewer than 500 employees and midpoint, with few outliers. sick leave and are overrepresented in certain public employers, temporarily groups of frontline workers.58 requiring employees to be paid sick leave benefits under certain conditions. When workers without paid leave get This helped reduce the spread of the sick, they face the choice of going to virus in workplaces and communities by work and potentially infecting others or removing a barrier to employees staying staying home and losing pay—or even home when necessary. However, these their jobs. They encounter similarly protections expired on December 31, impossible decisions when a child or 2020, despite the ongoing need for the another dependent family member use of paid leave to control the pandemic; gets sick. Therefore, access and the instead, Congress provided a tax credit ability to use job-protected paid time for employers to offer paid sick leave.68 off, especially dedicated paid sick leave, can strengthen infection control and But many workers, particularly low- resilience in communities by reducing wage workers, did not have access to the spread of contagious diseases and paid sick leave during the pandemic bolstering workers’ financial security. This and were therefore left to make is particularly important for industries impossible choices between protecting and occupations that require frequent their health and that of their family contact with the public. For example, or protecting their financial security. people working in food service, older State paid leave laws helped in a few adults and nursing care facilities and jurisdictions. Beginning in March 2020, childcare commonly have no paid sick two states with existing state paid sick leave.59 Low-wage workers60 and workers leave policies, California and Rhode of color are also less likely to have access Island, experienced large increases to paid leave compared with white and in temporary disability and family higher-earning workers.61 This often leads caregiving leave claims. California employees to work throughout an illness claims rose by 43 percent between or return to work before their symptoms February and March 2020.69 Rhode have fully subsided, when time off could Island claims nearly tripled between have dramatically reduced the potential February and March 2020.70 A January of workplace infections.62,63 Biden administration proposal, if adopted by Congress, would provide The public health benefit is clear: at paid leave to people who are: sick with a societal level, flu rates have been

26 TFAH • tfah.org Covid-19 symptoms; quarantining receive routine checkups, dental care, because of Covid-19 exposure; needing and flu shots.72 time off to get the vaccine; caring for In 2019, 55 percent of workers in states, family members who are sick with on average, took some type of paid time Covid-19 symptoms; caring for children off—the same percentage as in 2018— whose school or day care center is according to the Current Population closed because of the pandemic; caring Survey, which is sponsored jointly by for older relatives or adult dependents the U.S. Census Bureau and the U.S. whose long-term care facility is closed Bureau of Labor Statistics.73 Connecticut because of the pandemic.71 (64 percent), the District of Columbia Paid time off also increases access to (65 percent), Mississippi and Oregon preventive care among workers and their (63 percent), and Texas (68 percent) families, including routine checkups, stood out as states where relatively screenings, and . Delaying high percentages of workers used such or skipping such care can result in poor benefits, whereas fewer workers used health outcomes and can ultimately lead them in Arkansas (45 percent), South to costlier treatments. Workers without Carolina (45 percent), South Dakota paid sick days are less likely to get a flu (44 percent), Utah (45 percent), and shot, and their children are less likely to Wyoming (47 percent).74 (See Table 9.)

TABLE 9: 55 Percent of Workers, On Average, Used Paid Time Off Percent of employed population that took paid time off, 2019 States Percent of Workers TX 68% DC 65% CT 64% MS, OR 63% MD, NM, NY 61% AK, IA, WA 60% GA, HI, MA 59% MT, VA 58% NE 57% CA, CO, KS, RI, VT, WI 56% AL, IL, NV, OK, WV 55% FL, NH 54% LA, MO, TN 53% MN, NJ 52% ID, IN, ME, NC, ND, PA 51% MI, OH 49% AZ, DE, KY 48% WY 47% AR, SC, UT 45% SD 44% Note: Paid time off includes sick leave, vacations, and holidays. The data are measured based on a survey of a sample of the general population. The specification of this indicator has been adjusted slightly from a measure of those who received paid time off to a measure of those who used it. Source: NHSPI analysis of data from the Annual Social and Economic Supplement of the Current Population Survey.75

TFAH • tfah.org 27 INDICATOR 8: FLU The CDC recommends that, with few and establishing policies that support VACCINATION RATE exceptions, everyone ages 6 months vaccinations can help prepare the or older get vaccinated for seasonal country to vaccinate all Americans influenza annually; yet, year after year, quickly during the pandemic. A major KEY FINDING: Flu vaccination even with a steady increase among concern as the 2020–2021 adults over the past three decades, opened was that a high of coverage rose for the second coverage estimates indicate that just over seasonal flu coupled with the amount consecutive year during the half of Americans do.76 Healthy People of illness caused by the pandemic 2019–2020 season, with a 2030 set federal 10-year benchmarks for would overwhelm health systems. improving the health of all Americans, During 2021, as the country works to greater share of every age including an overall seasonal influenza deliver the COVID-19 vaccine, seasonal group analyzed receiving a vaccination-rate target of 70 percent flu vaccination programs provide annually.77 important process lessons, networks, vaccine. Overall, 52 percent of communications strategies, and goals Vaccination is the long-standing best U.S. residents ages 6 months or for the COVID-19 vaccination effort. prevention against the seasonal flu, older received vaccinations— particularly for people at high risk of Under the Affordable Care Act, all still well below the overall severe flu-related outcomes, including routine vaccines recommended by the people with certain chronic health Advisory Committee on Immunization target level of 70 percent of the conditions and older adults, groups that Practices, including flu vaccines, are population vaccinated annually. are also at higher risk from COVID-19. fully covered when provided by in- In addition to protecting Americans network providers, except in states from the seasonal flu, establishing that have not expanded their Medicaid a cultural norm of vaccination, programs in accordance with the act. building vaccination infrastructure, Some barriers to flu vaccination may

28 TFAH • tfah.org include a belief that the vaccine does not work very well; TABLE 10: Just Over Half of Americans misconceptions about the safety of the vaccine;78 or a belief Received a Seasonal Flu Vaccination States’ seasonal flu vaccination rates for people ages 79 that the flu does not carry serious risks. State laws may 6 months or older, 2019–2020 also make it more difficult for parents to get their children Vaccination Rate, State vaccinated by a pharmacist, as some states do not allow Ages 6 Months or Older children to get flu vaccines at a pharmacy and even more have Rhode Island 60.9 Connecticut 60.7 age restrictions and/or require a physician’s prescription. Massachusetts 60.6 During the 2019–2020 flu season, 52 percent of residents Virginia 58.8 South Dakota 58.7 ages 6 months or older were vaccinated, according to the Nebraska 58.3 CDC, the highest rate in at least a decade. This was a notable Wisconsin 58.3 uptick from 42 percent during the 2017–2018 flu season. One Maryland 57.8 District of Columbia 57.6 possible explanation is the increased awareness of the public, New Hampshire 57.6 clinicians, and public health officials about the importance of Vermont 57 vaccination, owing to the high number of illnesses and deaths Iowa 56.6 two years prior. The major role that vaccination will play in the North Dakota 56.5 Minnesota 56.3 country’s—and the world’s—recovery from the extraordinarily Washington 56.3 deadly COVID-19 pandemic will, hopefully, make an indelible Pennsylvania 56.1 impression on all Americans about the value of vaccination. North Carolina 55.8 Colorado 55.6 Across the country, states have taken noteworthy actions Maine 55.6 to vaccinate residents against seasonal flu. For example, Delaware 55 Arkansas 54.9 during the 2018–2019 flu season, the Tennessee Department Kansas 54.5 of Health organized statewide Fight Flu TN events with New Jersey 54 vaccination clinics, and last year, it launched a statewide media Oklahoma 54 New Mexico 53.2 campaign.80 The state’s flu vaccine rate (ages 6 months or New York 52.9 older) increased from 36 percent during the 2017–2018 flu Illinois 52.2 season to 49 percent during the 2019–2020 season. Indiana’s West Virginia 52.2 Department of Health has also engaged in focused efforts Utah 51.9 Oregon 51.4 to increase vaccination rates, particularly among people California 51.3 who are uninsured or underinsured. One way it has done Hawaii 51 this is by partnering with local health departments and Ohio 51 pharmacies to provide vaccinations, and by working with the Kentucky 50.9 Indiana 50.8 Indiana Immunization Coalition to create education and South Carolina 50.7 outreach materials and social media messaging.81 Indiana’s Missouri 50.2 flu vaccination rate (ages 6 months or older) improved from Michigan 49.7 Montana 49.6 37 percent for the 2017–2018 flu season to 51 percent for the Tennessee 49.1 2019–2020 season. Alabama 48.4 Louisiana 47.5 Rhode Island (61 percent), Connecticut (61 percent), and Texas 47.3 Massachusetts (61 percent) had the highest coverage, while Wyoming 47.3 vaccination rates were lowest in Nevada (44 percent), Florida Arizona 46.5 Georgia 45.9 (45 percent), and Idaho (45 percent). (See Table 10.) Mississippi 45.9 Alaska 45.8 Children, particularly young children, were more likely to Idaho 44.9 receive vaccinations than were adults. Nearly 64 percent of Florida 44.5 those ages 6 months to 17 years received vaccinations in 2019– Nevada 44.4 2020, compared with 48 percent of adults.82 Note: Data are calculated from a survey sample, with a corresponding sampling error. Source: Centers for Disease Control and Prevention.83,84 TFAH • tfah.org 29 INDICATOR 9: PATIENT SAFETY IN Every year, hundreds of thousands of people die from HOSPITALS hospital errors, injuries, , and infections, collectively making such incidents a leading cause of death in the United States.85,86 Keeping hospital patients safe from preventable KEY FINDING: On average, 31 percent of hospitals harm is an important element of preparedness; those hospitals that excel in safety are less likely to cause or contribute to a received an “A” grade in the fall 2020 hospital public health emergency and are better positioned to handle safety assessment administered by the Leapfrog any emergencies that put routine quality standards to the test.

Group, a nonprofit advocate for safety, quality, and During the COVID-19 pandemic, hospitals were an active transparency in hospitals. setting for viral , threatening the safety of patients, staff and visitors, and also discouraging people in need of urgent or emergency care from going to the ER, likely contributing to overall excess mortality.87 But universal masking and availability and proper use of PPE, in addition to other steps, such as adequate ventilation, limiting the sharing of patient rooms, and universal hand hygiene, proved to be critical in preventing outbreaks in hospitals.

The Leapfrog Group calculates its hospital safety score by using 28 evidence-based metrics that measure the success of healthcare processes and outcomes. The measures track such issues as healthcare-associated infection rates, the number of available beds and qualified staff in intensive- care units, patients’ assessments of staff communications and responsiveness, and a hospital’s overall culture of error prevention.88 These measures are especially critical for health systems’ readiness for emergencies and outbreak prevention and control, which include workforce training and availability, surge capacity, and infection-control practices.

In the Leapfrog Group’s fall 2020 assessment, 31 percent of general acute-care hospitals across the United States, on average, met the requirements for an “A” grade—a slight increase from fall 2018, when the share was 28 percent. But results varied widely state to state, from no hospitals in Alaska, North Dakota, or South Dakota receiving the top score, to a majority of hospitals doing so in Maine (63 percent), Idaho (58 percent), Delaware (57 percent), Massachusetts (57 percent), Oregon (55 percent), Virginia (53 percent), and North Carolina (52 percent). (See Table 11.)

30 TFAH • tfah.org TABLE 11: Hospital Patient Safety Scores Vary Significantly by State States percentage of hospitals with “A” grade, fall 2020 State Percent of Hospitals Maine 63% Idaho 58% Delaware 57% Massachusetts 57% Oregon 55% Virginia 53% North Carolina 52% Vermont 50% Colorado 48% Pennsylvania 47% Utah 46% Hawaii 45% Texas 43% Michigan 43% Washington 40% Maryland 38% New Jersey 37% Ohio 37% Florida 36% California 36% Kentucky 36% South Carolina 34% Illinois 34% Tennessee 33% Wyoming 33% Georgia 32% Kansas 32% Connecticut 32% Mississippi 30% Louisiana 29% Rhode Island 29% Arizona 26% Wisconsin 24% Missouri 24% Minnesota 23% Oklahoma 23% Montana 22% Nevada 21% District of Columbia 20% Alabama 20% Indiana 19% New Mexico 17% Iowa 16% New Hampshire 15% New York 10% Arkansas 7% Nebraska 6% West Virginia 5% Alaska 0% North Dakota 0% South Dakota 0% Note: This measure captures only general acute-care hospitals. Source: The Leapfrog Group.89

TFAH • tfah.org 31 INDICATOR 10: STATE Public health laboratories have been laboratories outside the CDC authorized 93 SURGE CAPACITY essential to emergency response and to conduct testing. Despite early effective disease surveillance systems challenges in the tests rolled out to states, throughout the pandemic. They help at least one public health laboratory in KEY FINDING: Every state detect and diagnose health threats as every state, DC, Puerto Rico, and Guam they emerge, and they track and monitor was able to test for COVID-19 as of reported having a plan in 2020 the spread of those threats, which can June 2020.94 Testing capacity increased for a six- to eight-week surge in help public health officials learn how over time, as private labs received laboratory-testing capacity to to control them. Public health labs authorization and ramped up capacity, exist in every state and territory and and as a variety of rapid molecular tests respond to an outbreak or other are the backbone of the Laboratory were manufactured and approved for use public health event. Response Network (LRN), a national at home; but the processing of the CDC’s network of laboratories that provide the 2019-nCoV Real-Time RT-PCR Diagnostic infrastructure and capacity to respond to Panel assisted officials throughout with public health emergencies.90 monitoring the course of the pandemic. Still, the country’s testing capacity never When a disaster or reached what most experts argued was strikes, public health laboratories must necessary to allow for comprehensive, be able to surge to meet increased timely surveillance of the virus’s spread demand, just like hospitals and other during the height of the pandemic. This responders. The Association of Public problem was most acute in spring 2020, Health Laboratories defines internal when an estimated one in 10 infections surge capacity as a “sudden and sustained were confirmed, improving somewhat to increase in the volume of testing that a roughly one in three in late 2020.95,96 LRN reference laboratory can perform in an emergency situation, implementing In addition, public health laboratories substantial operational changes as defined are studying the genetic sequencing of in laboratory emergency response plans the COVID-19 virus to identify variants. and using all resources available within Such genomic surveillance is critical the laboratory.”91 Surging capacity can to understanding and preventing the require staff movement or reassignment, spread of the virus but more federal extra shifts, and hiring. Labs also have funding is needed to support the work.97 to plan for infrastructure factors, such as Going forward, some challenges to the sufficient biological safety cabinets and effectiveness of public health laboratory chemical fume hoods; amount and type of preparedness include funding supplies; space for intake, processing, and gaps to invest in infrastructure and storage of samples; versatility and capacity modernization, workforce shortages, of analytical equipment and instruments; a lack of standardized platforms to availability of PPE; and power supply.92 exchange data electronically, and a It should also be noted that while the limited ability to detect radiological, existence of surge plans are important, nuclear, and chemical threats.98 these plans have to be funded, tested, and regularly updated. In 2020, the District of Columbia and all states reported to the Association of State public health laboratories have Public Health Laboratories that they been critical assets throughout the had a plan for a six- to eight-week surge COVID-19 pandemic, especially in in testing capacity, a net increase of six early 2020, when they were the only since 2017 and 2018. (See Table 12.) 32 TFAH • tfah.org TABLE 12: Every State Planned for a Laboratory Surge. State public health laboratories with a plan for a six- to eight-week surge in testing capacity, 2020 Had a Plan Alabama Illinois Montana Rhode Island Alaska Indiana Nebraska South Carolina Arkansas Iowa Nevada South Dakota Arizona Kansas New Hampshire Tennessee California Kentucky New Jersey Texas Colorado Louisiana New Mexico Utah Connecticut Maine New York Vermont Delaware Maryland North Carolina Virginia District of Columbia Massachusetts North Dakota Washington Florida Michigan Ohio West Virginia Georgia Minnesota Oklahoma Wisconsin Note: This indicator tracks only the existence of a plan, not its quality or comprehensiveness, or Hawaii Mississippi Oregon Wyoming the frequency with which it is used or tested. Source: Association of Public Health Idaho Missouri Pennsylvania Vermont Laboratories.99

TFAH • tfah.org 33 TABLE 13: INDICATORS OF PUBLIC HEALTH EMERGENCY PREPAREDNESS TABLE 13: INDICATORS OF PUBLIC HEALTH EMERGENCY PREPAREDNESS Public Health Emergency Management Nurse Licensure Hospital Preparedness Public Health Accreditation Board Accreditation Program Water Security Paid Time Off Seasonal Flu Vaccination Patient Safety Public Health Lab Capacity State Performance Compact (NLC) Program Funding (PHAB) (EMAP) Percent of hospitals Percentage Percent of population who used a Percent of employed Seasonal flu vaccination rate Public health laboratories had a State participates in Accredited by PHAB, Accredited by EMAP, Percentage of hospitals with “A” participating in change, FY community water system in violation population who used for people ages 6 months or plan for a six- to eight-week surge Scoring tier, 2020 NLC, 2020 2020 2020 grade, fall 2020 coalitions, 2017 2019-20 of health-based standards, 2019 paid time off, 2019 older, 2019–20 in testing capacity, 2020 Alabama 3 95% 3 3 -4% 2% Alabama 55% 48.4 20% 3 Middle Alaska 100% 118% 4% Alaska 60% 45.8 0% 3 Low Arizona 3 72% 3 3 52% 5% Arizona 48% 46.5 26% 3 Low Arkansas 3 81% 3 3 -2% 8% Arkansas 45% 54.9 7% 3 Low California 70% 3 3 40% 1% California 56% 51.3 36% 3 Middle Colorado 3 100% 3 3 9% 2% Colorado 56% 55.6 48% 3 High Connecticut 100% 3 3 8% 3% Connecticut 64% 60.7 32% 3 High Delaware 3 100% 3 3 8% 2% Delaware 48% 55 57% 3 High D.C. 100% 3 3 2% 5% D.C. 65% 57.6 20% 3 High Florida 3 73% 3 3 8% 3% Florida 54% 44.5 36% 3 Middle Georgia 3 97% 3 3 3% 7% Georgia 59% 45.9 32% 3 High Hawaii 100% -2% 0% Hawaii 59% 51 45% 3 Low Idaho 3 98% 3 3 2% 1% Idaho 51% 44.9 58% 3 High Illinois 88% 3 3 7% 1% Illinois 55% 52.2 34% 3 Middle Indiana 3 75% 0% 1% Indiana 51% 50.8 19% 3 Low Iowa 3 80% 3 3 -3% 4% Iowa 60% 56.6 16% 3 Middle Kansas 3 96% 3 3 13% 5% Kansas 56% 54.5 32% 3 High Kentucky 3 93% 3 1% 4% Kentucky 48% 50.9 36% 3 Middle Louisiana 3 100% 3 3 3% 13% Louisiana 53% 47.5 29% 3 Middle Maine 3 94% 3 24% 1% Maine 51% 55.6 63% 3 High Maryland 3 89% 3 4% 0% Maryland 61% 57.8 38% 3 High Massachusetts 82% 3 3 4% 7% Massachusetts 59% 60.6 57% 3 High Michigan 90% 3 14% 2% Michigan 49% 49.7 43% 3 Middle Minnesota 100% 3 78% 0% Minnesota 52% 56.3 23% 3 Middle Mississippi 3 100% 3 3 2% 8% Mississippi 63% 45.9 30% 3 High Missouri 3 87% 3 3 -1% 9% Missouri 53% 50.2 24% 3 Low Montana 3 83% 3 2% 8% Montana 58% 49.6 22% 3 Middle Nebraska 3 95% 3 3 7% 2% Nebraska 57% 58.3 6% 3 High Nevada 100% 3 15% 0% Nevada 55% 44.4 21% 3 Low New Hampshire 3 47% 11% 2% New Hampshire 54% 57.6 15% 3 Low New Jersey 3 82% 3 3 2% 16% New Jersey 52% 54 37% 3 Middle New Mexico 3 71% 3 3 8% 6% New Mexico 61% 53.2 17% 3 High New York 86% 3 3 0% 45% New York 61% 52.9 10% 3 Low North Carolina 3 95% 3 2% 2% North Carolina 51% 55.8 52% 3 High North Dakota 3 100% 3 3 31% 0% North Dakota 51% 56.5 0% 3 Middle Ohio 25% 3 3 13% 1% Ohio 49% 51 37% 3 Low Oklahoma 3 95% 3 3 29% 15% Oklahoma 55% 54 23% 3 High Oregon 100% 3 0% 16% Oregon 63% 51.4 55% 3 Middle Pennsylvania 86% 3 3 0% 9% Pennsylvania 51% 56.1 47% 3 Low Rhode Island 100% 3 3 3% 4% Rhode Island 56% 60.9 29% 3 High South Carolina 3 56% 3 3% 3% South Carolina 45% 50.7 34% 3 Low South Dakota 3 100% 2% 4% South Dakota 44% 58.7 0% 3 Low Tennessee 3 91% 3 9% 4% Tennessee 53% 49.1 33% 3 Middle Texas 3 80% 28% 4% Texas 68% 47.3 43% 3 Middle Utah 3 100% 3 3 9% 5% Utah 45% 51.9 46% 3 High Vermont 100% 3 3 7% 0% Vermont 56% 57 50% 3 High Virginia 3 100% 3 -6% 3% Virginia 58% 58.8 53% 3 High Washington 100% 3 6% 0% Washington 60% 56.3 40% 3 High West Virginia 3 97% 6% 16% West Virginia 55% 52.2 5% 3 Low Wisconsin 3 98% 3 3 2% 5% Wisconsin 56% 58.3 24% 3 High Wyoming 3 92% 8% 2% Wyoming 47% 47.3 33% 3 Low 51-state average N/A 89% N/A N/A 12% 5% 51-state average 55% 52.8 31% N/A N/A Note: See “Appendix A: Methodology” for a description of TFAH’s data-collection process and scoring details. States with conditional or pending accreditation at the time of data collection were classified as having no accreditation. Some state residents use private drinking-water sources, rather than community water systems. Private sources are not captured by these data. Only regulated contaminants are measured. Paid time off includes sick leave, vacations, and holidays. The patient safety measure captures only general acute-care hospitals. 34 TFAH • tfah.org TABLE 13: INDICATORS OF PUBLIC HEALTH EMERGENCY PREPAREDNESS TABLE 13: INDICATORS OF PUBLIC HEALTH EMERGENCY PREPAREDNESS Public Health Emergency Management Nurse Licensure Hospital Preparedness Public Health Accreditation Board Accreditation Program Water Security Paid Time Off Seasonal Flu Vaccination Patient Safety Public Health Lab Capacity State Performance Compact (NLC) Program Funding (PHAB) (EMAP) Percent of hospitals Percentage Percent of population who used a Percent of employed Seasonal flu vaccination rate Public health laboratories had a State participates in Accredited by PHAB, Accredited by EMAP, Percentage of hospitals with “A” participating in health care change, FY community water system in violation population who used for people ages 6 months or plan for a six- to eight-week surge Scoring tier, 2020 NLC, 2020 2020 2020 grade, fall 2020 coalitions, 2017 2019-20 of health-based standards, 2019 paid time off, 2019 older, 2019–20 in testing capacity, 2020 Alabama 3 95% 3 3 -4% 2% Alabama 55% 48.4 20% 3 Middle Alaska 100% 118% 4% Alaska 60% 45.8 0% 3 Low Arizona 3 72% 3 3 52% 5% Arizona 48% 46.5 26% 3 Low Arkansas 3 81% 3 3 -2% 8% Arkansas 45% 54.9 7% 3 Low California 70% 3 3 40% 1% California 56% 51.3 36% 3 Middle Colorado 3 100% 3 3 9% 2% Colorado 56% 55.6 48% 3 High Connecticut 100% 3 3 8% 3% Connecticut 64% 60.7 32% 3 High Delaware 3 100% 3 3 8% 2% Delaware 48% 55 57% 3 High D.C. 100% 3 3 2% 5% D.C. 65% 57.6 20% 3 High Florida 3 73% 3 3 8% 3% Florida 54% 44.5 36% 3 Middle Georgia 3 97% 3 3 3% 7% Georgia 59% 45.9 32% 3 High Hawaii 100% -2% 0% Hawaii 59% 51 45% 3 Low Idaho 3 98% 3 3 2% 1% Idaho 51% 44.9 58% 3 High Illinois 88% 3 3 7% 1% Illinois 55% 52.2 34% 3 Middle Indiana 3 75% 0% 1% Indiana 51% 50.8 19% 3 Low Iowa 3 80% 3 3 -3% 4% Iowa 60% 56.6 16% 3 Middle Kansas 3 96% 3 3 13% 5% Kansas 56% 54.5 32% 3 High Kentucky 3 93% 3 1% 4% Kentucky 48% 50.9 36% 3 Middle Louisiana 3 100% 3 3 3% 13% Louisiana 53% 47.5 29% 3 Middle Maine 3 94% 3 24% 1% Maine 51% 55.6 63% 3 High Maryland 3 89% 3 4% 0% Maryland 61% 57.8 38% 3 High Massachusetts 82% 3 3 4% 7% Massachusetts 59% 60.6 57% 3 High Michigan 90% 3 14% 2% Michigan 49% 49.7 43% 3 Middle Minnesota 100% 3 78% 0% Minnesota 52% 56.3 23% 3 Middle Mississippi 3 100% 3 3 2% 8% Mississippi 63% 45.9 30% 3 High Missouri 3 87% 3 3 -1% 9% Missouri 53% 50.2 24% 3 Low Montana 3 83% 3 2% 8% Montana 58% 49.6 22% 3 Middle Nebraska 3 95% 3 3 7% 2% Nebraska 57% 58.3 6% 3 High Nevada 100% 3 15% 0% Nevada 55% 44.4 21% 3 Low New Hampshire 3 47% 11% 2% New Hampshire 54% 57.6 15% 3 Low New Jersey 3 82% 3 3 2% 16% New Jersey 52% 54 37% 3 Middle New Mexico 3 71% 3 3 8% 6% New Mexico 61% 53.2 17% 3 High New York 86% 3 3 0% 45% New York 61% 52.9 10% 3 Low North Carolina 3 95% 3 2% 2% North Carolina 51% 55.8 52% 3 High North Dakota 3 100% 3 3 31% 0% North Dakota 51% 56.5 0% 3 Middle Ohio 25% 3 3 13% 1% Ohio 49% 51 37% 3 Low Oklahoma 3 95% 3 3 29% 15% Oklahoma 55% 54 23% 3 High Oregon 100% 3 0% 16% Oregon 63% 51.4 55% 3 Middle Pennsylvania 86% 3 3 0% 9% Pennsylvania 51% 56.1 47% 3 Low Rhode Island 100% 3 3 3% 4% Rhode Island 56% 60.9 29% 3 High South Carolina 3 56% 3 3% 3% South Carolina 45% 50.7 34% 3 Low South Dakota 3 100% 2% 4% South Dakota 44% 58.7 0% 3 Low Tennessee 3 91% 3 9% 4% Tennessee 53% 49.1 33% 3 Middle Texas 3 80% 28% 4% Texas 68% 47.3 43% 3 Middle Utah 3 100% 3 3 9% 5% Utah 45% 51.9 46% 3 High Vermont 100% 3 3 7% 0% Vermont 56% 57 50% 3 High Virginia 3 100% 3 -6% 3% Virginia 58% 58.8 53% 3 High Washington 100% 3 6% 0% Washington 60% 56.3 40% 3 High West Virginia 3 97% 6% 16% West Virginia 55% 52.2 5% 3 Low Wisconsin 3 98% 3 3 2% 5% Wisconsin 56% 58.3 24% 3 High Wyoming 3 92% 8% 2% Wyoming 47% 47.3 33% 3 Low 51-state average N/A 89% N/A N/A 12% 5% 51-state average 55% 52.8 31% N/A N/A Note: See “Appendix A: Methodology” for a description of TFAH’s data-collection process and scoring details. States with conditional or pending accreditation at the time of data collection were classified as having no accreditation. Some state residents use private drinking-water sources, rather than community water systems. Private sources are not captured by these data. Only regulated contaminants are measured. Paid time off includes sick leave, vacations, and holidays. The patient safety measure captures only general acute-care hospitals. TFAH • tfah.org 35 SECTION 2: SECTION 2: RECOMMENDATIONS FOR POLICY ACTIONS Ready or Not Recommendations for 2021 Policy ActIons

As 2020 has shown, saving lives and protecting the country’s economic stability during a pandemic requires pre-event investment and planning, a strong public health system, federal leadership, and a coordinated response. The same is true for all types of public health emergencies. Effective preparedness and response require sufficient funding, a trained workforce, and multisector teamwork. Authentic engagement with community- based leaders and organizations are also necessary.

TFAH based the following policy recommendations on research and analysis, consultation with experts, and a review of gaps in federal and state preparedness. TFAH offers the following recommendations for federal, state, local, tribal, and territorial policymakers and other stakeholders to improve public health emergency readiness.

Priority Area 1: Provide Stable, Sufficient Funding for Domestic and Global Public Health Security The COVID-19 pandemic has uncovered the only federal source of funding to the tragic consequences of the nation’s help the healthcare delivery system long-term neglect of public health prepare for and respond to disasters, capacity at the global, federal, state, has been cut by nearly half over the local, tribal, and territorial levels. same time period, or by nearly two- Understaffed health departments thirds, after adjusting for inflation.104 are in some cases using 20th-century Therefore, health departments were tools, such as telephones and fax already working from a deficit when machines,100,101 to respond to a 21st- the pandemic emerged. Federal century pandemic.102 At the same policymakers need to rapidly improve time, funding for the Public Health the COVID-19 response and build Emergency Preparedness cooperative back a system currently unprepared to MARCH 2021 agreement, a critical source of funding address future emergencies. Short-term for health departments to build investments made through COVID capabilities to effectively respond to response funding legislation cannot fill a range of public health threats, has the gap left by ongoing public health been cut by just over one-quarter funding shortfalls, nor can they address since FY 2003, or about half, after underlying health inequities that are adjusting for inflation.103 The HPP, making the nation less resilient. 36 TFAH • tfah.org RECOMMENDATIONS FOR FEDERAL GOVERNMENT: l Rebuild and modernize the public health system, including by creating a mandatory $4.5 billion per year Public Health Infrastructure Fund to support foundational public health capabilities at the state, local, territorial, and tribal levels (STLT). Strong foundational capabilities would improve the protection of all communities across a range of threats. However, a nationwide funding shortage, exacerbated by the pandemic, has prevented health departments across the country from developing and maintaining these capabilities. An additional funding limitation is that health departments receive very little funding that is not tied to specific diseases or categories. Congress should meant that the agency and its partners year to the CDC’s data modernization invest in cross-cutting public health are reliant on archaic data systems. initiative to modernize and sustain these capabilities, such as proposed in the Americans felt the pain of delayed systems. New data systems should be Public Health Infrastructure Saves Lives and disjointed disease surveillance interoperable and cloud-based. Act.105 Congress must also increase throughout the pandemic, as the public funding for specific programs that l Ensure complete, disaggregated health surveillance infrastructure relied support health security, including the demographic data collection and on antiquated, disconnected systems Public Health Emergency Preparedness reporting during public health and methods for tracking and responding and the HPP cooperative agreements. emergencies. The gaps in COVID- to diseases. Congress wisely invested These state and local preparedness 19 data reporting by race, ethnicity, $500 million in the Coronavirus Aid, programs have demonstrated their value sexual identity, gender identity, Relief, and Economic Security Act by saving lives, improving the speed and primary language, disability status, the (P.L.116-136) and $50 million in the quality of response during emergencies, intersections of these demographics, FY 2020 and FY 2021 appropriations and ensuring that local authorities can and other factors hindered the bills as a down-payment on the adequately respond to most local health response and masked the true breadth CDC’s data modernization initiative. emergencies and outbreaks without of inequities during the pandemic. These investments will help build the federal assistance. Congress should These gaps exposed long-standing foundations for data sharing across provide additional funding to modernize shortcomings in demographic data public health, modernize the CDC’s public health and response functions at collection and reporting in public services and systems, leverage new the CDC and ensure the agency has the health. Congress should invest in data data sources, and ensure public health capacity to respond to any event. modernization for STLT public health to can act on innovative data analytics. enable accurate and comprehensive data l Invest in sustained public health data However, these advancements must collection. In addition, HHS should stand modernization. Sustained investment in be augmented and sustained, making up a task force—including the Office of health data systems at the federal, state, up for decades of neglect. Congress the Assistant Secretary for Planning and and local levels is imperative. The CDC is should build on these initial investments Evaluation, CDC, Office of the National the world’s premier public health agency, with at least $450 million in immediate Coordinator on Health Information yet years of inadequate funding has funding and at least $100 million per Technology, Office of Minority Health,

TFAH • tfah.org 37 and CMS, in consultation with state, not come from existing preparedness local, territorial and tribal agencies and resources, as response capacity cannot private-sector stakeholders—to identify substitute for adequate readiness. The and address barriers to the collection HHS secretary should only use such and regular reporting of disaggregated, funding for acute emergencies that detailed demographic data during require a rapid response to save lives the pandemic and beyond. If needed, and protect the public. Congress should provide HHS agencies l Demonstrate a long-term commitment the authority to require jurisdictions to to global health security. The United report race and ethnicity during public States should recommit to partnerships health emergencies.106 with international bodies such as the l Accelerate crisis responses through WHO, and Congress should solidify a standing public health emergency America’s role as a global health leader, response fund and faster supplemental commit to implementing the Global funding. In addition to stable core Health Security Strategy,107 and provide funding, the federal government sustained annual funding for global needs readily available funds on hand health security programs at the CDC to enable a rapid response while and the U.S. Agency for International Congress assesses the necessity for Development. Congress should fund supplemental funding. Congress should and the CDC should implement the continue a no-year infusion of funds modernization of the U.S. quarantine into the Public Health Emergency Rapid system, including IT systems, Response Fund and/or the Infectious quarantine stations, regulatory Disease Rapid Response Fund to serve framework, and traveler engagement as available funding that would provide a and information. temporary bridge between preparedness Editor’s note: on January 21, 2021, and supplemental emergency funds. the Biden administration restored U.S. Congress should replenish such funding membership in the WHO. on an annual basis, and funding should

RECOMMENDATION FOR FEDERAL AND STATE GOVERNMENT: l Enable efficient use of emergency disconnected and less effective funding. During an emergency, emergency responses on the ground. responding agencies at all levels of The Office of Management and government must be able to adapt Budget, HHS, and FEMA should allow spending policies. States should review waivers of regulatory or administrative their administrative preparedness requirements to awardees of emergency to ensure they can efficiently use response funding to allow funding emergency monies, including speeding braiding, to encourage coordination up contracting and hiring procedures. between programs and funding In addition, Congress may allocate streams with similar goals, to provide emergency funding to multiple federal flexibility to best meet the needs of the agencies. However, differing agency affected populations, and to increase policies and practices can impede efficiencies and reduce administrative speed and coordination of funding duplication, such as in grant reporting. across agencies. This can lead to 38 TFAH • tfah.org Priority Area 2: Prevent Outbreaks and Pandemics Infectious diseases represent a threat and long-term mental health impacts to respond to “everyday” outbreaks: to the health, safety, and economic have yet to be fully understood. As TFAH, seasonal influenza, vaccine-preventable and social stability of the country. The scientists, and public health experts have diseases, healthcare-associated infections, COVID-19 pandemic has cost the nation warned for many years, the nation was and resistance continue to hundreds of thousands of lives and at not prepared for a severe pandemic. pose threats to health and safety. The least $16 trillion in losses to the U.S. gross At the same time as the nation battles United States must be able to prevent domestic product as of October 2020.108 the worst pandemic in a century, public and respond to both major pandemics The toll in lost educational achievement health and medical providers continue and localized outbreaks.

RECOMMENDATIONS FOR FEDERAL GOVERNMENT, HEALTHCARE, AND AGRICULTURE: l Support the vaccine infrastructure. to HHS to study the causes of vaccine prevention methods of detecting and The CDC’s immunization program, resistance and to educate clinical containing outbreaks supported by the sometimes called the “317 program,” providers on methods for improving Antibiotic Resistance Solutions Initiative supports state and local immunization vaccine acceptance, such as those at the CDC. The CDC is investing in systems to increase vaccination rates proposed in the VACCINES Act.111 prevention measures in every state to among uninsured and underinsured strengthen lab capacity, track infections l Ensure first-dollar coverage for adults and children, to respond to across healthcare systems, detect new recommended vaccines under outbreaks, to educate the public, threats, disrupt pathogens, coordinate Medicaid, Medicare, and commercial to target hard-to-reach populations, prevention strategies, educate insurance. Public and private payers to improve vaccine confidence, to healthcare providers on appropriate should ensure that all vaccines establish partnerships, and to improve antibiotic use, and advocate for other recommended by the Advisory information systems. Yet, funding has innovations. To fully address the scope Committee on Immunization Practices not kept up with needs, as states of AR spread, particularly in healthcare (ACIP) are fully covered, as cost have to spend immunization dollars settings, Congress should increase sharing, such as co-pays, can be a to respond to outbreaks,109 deal funding for healthcare associated significant barrier to vaccination.112 with increases in the numbers of infection/antibiotic resistance programs Congress should require zero cost residents who lack health insurance,110 and activities at state and local health sharing in Medicare Part D and B and attempt to manage the impact departments. In addition, increases in plans, and CMS should incentivize of vaccine underutilization. State, funding are necessary to build global Part D plans to eliminate cost sharing local, and tribal health departments capacity to prevent and detect resistant and increase receipt of vaccines.113 are depending on this underfunded infections and to combat the threat to An example of legislation that takes infrastructure to distribute and national security. steps to improve senior vaccination dispense the COVID-19 vaccine, yet rates is the Protecting Seniors Through l Create incentives for new-product COVID funding was not distributed until Immunization Act. CMS should discovery to fight resistant infections. It January 2021. Congress should monitor encourage state Medicaid plans in is extremely challenging for companies the COVID-19 vaccination progress and states that have not expanded Medicaid to earn a return on their investments for provide additional funding, if needed. to cover all ACIP-recommended the development of new : (1) Congress should also increase annual vaccines without cost sharing.114 antibiotics are typically given for a short funding for the CDC’s immunization duration; (2) the most highly resistant program as well as the seasonal l Significantly increase investments infections are still relatively rare; and (3) influenza program and post-licensure in public health initiatives to combat new antibiotics must be used judiciously vaccine safety monitoring. Congress antibiotic resistance. Congress to preserve their effectiveness. These should also provide needed resources should increase funding for innovative

TFAH • tfah.org 39 factors have resulted in nearly all major patterns. Farmers and the food industry to work with public health stakeholders pharmaceutical companies exiting the should stop using medically important to track progress in prescribing rates antibiotics market, leaving the critical antibiotics to promote growth and and resistance patterns.117 All relevant innovation domain of discovering prevent disease in healthy animals, as facilities must drastically improve and developing new antibiotics to recommended by the WHO,115 and they their reporting of antibiotic use and small biotech companies with limited should invest in research to develop resistance through the National budgets and limited research and and adopt husbandry practices that Healthcare Safety Network and should development capacity. Legislation, such reduce the need for routine antibiotics. adopt stewardship programs that meet as the DISARM Act, would strengthen the CDC’s Core Elements.118 l Decrease over-prescription of the market for antibiotic developers, antibiotics through implementation of l Fund the CDC to support state and improving patient access for those who antibiotic stewardship and antibiotic- local public health laboratories. The need it most. use reporting. The CDC estimates CDC should be sufficiently funded to l Eliminate overuse of antibiotics in that improving prescribing practices strengthen the Laboratory Response agriculture. The FDA should enforce and preventing infections could save Network and to support state and local rules regarding veterinary oversight 37,000 lives over five years.116 CMS public health laboratories; currently, the and the judicious use of antibiotics in should finalize, implement, and enforce Epidemiology and Laboratory Capacity food animals, ensure data collection requirements for all CMS-enrolled grant is only funding approximately and publication, promote antibiotic facilities to have effective antibiotic half of what laboratories and health stewardship programs, and track the stewardship programs that align with department epidemiologists nationwide impact of these policies on resistance the CDC’s Core Elements guidance and have requested.

RECOMMENDATIONS FOR FEDERAL AND STATE GOVERNMENT: l Provide job-protected paid leave. The l Minimize state vaccine exemptions all ACIP-recommended vaccinations pandemic has called attention to the fact for schoolchildren and increase to protect staff and patients, assure that paid family and medical leave are vaccination of healthcare workers. continuity of operations in the event of important infection-control measures, States should enact policies that an outbreak, and achieve necessary protecting both workers and customers, enable universal childhood vaccinations healthcare infection control. As in addition to creating economic security. to ensure children, their classmates, this report was being prepared for Workers are unable to adhere to public educators, and the general public are publication, the COVID-19 vaccine health guidance to isolate if they risk protected from vaccine-preventable was not an ACIP-required vaccine. losing their jobs or paychecks. While diseases. This includes eliminating Healthcare facilities should ensure Congress temporarily expanded access nonmedical exemptions and opposing access to vaccines for all staff and to paid leave during the pandemic, a legislation to expand exemptions.119 contractors, and they should remove permanent fix is needed. Congress should States should ensure medical vaccine any barriers to staff receiving vaccines. enact a permanent federal paid family exemptions are only given when Healthcare facilities should also report and medical leave policy and dedicated appropriate and are not used as a healthcare worker vaccination status, paid sick days protections, and states de facto personal-belief exemption such as for seasonal flu and COVID- should ensure effective implementation in states where those exemptions 19, to the CDC’s National Healthcare by passing paid leave laws and/or have been eliminated. States should Safety Network. removing preemption exemptions. require healthcare personnel to receive

40 TFAH • tfah.org Priority Area 3: Build Resilient Communities and Promote Health Equity in Preparedness Social, economic, and health disparities risk of exposure due to living in engaging with the people and impact how people within specific crowded or inadequate housing;121 communities most likely to be impacted communities’ experience disasters and more severe economic impacts for throughout the emergency planning and how quickly they can recover. lower-income workers has meant that and response process are critical to Unfortunately, the disproportionate people of color and Tribal Nations are reducing vulnerability and ensuring impact of COVID-19 on communities bearing a disproportionate burden from that all receive appropriate services, of color and Tribal Nations was the pandemic. When intersectional regardless of circumstance. Equity foreseeable: underlying health issues, such as homelessness, must be an explicit and foundational conditions driven by years of structural incarceration, disability, age, lack of principle in all emergency planning. racism; uneven access to prevention and access to paid leave, LGBTQ+ status, Some communities have taken steps care during the pandemic; increased and immigration status are also at play, to integrate principles of equity risk of exposure due to being frontline the inequities are more pronounced. throughout public health emergency workers, such as in food processing, Addressing underlying inequities activities,122 but more needs to be done. food service, or healthcare;120 increased and intentionally and meaningfully

RECOMMENDATIONS FOR FEDERAL, STATE, AND LOCAL GOVERNMENT: l Examine and address gaps in equity access; fight poverty; and implement a disproportionate burden during in response capabilities. An external other policies proven to advance health. disasters. Evacuation plans should body (such as the GAO or the National Congress should fund a public health be inclusive of the community as a Academy of Sciences, Engineering approach to address SDOH, such as whole by meeting and enforcing the and ) should conduct the approach proposed in the Improving requirements of the Americans with an assessment of the pandemic Social Determinants of Health Act. The Disabilities Act. Grants should support specifically focused on gaps in legislation would strengthen SDOH culturally and linguistically appropriate equitable response, including inequities capacity at the CDC and enable grants public health campaigns that address in allocation of scarce resources, to public health agencies to build prevention and treatment, providing healthcare capacity, data collection and cross-sector partnerships and develop community leaders the opportunity to reporting, and planning for communities community solutions to SDOH. For fully participate in planning activities, at higher risk, underserved further discussion on policy options to allowing organizations to hire and communities, and communities of color. address SDOH, see TFAH’s Blueprint engage community members so and PHACCS reports.124,125 emergency plans better reflect the l Invest in policies and capacity to community, and improving data address the social determinants of l Provide resources and technical collection and sharing. Federal and health (SDOH): People at highest assistance to communities to enhance other grant makers and states should risk during disasters and those who equity and resilience before, during, ensure that existing grants and sub- have the hardest time recovering and after an event. Rather than a awards reach the grassroots level and are often those with unstable or top-down approach to promote equity communities most in need. unhealthy housing, those with limited and resilience, policymakers should access to transportation, and those support an asset-based approach l Public health agencies should who live in low-socioeconomic-status that relies on communities identifying strengthen their health equity communities,123 all of which bore and leveraging their assets. Congress leadership and adopt strategies and out during the COVID-19 pandemic. should direct targeted resources to accountability metrics to incorporate Addressing SDOH can improve community-based organizations and equity into preparedness. Equity must resilience, but it must be a cross-sector existing community health networks not be considered separate from effort to increase healthy, affordable that focus on the health of communities preparedness activities but must serve housing; improve transportation of color and other groups that bear as the foundation for a more resilient

TFAH • tfah.org 41 community. Ensuring equity is central internal infrastructure to drive equity, policies and plans;127 to improve to all preparedness activities and including by identifying a chief health staff capacity to understand how the requires integrating equity accountability equity officer who has a leadership role legacies of discrimination, current-day measures into all elements of in the emergency operations center racial trauma, and other structural emergency response. Congress should and/or incident command structure inequities affect disaster resilience provide the CDC funding to extend its for all-hazards events and is engaged and recovery; develop and disseminate COVID-19 Health Equity Strategy126 to in every emergency operation center communications materials that are ongoing preparedness and response activation. Health equity and emergency culturally and linguistically tailored; and work at the agency and with partners. All preparedness officials should work to collect and leverage data to identify state and local governments, including across programs to incorporate equity unique community assets and advance health departments, should build up issues and goals into preparedness equity before and during events.

RECOMMENDATIONS FOR STATE AND LOCAL GOVERNMENT AND COMMUNITY LEADERS: l Plan with communities, not for them, management agencies should rely During the COVID-19 pandemic, there and empower their involvement with on the expertise, community trust, have been reports of increases in a resources. Emergency planners must and networks of those who may bear number of mental health concerns,128 conduct meaningful engagement, a disproportionate risk, such as including suicide ideation129 and drug partnerships, and listening efforts older adults, people with disabilities, overdoses.130 Short-term regulatory as well as ongoing inclusion and individuals with chronic health relief, like take-home medication for and local hiring (especially from conditions to ensure emergency plans, opioid use disorder131 and waivers communities typically at higher risk procedures, and evacuation shelters for telehealth,132 have helped, but in disasters) in emergency planning meet the needs of all in the community. coordination among state, local, and response. Officials should and federal agencies remains vital l Address mental health and substance establish relationships with services to delivering resources to affected use gaps, bolster crisis resources, and organizations that serve these communities. Policymakers should and incorporate mental health first-aid populations before emergencies also incorporate behavioral health and long-term treatment into disaster take place, and government should needs into disaster planning, as response and recovery strategies. fund community leaders and required by the Pandemic and All- Emergencies can exacerbate existing community-based organizations to Hazards Preparedness and Advancing mental health and substance use participate in preparedness efforts. Innovation Act. concerns and disrupt access to care. Health departments and emergency

42 TFAH • tfah.org Priority Area 4: Ensure Effective Leadership, Coordination, and Workforce The political polarization and more important than any technology contradictory messaging exhibited or invention is the presence of throughout the pandemic contributed trained, experienced people, from to a wide variation in how individuals the frontline responder to the top of and communities responded. Issues government. The nation’s local public such as face coverings, business- and health departments responded to the school-closure decisions, and even the pandemic with an estimated 26,000 mortality numbers became matters fewer public health workers compared for debate by a vocal minority of with before the 2008 recession.134 The Americans.133 Clear national leadership state budget cuts likely to continue and communication, following the in the years following the pandemic advice of public health and scientific threaten to intensify this workforce experts, is needed to ensure consistent shortage. Effective crisis response policies and messaging during a requires coordination, cooperation, and situation as complicated and dangerous leadership—elements that governments as a public health emergency. Perhaps must build and sustain over time.

RECOMMENDATIONS FOR FEDERAL GOVERNMENT: l Strengthen federal leadership, the CDC and the FDA. Policy decisions guidance and regulatory authorities from the federal to the local level for public health emergencies. During should be based on the best available the COVID-19 pandemic, authority and science, led by public health experts, decision-making over the response was and free from any perception of political ceded to states to an unprecedented interference. The president, the HHS degree. This diffusion of responsibility secretary, and the leadership of federal meant wide variation in policy and public health and emergency response response decisions regarding business agencies, including the CDC, ASPR, closures, mask mandates, testing DHS, FEMA and the FDA, must conduct strategies, and other tactics. The CDC a thorough review on the independence must be empowered to lead the public and performance of these agencies. health response during a pandemic Leaders should establish procedures and and issue clear, feasible guidance and policies to ensure the scientific integrity regulations for state, local, tribal, and and independence of the agencies, territorial officials and to the public to without political interference, and they minimize variation across jurisdictions. must correct any errors made during the The optimal approach is a federal-state COVID-19 response. At the same time, partnership rooted in shared decision- elected leaders must publicly support making and a clear division of labor. public health to rebuild confidence in those agencies and officials. All federal l Rebuild trust in federal public health messages and messengers about public agencies. The COVID-19 pandemic health issues must be consistent and has damaged faith in federal agencies, based in science. including public health agencies such as

TFAH • tfah.org 43 l The White House should reestablish a health security directorate with public health expertise. The White House should ensure senior advisors to the president have a strong background in public health and/or biodefense, and the White House should ensure that senior-level interagency cooperation is progressing before, during, and after public health emergencies.

Editor’s note: on January 20, 2021, the Biden administration reestablished a National Security Council Directorate for Global Health Security and Biodefense.

l Clarify and restore roles and responsibilities for government’s emergency support functions. The Sundry Photography White House, HHS, CDC, ASPR, U.S. l Invest in public health communications. Department of Homeland Security, Congress must make a significant FEMA, and FDA should work together investment in effective public health to clarify roles and responsibilities communications, including research into to improve the nation’s emergency best practices for different audiences. The preparedness and response capacity. CDC and other federal, state, and local public health agencies should engage l Fund the recruitment and training of with a diverse group of stakeholders public health personnel. The health to research and test effective enterprise requires trained, health messaging. From vaccines to experienced personnel. Federal, state, mask-wearing, there are subgroups of and local governments must prioritize Americans who are skeptical, hesitant, stable, long-term funding for recruitment or confused about COVID-19 public and retention of a diverse workforce, health guidance for various reasons. including one with experience in public While some will be recalcitrant, many health informatics, laboratory science, Americans are simply hesitant or have health equity, and epidemiology. not been properly engaged. While the Congress should also invest in public substance of communications should be health workforce development and consistent, messages must acknowledge retention programs, such as student the historical context of distrust and loan repayment and other incentives, be linguistically and culturally tailored especially in underserved areas. Public for different populations, and trusted, health schools should incorporate nongovernmental messengers should health equity and cultural competency receive funding to help deliver messages. into their preparedness curricula.

44 TFAH • tfah.org Priority Area 5: Accelerate Development and Distribution of Medical Countermeasures A robust Public Health Emergency federal responsibilities being left to Medical Countermeasures Enterprise states or to the private sector. The (PHEMCE)135 could negate a range of federal government circumnavigated or health threats, but a drug or vaccine significantly modified established MCM is only effective if it reaches the right and medical supply-chain coordination person at the right time. Medical and distribution channels at various countermeasures (MCM) are FDA- points in the pandemic, contributing regulated products that could be to confusion and chaos. For example, used in the event of a public health the lack of federal coordination and emergency; they include biologics, transparency left individual hospitals drugs, and devices.136 The challenges and states to compete with each other faced in distributing scarce medical for scarce resources,137 and FEMA and resources during the pandemic as the U.S. Department of Defense were well as the deployment of COVID-19 brought in to manage some supply- vaccine demonstrate the urgency of chain operations despite long-standing the right-product/right-time equation. systems in place at HHS. Clear federal During the first ten months of the coordination is necessary during the pandemic, there was a notable gap pandemic, with an eye toward preventing in federal coordination, with many future shortages and shortfalls.

RECOMMENDATIONS FOR FEDERAL GOVERNMENT: l Provide significant, long-term funding products for a range of biothreats, for the entire MCM enterprise. The rather than focusing on products for a MCM enterprise involves research, single pathogen.138 manufacturing, surveillance, delivery, l Prioritize the distribution and training, and monitoring. Long-term dispensing of MCMs. It is important coordinated and transparent funding that MCMs reach the right person at to the Biomedical Advance Research the right time during emergencies; and Development Authority, Strategic the challenges in mass vaccination National Stockpile, CDC, FDA, NIH, were predicted by the CDC’s MCM and other components of the PHEMCE Operational Readiness Review.139,140 would offer more certainty to the HHS along with state, local, tribal, and biotechnology industry and researchers, territorial health departments should would strengthen public-private be properly resourced and require partnerships, and would enable the integration of private-sector healthcare purchase of ancillary medical supplies, supply distributors and supply-chain such as PPE. The United States should partners into planning, exercises, and grow its investment in innovative, emergency responses to better leverage flexible technologies and platforms existing systems and resources. Once that will enable faster production of

TFAH • tfah.org 45 the COVID-19 vaccination campaign Federal agencies should also explore is complete, HHS should access and all available authorities, such as address gaps in vaccine development, through the Defense Production Act, procurement, maintenance, deployment and communicate strategies with and administration; and improve the stakeholders to bolster the supply chain training of state and local personnel to during emergencies. The HHS secretary ensure vaccine administration is well- should clarify roles and responsibilities coordinated. for supply-chain management throughout the pandemic and, l Clarify and strengthen MCM and moving forward, should develop and supply-chain management for disseminate best practices for supply emergencies. HHS must maintain management.141 HHS should strengthen primary authority over public health the PHEMCE’s work, including regular emergency response, including interagency meetings; engagement with deployment of the Strategic National private-sector, supply-chain partners; Stockpile and emergency medical and improved transparency and supply-chain management, in communication with state, local, tribal, coordination with other federal agencies and territorial partners. and in consultation with private- sector and public health partners.

RECOMMENDATIONS FOR FEDERAL, STATE, AND LOCAL GOVERNMENTS AND PARTNERS: l Improve MCM guidance and proficient communities—to improve communications for groups at higher communications around MCM issues risk during an event. HHS, including before an event. Communities need the CDC, should consult with experts to be engaged before an outbreak or and work with healthcare professionals event to ensure their understanding and state, local, and tribal partners of the risks, benefits, and distribution to develop standardized guidance challenges of introducing a medical for dispensing MCMs to groups such product to a large portion of the as children, older adults, people population and ultimately improving with disabilities, and people who are acceptance and access to MCMs. It is homebound. And HHS and state, important to provide clear and accurate local, and tribal agencies should guidance to the public in multiple work with organizations that reach formats and languages, via trusted the public, especially communities at sources and multiple communications disproportionate risk—such as groups channels, including formats that are representing older Americans, people accessible to people with hearing or with disabilities, and limited English- vision loss.

46 TFAH • tfah.org Priority Area 6: Ready the Healthcare System to Respond and Recover In the 2019 and 2020 Ready or Not workforces, disruptions in the supply found that healthcare delivery reports, TFAH warned that medical chain, shortages of PPE and other readiness scores are in the lowest levels surge capacity for a pandemic supplies, interruptions in primary and among preparedness domains, with remained a major gap in the nation’s preventive care, lack of situational little progress in the past five years.145 preparedness. The COVID-19 pandemic awareness, and loss of revenue have Policymakers need to strengthen has placed tremendous on been among the significant challenges existing systems and consider long- the healthcare system, from acute- to the nation’s healthcare system. term mechanisms to create sustainable care facilities142 to long-term care The toll in lives lost due to these healthcare readiness across systems and facilities143 to small outpatient clinics.144 compounding issues has yet to be across geographic borders. Overcrowded facilities, exhausted calculated. The NHSPI has consistently

RECOMMENDATIONS FOR FEDERAL GOVERNMENT AND HEALTHCARE: l Strengthen the Hospital Preparedness as burn or pediatric care) across the preparedness standards by individual Program and fund regional coordination. country, and to leverage those assets healthcare facilities, these existing HPP can help build strong healthcare in a coordinated way.147 Congress mechanisms have not provided enough coalitions capable of engaging and should also provide increased funding incentive for many healthcare facilities supporting members during disaster for healthcare surveillance through to create meaningful surge capacity and responses, but the program has been CDC’s National Healthcare Safety cooperation across competing entities. severely underfunded. Congress must Network—which is the nation’s domestic Similarly, the Joint Commission’s provide more robust annual funding— tracking and response system to identify preparedness standards apply to which it has cut in half over the past emerging and enduring threat across individual facilities and not to the decade. HHS and the awardees 37,000 healthcare facilities, including readiness of the healthcare system as should ensure healthcare leaders COVID-19, healthcare-associated a whole.148 In addition to strengthening takes the lead on HPP planning and infections (HAIs), and antibiotic-resistant existing systems, Congress and HHS implementation to the extent possible, (AR) infections. These data drive should consider long-term sustainability with support and coordination from improvements in patient safety and for building healthcare readiness across public health, emergency management, monitor the surge capacity of healthcare the system, including meaningful and others, and awardees should facilities to confront new threats. incentives and disincentives, including: ensure as much funding as possible l Create incentives and ramifications • An external self-regulatory body, in is reaching healthcare coalitions. to build sustainable preparedness alignment with federal policy goals, Healthcare administrators should and surge capacity across healthcare could set, validate, and enforce ensure their facilities have tools and systems. The shortages of beds, standards for healthcare facility support for meaningful participation healthcare personnel, and equipment readiness, stratified by facility in healthcare coalitions, including during the pandemic underscores the type, with authority for financial the ability to share information and 149 need for cooperation among healthcare ramifications. resources across the coalition and with entities, across systems, and across • Payment incentives could sustain public health agencies. Congress should geographic borders. Although there has preparedness, surge capacity, provide additional funding for a tiered been progress in developing healthcare regional disaster partnerships, regional disaster system to coordinate coalitions in many regions and progress and reward facilities that maintain across coalitions and states,146 to in meeting CMS and other accreditation specialized disaster care. map specialized disaster care (such

TFAH • tfah.org 47 l Expand access to healthcare. Access l Assess impact of CMS Preparedness to healthcare is always important and Standards and improve transparency. particularly so during a pandemic or An external review by the GAO or disaster. Federal and state governments a similar entity should assess must ensure every person has access to how CMS preparedness standards healthcare, including robust insurance have affected overall healthcare coverage. Millions of Americans readiness, and HHS should begin still lack insurance coverage, and tracking progress on preparedness disparities by race, ethnicity, sexual or measures over time. CMS should also gender identity, and other factors have strengthen preparedness standards been exacerbated by the pandemic- by adding medical surge capacity and induced recession.150 Congress and other capabilities, including infection the administration should strengthen prevention and control, stratified incentives for states to expand by facility type, as a necessary Medicaid, make marketplace coverage requirement within the next iteration more affordable, and improve outreach of the rule.152 and marketing for enrollment.151

RECOMMENDATIONS FOR STATE GOVERNMENT AND HEALTHCARE: l Integrate healthcare delivery into of disasters, and full engagement in emergency preparedness and response. regional collaborations and coalitions. Jurisdictions should engage and l Strengthen state policies regarding integrate the healthcare sector into disaster healthcare delivery. States emergency planning and responses, should review credentialing standards to including plugging healthcare coalitions ensure healthcare facilities can call on and other entities representing private providers from outside their states, and healthcare and the healthcare supply health systems should ensure they can chain into emergency planning and receive outside providers quickly during response and incident command. a surge response. States should also Health systems, healthcare coalitions, adopt policies that promote healthcare and public health should develop readiness and ease the ability to surge memoranda of understanding ahead care and services, such as the NLC, the of disasters to improve situational Interstate Medical License Compact, the awareness across healthcare and Recognition of EMS Personnel Licensure to enable movement of patients, Interstate CompAct,153 the Uniform personnel, and supplies. Private- Emergency Volunteer Health Practitioners sector healthcare leadership should Act,154 emergency prescription refill laws prioritize preparedness moving forward, and protocols, and implementation and including training and workforce education of providers regarding crisis protections, surveillance for emerging standards of care guidelines.155,156 threats, stockpiling of supplies ahead

48 Priority Area 7: Prepare for Environmental Threats and Extreme Weather Climate change, environmental hazards, least ready to deal with it (see sidebar on hazards impact communities differently and extreme weather pose serious page 60). Environmental health involves and exacerbate disparities among threats to human health. According to detecting and protecting communities people living in poverty, people of a December 2020 report by TFAH and from hazardous conditions in air, color, people with underlying health the Johns Hopkins Bloomberg School of water, food, and other settings, and it conditions, and children and older Public Health, many of the states most is therefore a critical component of the people—all of whom are at particular at risk from climate change are also the nation’s health security. Environmental risk.157

RECOMMENDATIONS FOR FEDERAL AND STATE GOVERNMENT: l Enact legislation requiring a national locations.159 Congress should increase should restore the Clean Water Rule, strategic plan. The United States funding for environmental health which includes measures to protect a urgently needs a strategic action plan to programs, including the CDC’s Climate safe water supply, such as addressing address the health impacts of climate and Health program and environmental the ongoing problem of lead, per- and change. Policymakers should enact health tracking to conduct surveillance polyfluoroalkyl substances, and other legislation requiring HHS to develop such and target interventions. toxins in drinking water; taking steps a plan and to fund development and to reduce the potential for waterborne l Develop sustainable state and local ongoing maintenance of health system illnesses; and increasing protection -control programs. As the capacity specifically for this purpose. against potential acts of terrorism on threat and geographic distribution of America’s drinking and agricultural l Support public health climate- mosquitos, ticks, and other vectors water. All states should include water adaptation efforts. Funding for the CDC’s changes, Congress should expand security and sewage removal in their Climate and Health program stands at funding for the vector-borne disease preparedness plans, and they should $10 million per year, while the annual program at the CDC to support state build relationships among health health costs of climate change events and local capacity to prevent and detect departments and local environmental were estimated to be more than $14 vector-borne diseases, such as Zika, and water agencies. The CDC should billion in 2008.158 Climate-informed West Nile Virus, and Lyme disease. include national guidance and metrics health interventions include identifying l Guarantee clean water for all U.S. for planning for a range of water- likely climate impacts, potential health residents, including after disasters. related crises. effects associated with these impacts, The administration and Congress and the most at-risk populations and

RECOMMENDATIONS FOR STATE GOVERNMENT: l Every state should have a comprehensive State and local public health officials and local levels. The assessments should climate vulnerability assessment and should incorporate environmental health focus especially on populations at highest adaptation plan that incorporates public into emergency operations planning and risk and the health threats most pertinent health. Public health and environmental incident command. to them. States must also push ahead agencies should work together to track to complete all steps of the framework, l Complete all steps of the CDC’s Building concerns, coordinate risk-management including identifying and implementing Resilience Against Climate Effects, or and communications, and prioritize evidence-based interventions to protect “BRACE,” framework, and continuously necessary capabilities to reduce and residents. Finally, as agencies implement work to enhance and refine preparations address threats. States and localities interventions, they should continually for climate change. State agencies should investigate what additional evaluate effectiveness and strive for must conduct and facilitate rigorous capacities are necessary and identify quality improvement. vulnerability assessments at the state vulnerable populations and communities. TFAH • tfah.org 49 APPENDIX A APPENDIX A: YEAR IN REVIEW – 2020 HEALTH THREATS INCIDENTS AND ACTIONS Ready or Not Year in Review – 2020 Health 2021 Threats Incidents and Actions

This section reviews 2020’s major events, research, and policy actions related to global and domestic health security.

Disease Outbreaks Notable Incidents l COVID-19 that the pandemic response itself • The novel coronavirus SARS-CoV-2, may have indirectly caused mortality the virus that causes COVID-19, due to limited access to healthcare emerged internationally in late during pandemic surges and due 2019. As of late February 2021, to those who avoided seeking care 167,168 as this report was being prepared in hospitals. The Centers for for publication, over 28 million Disease Control and Prevention cases; and over 500,000 deaths (CDC) found that in the 10 weeks have been reported in the U.S. following declaration of the COVID- alone.160 Globally, there have been 19 national emergency, emergency over 109 million confirmed cases department visits declined 23 of COVID-19, and over two million percent for heart attack, 20 percent deaths, reported to the World for stroke, and 10 percent for 169 Health Organization (WHO).161 The hyperglycemic crisis. number of cases and the number of • Those at highest risk for severe deaths from COVID-19 is higher in disease and death are the elderly the United States than in any other and people with underlying medical 162 country. In the United States, conditions, but COVID-19 has severely slightly more women than men have sickened and killed many young and been infected, but deaths in men are otherwise healthy individuals, as well. disproportionate (54 percent to 46 Researchers are trying to determine 163 percent). Black people account if certain genetic characteristics are for nearly 16 percent of COVID-19 responsible for severe versus mild deaths, where race is known, despite disease.170 The disease in young representing 13 percent of the U.S. children is usually mild, but in rare 164 population. Hispanic or Latino cases it is associated with multisystem people account for 18 percent of inflammatory syndrome in children, reported COVID-19 cases in the U.S. in which different body parts can as of late January 2021, a proportion become inflamed, including the approximately equal to their heart, lungs, kidneys, brain, skin, eyes, 165 MARCH 2021 percentage of the U.S. population. or gastrointestinal organs.171 National In addition, research indicates a data reported between March significant level of asymptomatic and July 2020 showed that MIS-C cases, so true infection counts are disproportionately impacted Black 166 likely higher than confirmed cases. and Latino children.172 The long-term Deaths may also be underreported effects of COVID-19 infection aren’t due to inadequate testing and given fully known, but findings show heart 50 TFAH • tfah.org and lung damage in some patients, and many patients report lingering fatigue, shortness of breath, and confusion.173

• In June 2020, the U.S. Department of Health and Human Services (HHS) Office of Minority Health announced Morehouse School of Medicine as the awardee for a new $40 million initiative to fight COVID-19 in racial- and ethnic-minority, rural, and socially vulnerable communities. The initiative—the National Infrastructure for Mitigating the Impact of COVID-19 within Racial and Ethnic Minority Communities (NIMIC)—is a three-year project designed to work with community- based organizations nationwide to

deliver education and information nycshooter on resources to help fight the homes, also began in December 2020. pandemic. Its aim is to strengthen • The Trump Administration created a efforts to link communities to centralized system to order, distribute, COVID-19 testing, healthcare, and track COVID-19 vaccines.177 and and to share States can order vaccine quantities and implement effective response, (as supply allows) from the CDC. recovery, and resilience strategies.174 Airlines worldwide are providing • The United States has undertaken transportation for billions of doses of unprecedented efforts to accelerate vaccine that must be stored in frigid the development, manufacturing, and temperatures. FedEx and UPS are distribution of COVID-19 vaccines installing ultracold freezers near their and therapeutics through significant air-cargo hubs, and dry-ice producers federal investments and scientific are increasing production to support cooperation, while maintaining vaccine distribution.178 The U.S. standards for safety and efficacy.175 Department of Defense and HHS Usually, vaccines take years of research coordinated the shipment of the initial and testing before they are available doses to states.179 The CDC released to the public. As of December 2020, a playbook for state, tribal, territorial, two vaccines, one developed and and local jurisdictions on how to manufactured by Pfizer-BioNTech, plan and operationalize a vaccination the other by Moderna, received response to COVID-19 within emergency-use authorization (EUA) their jurisdictions.180 The Advisory from the U.S. Food and Drug Committee on Immunization Practices Administration (FDA).176 Initial recommended priority groups administration of the vaccine to to receive the initial doses of the priority groups, including healthcare vaccines,181 but the final decisions on workers and residents of nursing population prioritization and logistics

TFAH • tfah.org 51 are up to the states to determine, with being finalized, a specific time frame most states prioritizing healthcare for availability of the vaccine to the providers and long-term care facility general population was unclear and residents in the initial phase.182 may be different from state to state.186

• While shipping of the vaccine Editor’s note: In January 2021, the Biden began shortly after the FDA issued administration set a goal and put in place emergency-use authorizations, the a plan to administer 100 million vaccine initial administration of the newly doses during its first 100 days in office.187 approved vaccines fell far short of That goal was later increased to 150 million projected goals. As of December doses. FEMA and National Guard troops 30, 2020, 12.4 million vaccine doses went to work in many states to assist in had been distributed to states, the vaccination effort. As of March 1, but only 2.6 million had been 2021, 96,402,490 vaccine doses had been administered. Experts called on the distributed nationwide and 76,899,987 federal government to provide more had been administered.188 However, based coordination and resources to the on preliminary data from 17 states, during states to increase their capacity to the first two months of vaccine distribution, quickly administer the vaccine to Blacks and Hispanics were being vaccinated more people.183 The challenges in at a much lower rate than were whites.189 initial administration of the vaccine likely occurred for many reasons, l Seasonal flu.As TFAH was preparing including: funding for states to this report, flu rates for the 2020–2021 administer the vaccine was not flu season were lower than usual for signed into law until December 27, major regions of the country.190 The 2020, which hindered planning, 2019–2020 flu season was of “moderate communications, hiring, and training; severity”; however, the severity of the the lack of a centralized planning season in some age groups was higher: effort; the lack of federal leadership; hospitalization rates among children the lack of communication between ages 0 to 4 years old and adults ages 18 to federal, state, and local planners on 49 years old were higher than observed the number of initial doses available during the 2009 H1N1 pandemic.191 The and when; slow engagement with local CDC estimates found that the 2019–2020 partners; and the sheer immensity flu accounted for approximately 38 and complexity of the project.184,185 million illnesses, 405,000 hospitalizations, HHS is partnering with pharmacies, and 22,000 flu deaths.192 Seasonal including CVS and Walgreens, to flu vaccine coverage rates increased deliver vaccines on-site at nursing modestly across all age groups in 2019– homes and assisted-living facilities. 2020, with vaccine rates among adults Following distribution to the initial increasing 3.1 percentage points over the critical populations, states are previous season and up 1.2 percentage planning for COVID-19 vaccines to points among children—but that was be available in a phased approach to still far below Healthy People 2020 and the priority groups in the broader 2030 goals.193 The CDC estimates that population at locations such as retail influenza vaccination prevented 7.5 pharmacies, healthcare facilities, and million illnesses, 3.7 million medical vaccination sites, but as this report was visits, 105,000 hospitalizations, and 6,300

52 TFAH • tfah.org deaths due to influenza during the 1996—869,770 confirmed cases l . Cholera, an acute intestinal 2019–2020 season.194 The low 2020–2021 and an estimated 207,500 deaths.206 infection, is rare in the United States, seasonal flu activity was likely a result of Fortunately, as of September 2020, but cases have increased steadily the mitigation measures to reduce the the number of confirmed cases since 2005 globally,214 and it is a spread of COVID-19.195 worldwide was much lower, though the major cause of diarrhea Democratic Republic of the Congo, in the developing world. Regions l Hepatitis A. In 2020, 27 states , and Nigeria reported high with humanitarian crises, high experienced outbreaks of the Hepatitis numbers and there were ongoing rates of poverty, and a lack of water A virus, driven in part by increases outbreaks in other nations.207 However, and sanitation infrastructure are among those who reported drug use COVID-19 is increasing the risk of at higher risk. In 2020, Yemen and and homelessness.196 Hepatitis A is a outbreaks, following the Somalia faced serious outbreaks.215 highly transmissible infection.197 The suspension of measles vaccination Researchers estimate that every year, Hepatitis A vaccine is recommended campaigns in 26 countries. On the there are 1.3 to 4.0 million cases and for certain populations; in 2019, the current trajectory, experts predict 21,000 to 143,000 deaths worldwide Advisory Committee on Immunization more child deaths from measles than due to cholera.216 Practice updated its recommendations from COVID-19 in .208 to include people experiencing l . In August 2020, the African homelessness in the populations who l The Democratic Republic of Congo was certified wild poliovirus should receive the vaccine.198 Hepatitis outbreak. On June 1, 2020, the free by the World Health Organization, A infections had been going down Democratic Republic of the Congo making the world poliovirus free except between 2000 and 2012 but increased declared its 11th outbreak of Ebola for Pakistan and Afghanistan.217 After in 2013, 2016, and 2018.199 As of virus disease.209 In November 2020, it months of severe disruptions from the December 4, 2020, there have been was declared over, following a total of COVID-19 pandemic, polio vaccination 36,848 reported cases that lead to 22,546 130 cases and 55 deaths.210 campaigns have resumed in both hospitalizations and 348 deaths since the countries as of August 2020. UNICEF l Candida auris. C. auris is an ongoing outbreak began in 2016.200 estimates up to 50 million children emerging drug-resistant fungus missed their vaccinations when efforts l Measles outbreaks, United States. that has led to severe illnesses in were halted in March 2020 to minimize In 2020, U.S. measles cases were hospitalized patients. A majority transmission of COVID-19.218 low—only 13 confirmed cases in of reported cases in 2020 were in eight jurisdictions, as of November New Jersey, New York, and Illinois. l Foodborne illnesses. In 2020, multistate 30, 2020.201 Conversely, 31 states Infection by this multi-drug-resistant outbreaks resulted confirmed 1,282 individual cases of fungus has a close to 60 from mushrooms, peaches, onions, measles in 2019.202 Measles is a highly percent and presents a serious global clover sprouts, deli , and bagged contagious disease that predominantly health threat.211 As of November 30, salads. The pathogens involved include affects young children and can cause 2020, in the United States, there were several strains of Salmonella and E. coli, hospitalization, and death and serious 1,595 reported clinical cases of C. as well as Listeria and Cyclospora.219 The complications, such as pneumonia, auris and an additional 3,056 patients CDC estimates that 48 million people encephalitis.203 It can cause up to a 90 identified with C. auris. There is get sick, 128,000 are hospitalized, and percent chance of disease contraction transmission in multiple countries, 3,000 die from foodborne illness each in unimmunized individuals.204 as well.212 With the increase of year in the United States.220 The five Outbreaks have been linked to the patient transfers from long term care most common pathogens that cause sustained spread of measles among facilities to ICUs due to COVID-19, foodborne illness are: (1) Norovirus, unvaccinated communities.205 the CDC said that it expects C. auris (2) Salmonella, (3) Clostridium and other fungal infections to remain perfringens, (4) Campylobacter, and l Measles outbreaks, global. The WHO an infection control challenge for (5) .221 reported that during 2019, there healthcare facilities in the U.S. and were more measles cases reported around the world.213 worldwide than in any year since

TFAH • tfah.org 53 Notable Events and Policy Actions:

COVID RESPONSE

l Public Health Emergency Declaration • The Families First Coronavirus Coronavirus Response. The bill and early COVID-19 response. On Response Act (P.L. 116-127). The extended the Paycheck Protection January 31, 2020, U.S. Health and President signed the act into law Program and small-business loans Human Services Secretary Alex Azar on March 18, 2020; it included the and allocated funding for healthcare declared a public health emergency Second Coronavirus Preparedness providers and COVID-19 testing. for the United States for the 2019 and Response Supplemental • The Coronavirus Response and 222 novel coronavirus. Since then, Appropriations Act. The legislation Relief Supplemental Appropriations HHS has renewed the declaration expanded food and nutrition programs, Act, 2021 (P.L. 116-26). Congress several times. The declaration unemployment benefits, and passed and the President signed the allowed some flexibilities for states, emergency family and medical leave; act with the fiscal year (FY) 2021 such as temporary reassignment of it also required certain employers to appropriations bills and signed it into personnel to the response. Before provide paid sick leave for workers law on December 27, 2021. The bill the declaration and before the Trump unable to work due to COVID-19, and provided $900 billion in emergency administration requested emergency it provided access to COVID-19 testing appropriations, including $73 billion funding, Secretary Azar tapped $105 with no cost to the individual. for HHS, of which $8.75 billion will million from the Infectious Disease • The Coronavirus Aid, Relief, and support the vaccination campaign. Rapid Response Reserve Fund for the Economic Security (CARES) Act 223 l Payments to healthcare providers. initial response. The WHO issued a (P.L. 116-136). The President signed The CARES Act, Paycheck public health emergency declaration of the act into law on March 27, 2020, Protection Program and Health international concern in January and providing over $2.2 trillion in relief to Care Enhancement Act, and the labeled the outbreak as a pandemic in individuals; businesses; state, local, 224 225 Coronavirus Response and Relief March, 2020. and federal agencies; and industry Supplemental Appropriations Act sectors affected by the COVID-19 l COVID Response Legislation. allocated $178 billion for a provider pandemic and the government- Congress has enacted several relief fund for hospitals, clinics, led effort to limit its public health public laws providing funding and and other healthcare providers to impact. It also included a variety authorities to assist in the response recover some revenue lost due to the 226,227 of oversight provisions designed to to the pandemic: pandemic.229 In addition, changes in increase the information available • Coronavirus Preparedness HHS telehealth policies were put in to Congress regarding the federal and Response Supplemental place to expand access to telehealth government’s implementation of Appropriations Act (P.L. 116-123). services during the pandemic.230 the CARES Act and response to the The President signed the act into COVID-19 pandemic.228 COVID-19 Vaccine law on March 6, 2020, providing l $8.3 billion in emergency funding for • The Paycheck Protection Program COVID-19 Vaccine. As of December public health measures, including and Health Care Enhancement 2020, two vaccines—one developed the development of medical Act (P.L. 116-139). The President and manufactured by Pfizer-BioNTech, countermeasures and grants for signed the act into law on April the other by Moderna—received public health agencies. 24, 2020; it included Additional emergency-use authorization from the Emergency Appropriations for FDA (see COVID sidebar, on page 55).

54 TFAH • tfah.org COVID RESPONSE

Additional COVID-19 Response become the National Special Pathogen national trauma system) for all special Actions: System (NSPS) through COVID-19 pathogens. l emergency supplemental funding. Medical supply shortages. The l Crisis standards of care. Major The NSPS builds on the Regional quantities of medical supplies in surges in COVID-19 patients caused Ebola Treatment Network and was the Strategic National Stockpile and hospitals and intensive-care units to originally created to support the through the private-sector supply exceed capacity. Hospitals canceled urgent preparedness and response chain were not sufficient for a admissions and nonemergency needs of hospitals, health systems, pandemic as widespread as COVID- procedures and established alternate 231 232 and healthcare providers on the front 19. Shortages of PPE, ventilators, care sites. In December 2020, 10 233 lines of the COVID-19 outbreak. The testing supplies, and other medical national organizations issued a system is designed to to help prepare supplies and products reached critical statement outlining urgent action hospitals and health systems to levels at different phases of the for states, healthcare systems, and identify, isolate, assess, transport, pandemic. President Trump invoked health departments to implement and treat patients with COVID-19 or the Defense Production Act in April crisis standards of care, including other special pathogens or persons 2020 to try to spur private-sector legal protections for healthcare 234 under investigation for such illnesses. production of these supplies. workers, statewide information The long-term vision of the NSPS sharing, distribution of patients and l National Special Pathogen System. is to create a nationwide systems- resources, and care coordination In March 2020, ASPR expanded the based network approach, similar across jurisdictions.235 Regional Ebola Treatment Network to to other national systems (e.g., the

Vaccines: Earning Trust and Access in Communities of Color and Tribal Nations The reported hesitance among to earn vaccine trust and increase messaging must be culturally and some populations of color and Tribal vaccine access within communities of linguistically appropriate. Messaging Nations toward COVID-19 vaccines236 color and Tribal Nations. The experts campaigns must feature trusted has a basis in historic mistreatment concluded that earning such trust will messengers, and education programs and the effect of current-day require working with leaders in those should take advantage of existing structural racism. These experiences communities to use their agency as health communications networks. could have long-term impacts on trusted messengers. Leaders from Read the full policy brief, Building vaccine confidence and vaccination these communities must have a place Trust in and Access to a COVID-19 rates in these groups. In October at the planning table and be provided Vaccine Within Communities of Color 2020, TFAH, the National Medical the resources needed to engage and Tribal Nations, or find it on the Association, and UnidosUS partnered with and share information with their TFAH website.237 to an expert convening on how stakeholders. All vaccine education

TFAH • tfah.org 55 l Ending the HIV epidemic. In FY 2020, Roadmap to Elimination 2021–2025, the Trump administration awarded which serves as a roadmap to hepatitis funding to its Ending the HIV Epidemic: elimination. HHS sought input from a A Plan for America Initiative, which aims broad mix of stakeholders on whether to reduce the number of new HIV the plan’s goals, objectives, and infections in the United States by 90 strategies appropriately address the percent by 2030. In December 2019, viral hepatitis epidemic and whether Congress approved the largest increase there are any critical gaps.242 to domestic HIV/AIDS-prevention l National Action Plan for Combating programs from multiple federal sources, Antibiotic-Resistant (CARB). including the CDC, in decades, bringing resistance, the rise of federal funding in FY 2020 for HIV/ superbugs that are resistant to existing AIDS (across multiple programs) to , is a major threat to health. just over $28 billion.238,239 In addition, Originally released in 2015, the 2020– HHS, through the Health Resources 2025 CARB builds on the original by and Services Administration (HRSA), expanding evidence-based activities that awarded more than $2 billion in Ryan have been shown to stop the spread of White HIV/AIDS Program grants antibiotic resistance, such as increasing to cities, counties, states, and local infection prevention and control and community-based organizations. This improving the way antibiotics are used. funding supports a comprehensive Developed by the HHS Office of the program of HIV primary medical care, Assistant Secretary for Planning and medication, and essential support Evaluation and authored by agencies services with the goal of improving the within the CARB Task Force, which is co- health quality of more than half a million chaired by HHS, the U.S. Department people with HIV in the United States.240 of Agriculture, and the U.S. Department l Emerging infectious diseases. The of Defense, the plan’s purpose is to National Institute of Allergy and guide U.S. government activities, as well Infectious Diseases (NIAID), within as action by public health, healthcare, NIH, awarded 11 grants totaling and veterinary partners to address approximately $17 million to establish urgent and serious antibiotic-resistant the Centers for Research in Emerging threats that affect people in the United Infectious Diseases. The new global States and globally.243 network will involve multidisciplinary l United States officially withdraws from investigations into how and where the World Health Organization. In and other pathogens emerge July 2020, President Trump formally from wildlife and spillover to cause announced his intention to withdraw disease in people. NIAID intends to the United States from the WHO, provide approximately $82 million over effective July 6, 2021.244 five years to support the network.241 Editor’s note: on January 21, 2021, l Viral hepatitis strategic plan. HHS the Biden administration restored U.S. released the Viral Hepatitis National membership in the WHO. Strategic Plan for the United States: A

56 TFAH • tfah.org l Food safety. In July 2020, the FDA 1 clinical trial, testing the safety and released its New Era of Smarter Food effectiveness of a monoclonal antibody Safety Blueprint, which reflects input against , began. If effective, it from a variety of stakeholders and would prevent malaria infections for outlines a path forward building on several months with a single dose—a the implementation of the FDA Food benefit to tourists, medical workers, Safety Modernization Act.245 Its four and military personnel.249 core elements are: (1) tech-enabled l Eastern Equine Encephalitis vaccine. In traceability and foodborne outbreak June 2020, Bavarian Nordic announced response—using technologies, data topline results from the first-in-human streams, and approaches that will trial of a prophylactic vaccine candidate greatly reduce the time it takes to trace against three equine encephalitis the origin of a contaminated food; viruses (EEEV): western, eastern, (2) smarter tools and approaches for and Venezuelan. The study, although prevention—identifying new tools, small, showed that the vaccine was well processes, and communications tolerated and immunogenic across all to inform prevention efforts; (3) dose groups, with injection-site pain new business models and retail as the most common vaccine-related modernization—advancing the safety adverse event.250 of both new business models, such as e-commerce and home delivery of l Ebola treatment. In October 2020, the food, and traditional business models, FDA approved Inmazeb, a mixture of such as retail food establishments; and three monoclonal antibodies made (4) food safety culture—supporting by Regeneron. This is the first FDA- and strengthening cultures that approved treatment for Ebola virus embrace food safety within the FDA, infection in adult and pediatric patients, on farms, and in facilities.246 following a U.S. government-supported trial and expanded-access protocol in the Notable Research Findings, Democratic Republic of the Congo.251 Meetings, and Federal Hearings: l Universal flu vaccine study.A universal l Malaria treatment and prevention. influenza vaccine, FLU-v, which In May 2020, the FDA approved could confer long-lasting immunity artesunate for injection to treat from multiple influenza subtypes severe malaria in adult and pediatric among all age groups, demonstrated 247 patients. Treatment of severe immunogenicity and safety in its phase malaria with intravenous artesunate 2b study and will enter a larger phase 3 should always be followed by a trial.252 The FLU-v vaccine is designed complete treatment course of an to stimulate the production of flu- appropriate oral antimalarial regimen. specific cytotoxic T lymphocytes, which According to the CDC, approximately kill and remove influenza-infected cells, 2,000 cases of malaria are diagnosed by targeting internal viral proteins that in the United States each year, with are not as variable as the constantly 300 of those infected having severe mutating surface proteins currently 248 disease. In addition, the first phase targeted in seasonal flu vaccines.253

TFAH • tfah.org 57 Severe Weather and Natural Disasters Notable Incidents: l . In early March 2020 in the Hurricane Delta hit Louisiana in growth, which withered in the heat Nashville area, 24 people were killed October 2020, killing at least four.269 and became fuel for wildfires to by two tornadoes, one of which was was hit hard in 2020 spread quickly through dry land.278 an EF-4 traveling at 60 miles per hour with two back-to-back Category 4 In addition, the 2020 season was a (mph)—significantly harder to outrun storms: just weeks after Hurricane La Niña cycle—colder than average (or take cover from) than a typical Eta made landfall and killed over 130 surface-water temperatures in the ’s 10 to 20 mph speed.254 Also people, Hurricane Iota (a massive Pacific—which often trigger hotter during a two-day period in mid-March, Category 5 storm while in the and drier weather in the Southwest.279 over 100 tornadoes ravaged the South Atlantic) hit the same area. Together, Oregon also experienced an and Southeast,255 causing over $450 the storms killed over 200 people.270 especially destructive season: million in damage and 32 fatalities.256 In addition, the pandemic made 4,009 homes burned down in 2020, hurricane preparations, evacuations, compared with 93 homes total l Extreme heat. In the United States, and sheltering more difficult. from 2015 to 2019.280 In Colorado, extreme heat kills more people than wildfires have consumed 9 percent of any other weather-related threat.257 July l Iowa derecho. A powerful derecho—a Rocky Mountain National Park and 2020 nearly tied July 2019’s record of fast wind storm associated with strong destroyed several historic buildings.281 the hottest month ever recorded on —tore through central Exacerbating these fires is an ongoing Earth—coming in just 0.02 degrees Iowa in August 2020. Winds topped pine-beetle outbreak, which has shy.258,259 In August 2020, Death Valley 100 mph and destroyed miles of crops, increased the number of dead trees reached 130 degrees Fahrenheit, homes, businesses, and vehicles, and for fuel.282 Across the United States, and on September 6, 2020, Los killed four people. The derecho was 9.5 million acres have burned as of Angeles County recorded its highest officially the costliest December 4, 2020, compared with 4.6 temperature ever, at 121 degrees event in recorded U.S. history— million acres for the same period in Fahrenheit.260 September 2020 was also estimated at $7.5 billion in damages.271 2019.283 the hottest September on record.261 l Wildfires in California and other l California power outages. In l Hurricanes. The 2020 Atlantic states. Several states experienced an attempt to reduce the risk of hurricane season was the most active— wildfires in 2020, including California, overloading the power grid during breaking the record for the most Oregon, and Colorado.272,273 California an extreme heatwave, California’s named storms in a season, including experienced another historic fire Independent System Operator, six major hurricanes.262 In the United season in 2020—five of the six largest which manages the state’s power States, Hurricane Isaias made landfall wildfires since 1932 in California supply, ordered utilities to impose in North Carolina as a Category 1 happened in 2020.274 As of November temporary blackouts for the first time and killed nine people as it moved 29, 2020, over 4 million acres had in 19 years.284 While these outages up the coast,263 causing more than $4 burned, compared with just under only lasted an hour or two,285 there billion in damage.264 Laura formed 260,000 acres burned during the is potential for unplanned and in the Caribbean, leaving nine dead, same period in 2019.275 Thirty-three planned outrages to create health before developing into a Category people, including four firefighters, emergencies for some residents, 4 storm and making landfall in died in California in 2020 due to including by presenting significant Louisiana, where it killed 27 people265 wildfires.276 California’s average risks to patients in healthcare and and caused an estimated $10 to $12 temperature has increased by about long-term care facilities; people billion in damage.266 In September 3 degrees Fahrenheit over the past with electrically dependent medical 2020, Hurricane Sally hit Alabama as a century, which is three times the equipment or medicines, such as Category 2 and caused major flooding global temperature increase of 1 oxygen, wheelchairs, and insulin; and but no deaths,267 though damage degree Fahrenheit.277 Heavy spring the safety of food and water.286 is estimated at $8 to $10 billion.268 rains promoted extensive vegetation

58 TFAH • tfah.org Notable Events and Policy Actions: tool to help illustrate the nation’s l Public health emergency declarations. communities most at risk of natural In January 2020, HHS Secretary Azar hazards. It provides a holistic view declared a public health emergency of community-level risk nationwide for Puerto Rico following the late- by combining 18 hazards with December 2019 and socioeconomic and built-environment continuing aftershocks.287 Azar factors. The tool determines risk by declared emergencies in Louisiana reviewing a community’s expected and Texas due to Hurricane Laura annual loss, by measuring hazard and in Oregon and California due frequency, exposure, and historic loss to wildfires. The declarations and rate; social vulnerability, by measuring related waivers give HHS’s Centers for the susceptibility of impacted social Medicare & Medicaid Services (CMS) groups; and , by beneficiaries and their healthcare measuring the ability of a community providers and suppliers greater to recover from the impacts of natural flexibility in meeting emergency hazards. These data can help in health needs.288,289 developing a FEMA-approved hazard- mitigation plan to help increase l Health center support. In September community resilience, which is a 2020, HHS, through HRSA, awarded prerequisite for applying for FEMA’s more than $79 million in construction mitigation grants.292 and other capital support for 165 HRSA-funded health centers impacted l Climate reports. The ’ by Hurricanes Florence and Michael, World Meteorological Organization Mangkut, and Super released two reports on climate in Typhoon Yutu, as well as for wildfires 2020. The State of Climate Services and earthquakes that occurred in (2020) found that between 1970 2018 and tornadoes and that and 2019, 79 percent of disasters occurred in 2019.290 worldwide involved weather-, water-, and climate-related hazards, which Notable Research Findings, accounted for 56 percent of deaths Meetings, and Federal Hearings: and 75 percent of economic losses l Extreme rain. Research from the from disasters. The report highlights National Oceanic and Atmospheric progress made in early warning Administration on all Atlantic systems’ capacity, and it identifies hurricanes affecting the southeastern where and how governments can and eastern United States during the invest in effective early warning 20th century found that extreme rain systems to strengthen countries’ risk is highest after hurricanes weaken resilience to multiple weather-, into tropical storms. The heaviest water-, and climate-related hazards. rainfall over the largest areas occurs United in Science 2020, a new after major hurricanes become tropical multi-agency report from leading storms, not during the hurricanes— science organizations, highlights the even major hurricanes—themselves.291 increasing and irreversible impacts of climate change and documents how l National Risk Index. In November COVID-19 has impeded the ability to 2020, the Federal Emergency monitor these changes through the Management Agency (FEMA) released global observing system.293 the National Risk Index, an online

TFAH • tfah.org 59 CLIMATE CHANGE & HEALTH: MEASURING STATES’ VULNERABILITY AND PREPAREDNESS

TFAH and JHU Bloomberg School of Public Health study reports on states’ vulnerability to and readiness for the health impacts of climate change. Climate change poses serious, Fortunately, important opportunities immediate threats to human health. to protect people’s health from the Catastrophic impacts are well- impacts of climate change exist at the understood, such as death and state and local level. Adaptation, which injury from more frequent and more seeks to reduce injuries, illness, death, intense hurricanes and wildfires. and suffering, is an extension of public Many dangers, however, lack a health approaches that emphasize singular, spectacular event and are prevention and preparedness. Many of therefore more insidious: longer-lasting these actions are driven by state-level heatwaves; poorer air quality; chronic plans, policies, and programs, which flooding; increases in vector-, water-, provide a critical foundation and supply and food-related infections; and the of resources to support additional toll all of this takes on people’s mental efforts at the community level. health and well-being. Given the size and diversity of the The release of greenhouse gases country, each state and its communities through human activities over the past will experience climate change differently. two centuries has made some level State leaders must understand their of global warming inevitable. Humans particular risks and vulnerabilities in must learn to live with the effects order to plan effectively. In areas of a of this change (adaptation), even as state where vulnerability is higher, state they pursue the essential objective of leaders should invest more in adaptation minimizing future warming by reducing and preparedness. Likewise, states that greenhouse gas emissions (mitigation). are more vulnerable overall should go to greater lengths to adapt to climate- Climate change, however, does not related hazards. affect all people and places equally. A person’s experience depends, A December 2020 report, Climate Change in large part, on where she lives. & Health: Assessing State Preparedness, Many health outcomes are linked to by TFAH and the Johns Hopkins environmental factors and, therefore, Bloomberg School of Public Health, sensitive to changes in climate. Social examined states’ readiness to protect and demographic factors also drive residents from the health impacts of vulnerability, meaning that the health climate change in light of the nature and of some communities or people could level of risks they face.294 While every be more affected than others. In many state had engaged in at least some level cases, vulnerability reflects existing of planning and preparation, there was health risk factors and disparities, significant variation, and, in many places, which are in turn tied to structural and a great deal of room for improvement. Of systemic racism. greatest concern, states with the highest

60 TFAH • tfah.org The results provide a portrait of state-level preparedness for the health impacts of climate change in the United States. While researchers found that every state had engagedlevels of vulnerability—predominantly in at least some level of planningparticularly and those preparation—the who are most extentfully or effectivenessfunding the CDC’s Climate and oflocated plan in implementation,the Southeast—tended critical to be to preventingvulnerable, are adverse safe and outcomes, secure. The was notHealth part program, of the bolstering states’ assessment—thereamong the least prepared. was (See significant Table 14.) reportvariation, offers and,federal in and many state places, policy a greatcore publicdeal ofhealth room preparedness for improvement. Of greatest concern,and researchersprogram recommendations, found that states withcapabilities, the highest and establishing ongoing, Leaders at all levels of government levels of vulnerability—predominantlyincluding located enacting in the legislation Southeast—tended dedicated to be among state funding the and staff for must act with urgency and persistent least prepared. (See Table 1.) requiring a national strategic plan, climate-related preparations. focus to ensure that their people, Table 1 StatesTable Grouped 14. States by Level Grouped of Vulnerability by Level of and Vulnerability Preparedness and Preparedness Vulnerability Score Preparedness Score Vulnerability State Least Vulnerable: 3.4-4.7 Least Prepared: 4.0-5.0 Group More Vulnerable: 4.8-5.3 More Prepared: 5.1-5.8 Most Vulnerable: 5.4-6.3 Most Prepared: 5.9-6.6 “Most prepared,” among states Utah 3.8 6.6 that were Maryland 4.4 6.3 “least vulnerable.” Vermont 4.3 6.3 Colorado 4.0 6.2 Wisconsin 4.4 6.1 New Hampshire 4.1 6.0 Least District of Columbia 4.5 5.9 Maine 4.5 5.9 Vulnerable Minnesota 4.4 5.8 Washington 4.5 5.8 Michigan 4.7 5.8 Alaska 3.4 5.4 North Dakota 4.1 5.2 Nebraska 4.6 5.1 Idaho 4.2 5.0 Montana 4.3 4.8 “Least prepared,” among states Wyoming 4.2 4.5 that were Virginia 4.8 6.3 “least vulnerable.” Massachusetts 4.9 6.2 Rhode Island 4.9 6.0 Illinois 4.9 6.0 New York 5.3 5.9 Pennsylvania 5.3 5.9 More Connecticut 4.9 5.9 Oregon 4.8 5.8 Vulnerable Delaware 4.9 5.7 Kansas 5.1 5.3 Iowa 4.9 5.3 Indiana 5.0 5.0 Ohio 5.1 5.0 New Jersey 5.2 4.9 Hawaii 5.3 4.8 Nevada 4.9 4.6 South Dakota 4.8 4.5 North Carolina 5.5 6.0 Arizona 5.4 5.9 Alabama 5.8 5.8 California 5.5 5.8 Louisiana 5.9 5.7 New Mexico 5.8 5.7 Arkansas 6.1 5.5 Most Missouri 5.4 5.5 Florida 6.3 5.1 Vulnerable Tennessee 5.5 4.9 Georgia 5.6 4.9 Kentucky 5.9 4.8 South Carolina 5.9 4.8 Texas 5.5 4.6 Mississippi 5.9 4.5 Oklahoma 5.5 4.5 West Virginia 5.8 4.0

Climate Change & Health: Assessing State Preparedness 8

TFAH • tfah.org 61 All Hazards Events and Policy Actions Notable Incidents: l E-cigarette and vaping injuries and National Bio and Agro-Defense Resilience Institute of the University of deaths. According to the CDC, as of Facility, which will research foreign Illinois at -Champaign. NG911 February 18, 2020, a total of 2,807 animal diseases—to the U.S. will update the current nationwide hospitalized e-cigarette or vaping- Department of Agriculture. Foreign emergency response system to an associated lung injuries (EVALI) or animal diseases pose a risk to livestock Internet Protocol (IP) platform, which deaths were reported to the CDC from (and in rare cases, people) and the will enable voice, video, photographs, all 50 states, DC, Puerto Rico, and the facility will develop countermeasures text, and future communications U.S. Virgin Islands. Sixty-eight deaths for these diseases. A report by the technologies to be transmitted to and have been confirmed in 29 states and Government Accountability Office by the public and first-responders for DC. Due to continued declines in new (GAO) found that it may not be ready assistance.303 No system launch date has EVALI cases since September 2019, and to open in December 2022 as planned, been announced. the identification of vitamin E acetate as despite both departments following l HHS/ASPR Strategic Plan. In April a likely primary cause of EVALI, the CDC practices for a successful transfer.301 2020, the U.S. Office of the Assistant is no longer collecting case reports.295 l Radiological detection. The Defense Secretary for Preparedness and l Mass shootings. During 2020, in the Advanced Research Projects Agency Response (ASPR) released the ASPR United States, there were 611 mass (DARPA) greenlit an automated, Strategic Plan for FY 2020-23, which shootings—defined as an incident in networked radiation detection system organizes and identifies how ASPR which at least four people are shot, known as SIGMA for use by the Port will fulfill its mission of saving lives excluding the shooter—in 2020.296 Authority of New York and New Jersey, and protecting Americans from This is a significant increase since which is theoretically capable of 21st-century health security threats 2019, when there were 417 total mass providing counterterrorism support and achieve its strategic vision: “the shootings.297 These events have long- through constant monitoring for nation’s health care and response term health effects on communities radiological and nuclear threats. systems and the communities they and survivors, including post- DARPA has further developed and serve are prepared, responsive, and traumatic-stress disorder, substance tested sensors for SIGMA to add resilient, thereby limiting the adverse abuse, anxiety, and .298 chemical, biological, and explosive health impacts of emergencies and threat detection to its list of disasters.” The plan builds on the l Terror attacks. On Christmas day, capabilities. SIGMA is based in worn, successful foundation established by a bomb detonated in downtown portable sensors, vehicular-mounted the ASPR strategic plans issued in Nashville, damaging over 40 businesses sensors, and stationary sensors at key 2011 and 2014, and aligns with the in the area and injuring three people. transportation nodes, and it can be HHS Strategic Plan FY 2018-2022 Quick evacuations by first-responders constantly improved through regular and other relevant national strategies likely saved lives in the area.299 While software updates. Officials and first- and legislation. It is also informed the motivation for the Christmas Day responders can use SIGMA to track by experience and lessons from real- bombing is not known, the Center for alerts and threats in real time, allowing world incidents, exercises, and training Strategic and International Studies for enhanced coordination.302 activities occurring over more than a reported that white supremacists and decade. The plan organizes ASPR’s other like-minded extremists conducted l Next Generation 911. The U.S. efforts under four priority goals: (1) two-thirds of terrorist plots and attacks in Department of Homeland Security foster strong leadership; (2) sustain the United States as of October 2020.300 Science and Technology Directorate and robust and reliable public health the U.S. Department of Transportation security capabilities; (3) advance an Notable Events and Policy Actions: have begun systems interoperability innovative medical countermeasures l and compatibility testing for the Next Animal disease research. The U.S. enterprise; and (4) build a regional Generation 911 (NG911) through a Department of Homeland Security disaster health response system.304 is transferring a new facility—the contract with the Critical Infrastructure

62 TFAH • tfah.org Notable Research Findings, l Antibiotic resistance. Two novel capacity; and (5) improved federal Meetings, and Federal Hearings: investigative drugs that target antibiotic- coordination.314 Leading public health l Retention of the public health resistant infections began advanced experts sent the committee over workforce. As of November 2020, at development through the Biomedical 350 recommendations of short-term least 70 top public health officials had Advanced Research and Development and long-term proposals to address been fired, resigned, or planned to Authority to begin phase 2 and 3 clinical future pandemics on a range of leave their posts since the beginning trials. One drug tackles Clostridioides topics, including sustaining onshore of the pandemic.305 The alarming difficile (C. difficile) infections, which manufacturing, creating and sustaining trend often resulted from threats, causes an estimated12,800 deaths state stockpiles, and improving the 310 315 both in-person and via social media, per year. The second uses CRISPR federal stockpile. technology to kill Escherichia coli (E. scapegoating, or political retribution. l Preparedness Summit. In August 2020, coli) bacteria that cause recurring or Even before the pandemic and related more than 1,300 attendees—who work drug-resistant urinary tract infections. If recession, state health agencies had in all levels of government, emergency successful, it would be the first CRISPR- lost nearly 10 percent of their full- management, volunteer organizations, time equivalent (FTE) workforce from engineered bacteriophage therapy to 311 healthcare coalitions, and academia— 306 be FDA-approved. Bacteriophages 2012 to 2019, while local health participated in the first ever virtual are viruses that infect and replicate departments lost about 16 percent of Preparedness Summit, “Fixing Our 307 only in bacterial cells. They cannot their FTE staff from 2008 to 2019. Fault Lines: Addressing Systemic infect human cells, and because each l Vulnerabilities.” Attendees participated Recruitment and retention of type of bacteriophage only kills a in more than 115 demonstrations, scientists. A May 2020 GAO report specific set of bacteria, it’s less likely to workshops, and educational sessions, found that HHS has had trouble disturb the beneficial bacteria in the and heard from expert-led panels, recruiting and retaining medical, human body.312 In addition, the FDA which provided an opportunity to engineering, and other science and approved cefiderocol for hospital- prepare for, respond to, and recover technology professionals to support acquired, ventilator-associated bacterial from the waves of the COVID-19 activities like biomedical and clinical pneumonia due to multidrug-resistant pandemic and the many other threats research. The Cures 313 gram-negative bacteria. 316 Act provides additional hiring and to public health and health security. l Legislative pandemic preparation retention authority—allowing HHS to l COVID-19 and Achieving Health blueprint. In July 2020, then–Senate hire up to 2,000 scientists with certain Equity Report. In September 2020, Health, Education, Labor and Pensions specialized graduate degrees and to then–Senate HELP Committee (HELP) Committee Chairman Lamar increase the top pay to hire and retain Ranking Member Patty Murray 308 Alexander released “Preparing for the an expert staff. also released a report, “COVID- Next Pandemic,” a legislative blueprint l 19 & Achieving Health Equity: Rebuilding the Public Health with five recommendations for Congressional Action is Necessary Workforce. State and local revenue legislators to address future pandemics to Address Racism and Inequality in losses due to the COVID-19 economic based on lessons learned from COVID- the U.S. Health Care System.” The crisis is likely to lead to budget cuts 19 and the past 20 years of pandemic report included 30 recommendations at the state and local level and is planning. The five recommendations to Congress, including dedicated expected to worsen the public health involve: (1) accelerated research and funding for COVID-19 relief for workforce staffing shortfall. COVID development for tests, treatments, communities of color, requiring an response funding did allow for short- and vaccines; (2) expanded disease equitable vaccine distribution plan, term staffing increases but not for the surveillance; (3) improved stockpile and a federal right to paid sick days hiring of the permanent public health capacity and distribution process; (4) and family and medical leave.317 professionals necessary to meet 21st- improved state and local response century challenges.309

TFAH • tfah.org 63 APPENDIX B APPENDIX B: METHODOLOGY Ready or Not Appendix B: Methodology

2021 Trust for America’s Health (TFAH) made major refinements to its methodology for Ready or Not in 2018. For more information, see the 2019 edition of the series, Appendix A: Methodology.318

To meet TFAH’s criteria, each indicator their progress against each measure. must be: TFAH seeks measures that are l Significant. The indicator needed incorporated in the NHSPI and that to be a meaningful measure of most closely meet TFAH’s criteria. states’ public health emergency There is one exception: a measure of preparedness. The NHSPI first state public health funding-level trends measured significance by using a that the NHSPI does not track. multistage Delphi process with a Indicator Data Collection panel of experts and then again by TFAH through interviews with The NHSPI provided TFAH with data additional experts. for every indicator except five (those data tied to the NLC, public health l Broadly relevant and accessible. The funding, flu vaccination, hospital indicator needed to be relevant—and patient safety, and laboratory surge timely data needed to be accessible—for capacity). In cases where newer data every state and the District of Columbia. were available than those modeled in

l Timely. Data for the indicator needed the 2020 edition of the NHSPI, TFAH to be updated regularly. collected and verified figures from their original sources. l Scientifically valid.Data supporting the indicator needed to be credible Public Health Funding Data and rigorously constructed. Collection and Verification To collect public health funding data l Nonpartisan. The indicator, and data for this report, TFAH examined states’ supporting the indicator, could not publicly available funding documents be rooted in or seen as rooted in any and surveyed state officials. Informed by political goals. the Public Health Activities and Services Using these criteria, TFAH aims to select Tracking project at the University of a broad set of actionable indicators Washington, TFAH defines public health with which it—and other stakeholders, programming and services as inclusive of including states themselves—can communicable disease control; chronic continue to track states’ progress. disease prevention; injury prevention; environmental public health; maternal,

MARCH 2021 (Complete data were not available for U.S. territories.) TFAH will strive to child, and family health; and access retain all or most of these indicators for to and linkage with clinical care. multiple years to assist states in tracking Specifically, this definition includes: l Communicable disease control. to improve comparability between l Size of state public health budget Public health services related to the two years when a reorganization compared with the past year communicable disease epidemiology, of departmental responsibilities had (nominally, not inflation-adjusted). hepatitis, HIV/AIDS, immunization, occurred over the period. • No change or funding increase: 0.5 sexually transmitted diseases, All states and the District of Columbia point. tuberculosis, etc. verified their funding data. • Funding decrease: 0 points. l Chronic disease prevention. Public Scoring and Tier Placements l Percent of population who used a health services related to asthma, community water system that failed cancer, cardiovascular disease, TFAH grouped states based on their to meet all applicable health-based diabetes, obesity, tobacco, etc. performances across the 10 indicators, and TFAH gave partial credit for some standards: TFAH scored states l Injury prevention. Public health indicators to draw finer distinctions according to the number of standard services related to firearms, motor among states and within states over deviations above or below the mean vehicles, occupational injuries, time. TFAH placed states into three of state results. senior falls prevention, substance- tiers—high tier, middle tier, and • Within one standard deviation use disorder, other intentional and low tier—based on their relative above the mean (and states with unintentional injuries, etc. performance across the indicators. 0 percent of residents who used a noncompliant community system): l Environmental public health. Public Specifically, TFAH scored each indicator 1 point. health services related to air and water as follows: quality, fish and shellfish, food safety, • Within one standard deviation below hazardous substances and sites, lead, l Adoption of the NLC: 0.5 point. No the mean: 0.75 point. adoption: 0 points. onsite wastewater, solid and hazardous • Between one and two standard waste, zoonotic diseases, etc. l Percent of hospitals participating in deviations below the mean: 0.5 point. l Maternal, child, and family health. healthcare coalitions: TFAH scored • Between two and three standard Public health services related to states according to the number of deviations below the mean: 0.25 point. standard deviations above or below the the coordination of services; direct • More than three standard deviations mean of state results. service; family planning; newborn below the mean: 0 points. screening; population-based maternal, • Within one standard deviation above child, and family health; supplemental the mean (and states with universal l Percent of employed population with nutrition; etc. participation): 1 point. paid time off: TFAH scored states according to the number of standard • Within one standard deviation below l Access to and linkage with clinical deviations above or below the mean of the mean: 0.75 point. care. Public health services related to state results. beneficiary eligibility determination, • Between one and two standard • More than one standard deviation provider or facility licensing, etc. deviations below the mean: 0.5 point. above the mean: 1 point. • Between two and three standard TFAH excludes from its definition • Within one standard deviation above deviations below the mean: 0.25 point. insurance coverage programs, such the mean: 0.75 point. as Medicaid or the Children’s Health • More than three standard deviations • Within one standard deviation below Insurance Program, as well as inpatient below the mean: 0 points. the mean: 0.5 point. clinical facilities. l Accreditation by the PHAB: 0.5 point. • Between one and two standard TFAH, under the guidance of state Not accredited: 0 points. deviations below the mean: 0.25 point. respondents, revised data for the base l Accreditation by the EMAP: 0.5 point. • More than two standard deviations year. (In this report, that was FY 2019.) Not accredited: 0 points. below the mean: 0 points. For some states, this was necessary

TFAH • tfah.org 65 l Percent of people ages 6 months The highest possible score a state could or older who received a seasonal receive was 7.5 points. flu vaccination: TFAH scored states TFAH placed states whose scores according to the number of standard ranked among the top 17 in the high- deviations above or below the mean performance tier. TFAH placed states of state results. whose scores ranked between the 18th- • More than one standard deviation highest and 34th-highest in the middle above the mean: 1 point. tier. TFAH placed states with scores • Within one standard deviation above ranked between the 35th-highest and the mean: 0.75 point. 51st-highest in the low-performance tier. • Within one standard deviation below (Ties in states’ scores can prevent an the mean: 0.5 point. even distribution across the tiers.) • Between one and two standard This year, states in the high tier had deviations below the mean: 0.25 point. scores ranging from 6 to 7; states in the • More than two standard deviations middle tier had scores ranging from below the mean: 0 points. 5.25 to 5.75; and states in the low tier had scores ranking from 4 to 5. l Percent of hospitals with a top-quality ranking (“A” grade) on the Leapfrog Assuring data quality Hospital Safety Grade. TFAH scored TFAH conducted several rigorous phases states according to the number of of quality assurance to strengthen the standard deviations above or below the integrity of the data and to improve mean of state results. and deepen TFAH’s understanding • More than one standard deviation of states’ performance, especially above the mean: 1 point. that of outliers on specific indicators. During collection of state public health • Within one standard deviation above funding data, researchers systematically the mean: 0.75 point. inspected every verified data file • Within one standard deviation below to identify incomplete responses, the mean: 0.5 point. inconsistencies, and apparent data entry • Positive number, more than one errors. Following this inspection, TFAH standard deviation below the mean: contacted respondents and gave them 0.25 point. the opportunity to complete or correct • No hospitals with a top-quality ranking their funding data. (“A” grade): 0 points.

l Public 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.

66 TFAH • tfah.org Endnotes 1 Kliff S and Sanger-Katz M. “Bottleneck for 12 Centers for Disease Control and Preven- 21 Assistant Secretary for Preparedness and U.S. Coronavirus Response: The Fax Ma- tion. “2010-11 Through 2019-20 Influenza Response. “Introduction to the Hospital chine.” The New York Times, July 13, 2020. Seasons Vaccination Coverage Trend Preparedness Program.” Public Health https://www.nytimes.com/2020/07/13/ Report.” FluVaxView, National Center for Emergency Fact Sheet, U.S. Department of upshot/coronavirus-response-fax-machines. Immunization and Respiratory Diseases. Health and Human Services. https:// html (accessed January 25, 2021). https://www.cdc.gov/flu/fluvaxview/ www.phe.gov/Preparedness/planning/ reportshtml/trends/index.html (accessed hpp/Documents/hpp-intro-508.pdf (ac- 2 King A. “Embattled Public Health Workers January 25, 2021). cessed January 25, 2021). Leaving At ‘Steady And Alarming’ Rate.” All Things Considered, NPR, 13 U.S. Department of Health and Human 22 Office of the Assistant Secretary for Pre- November 25, 2020. https://www.npr. Services. “Increase Proportion of People paredness and Response. 2017-2022 Health org/2020/11/25/938873547/embattled- Who Get the Flu Vaccine Every Year.” Care Preparedness and Response Capabilities. public-health-workers-leaving-at-steady-and- Healthy People 2030, Office of Disease Preven- Washington: Public Health Emergency, alarming-rate (accessed January 25, 2021). tion & Health Promotion. https://health. U.S. Department of Health and Human gov/healthypeople/objectives-and-data/ Services, November 2016. https://www.phe. 3 “Building Strong Foundation of Public browse-objectives/vaccination/increase- gov/Preparedness/planning/hpp/reports/ Health Infrastructure.” In The Public Health proportion-people-who-get-flu-vaccine-every- Documents/2017-2022-healthcare-pr-capa- Center for Center Innovations. https://phnci. year-iid-09 (accessed January 25, 2021). blities.pdf (accessed January 25, 2021). org/national-frameworks/fphs (accessed January 25, 2021). 14 Clemans-Cope L, Perry CD, Kenney GM, 23 U.S. Department of Health and Human et al. “Access to and Use of Paid Sick Services. Department of Health and Human 4 “Celebrating 25 Years and Launching Leave Among Low-Income Families With Services Fiscal Year 2020, Public Health and the Revised 10 Essential Public Health Children.” Pediatrics, 122(2): e480-486, Social Services Emergency Fund, Justification of Services.” In Public Health National Center August 2008. https://pubmed.ncbi.nlm. Estimates for Appropriations Committee. Wash- for Innovation. September 2020. https:// nih.gov/18676534/ (accessed January ington: U.S. Department of Health and phnci.org/national-frameworks/10-ephs 25, 2021). Human Services. https://www.hhs.gov/ (accessed January 25, 2021). sites/default/files/fy-2020-cj-phssef-final- 15 U.S. Department of Labor. “Families First 5 Systems for Action. “National Longitudinal print.pdf (accessed January 25, 2021). Coronavirus Response Act: Employer Paid Survey of Public Health Systems.” accessed Leave Requirements.” https://www.dol. 24 Upton L, Kirsch TD, Harvey M, and August 14, 2020, http://systemsforaction. gov/agencies/whd/pandemic/ffcra-em- Hanfling D. “Health Care Coalitions as org/national-longitudinal-survey-public- ployer-paid-leave (accessed February 4, Response Organizations: Houston After health-systems 2021). Hurricane Harvey.” and 6 “Public Health Leadership Forum.” In Public Health Preparedness, 11(6): 637-639, 16 National Health Security Preparedness RESOLVE. https://www.resolve.ngo/ December 2017. https://www.cambridge. Index. NHSPI | National Health Security site-healthleadershipforum/developing-a-fi- org/core/journals/disaster-medi- Preparedness Index (accessed February nancing-system-to-support-public-health-infra- cine-and-public-health-preparedness/ 4, 2021). structure.htm (accessed January 25, 2021). article/health-care-coalitions-as-re- 17 “The Nurse Licensure Compact and sponse-organizations-houston-after-hurri- 7 Earth Institute. “Inadequate COVID-19 COVID-19 – a Tale of Two States.” In cane-harvey/65743EE4F17718DF05E9F- Response Likely Resulted in 130,000– National Council of State Boards of Nursing, C212BB17F0D/core-reader (accessed 210,000 Avoidable Deaths.” State of the Planet, June 2020. https://www.ncsbn.org/14826. January 25, 2021). Columbia University, October 22, 2020. htm (accessed January 25, 2021). https://blogs.ei.columbia.edu/2020/10/22/ 25 Fraley M. “Healthcare Coalitions: The covid-19-response-avoidable-deaths/ 18 “Nurse Licensure Compact Member States.” New Structure for .” (accessed January 25, 2021). In National Council of State Boards of Nursing, EMS1, September 11, 2020. https:// 2020. https://www.ncsbn.org/nlcmember- www.ems1.com/ems-products/person- 8 “Alzheimer’s Disease and Healthy Aging: states.pdf (accessed January 25, 2021). al-protective-equipment-ppe/articles/ Health Disparities.” In Centers for Disease healthcare-coalitions-the-new-struc- Control and Prevention, updated January 19 National Council of State Boards of Nurs- ture-for-disaster-response-Wf1Hxg2i1qB- 31, 2017. https://www.cdc.gov/aging/ ing. “Indiana Implements the Nurse Licen- 0L7iw/#:~:text=During%20the%20 disparities/ (accessed January 25, 2021) sure Compact.” Press release: June 29, 2020. COVID%2D19%20pandemic,Provid- https://www.prnewswire.com/news-re- 9 “National Trend Data.” In National Health ing%20PPE%20supplies (accessed Janu- leases/indiana-implements-the-nurse-licen- Security Health Preparedness Index. https:// ary 25, 2021). sure-compact-301084656.html (accessed nhspi.org/ (accessed January 25, 2021). January 25, 2021). 26 “COVID-19 Healthcare Planning Check- 10 “Nurse Licensure Compact Member list.” In Public Health Emergency, U.S. 20 “Nurse Licensure Compact Member States.” In The National Council of State Department of Health and Human Services, States.” In National Council of State Boards Boards of Nursing. https://www.ncsbn. 2020. https://www.phe.gov/prepared- of Nursing, 2020. https://www.ncsbn.org/ org/nlcmemberstates519.pdf (accessed ness/covid19/documents/covid-19%20 nlcmemberstates.pdf (accessed January January 25, 2021). healthcare%20planning%20checklist.pdf 25, 2021). (accessed January 25, 2021). 11 Ibid. TFAH • tfah.org 67 27 Branswell H. “A Severe Flu Season Is Stretch- 35 Public Health Accreditation Board. Public 44 “National Primary Drinking Water Reg- ing Hospitals Thin. That Is a Very Bad Health Accreditation Board Standards: An ulations.” In U.S. Environmental Protection Omen.” STAT, January 15, 2018. https:// Overview. Alexandria, VA: Public Health Agency, updated January 5, 2021. https:// www.statnews.com/2018/01/15/flu-hospi- Accreditation Board, December 2013. www.epa.gov/ground-water-and-drinking- tal-pandemics/ (accessed January 25, 2021). http://www.phaboard.org/wp-content/ water/national-primary-drinking-water-reg- uploads/StandardsOverview1.5_Bro- ulations (accessed January 25, 2021). 28 Popescu S and Leach R. “Identifying chure.pdf (accessed January 25, 2021). Gaps in Frontline Healthcare Facility 45 “Safe Drinking Water Information System High-Consequence Infectious Disease 36 Emergency Management Accreditation (SDWIS) Federal Reporting Services.” In Preparedness.” Health Security, 17(2), April Program. 2016 Emergency Management Stan- U.S. Environmental Protection Agency, up- 26, 2019. https://www.liebertpub.com/ dard. Falls Church, VA: Emergency Man- dated June 27, 2017. https://www.epa.gov/ doi/10.1089/hs.2018.0098 (accessed Jan- agement Accreditation Program, 2016. ground-water-and-drinking-water/safe-drink- uary 25, 2021). https://www.emap.org/index.php/root/ ing-water-information-system-sdwis-feder- about-emap/96-emap-em-4-2016/file (ac- al-reporting (accessed January 25, 2021). 29 National Academies of Sciences, Engi- cessed January 25, 2021). neering, and Medicine. “2. Perspectives 46 Ibid. on the Nation’s Capacity to Respond to 37 “Delaware Emergency Management 47 Centers for Disease Control and Pre- Threats to Health, Safety, and Security.” In Agency Earns Accreditation.” In Del- vention. “CDC Investigation: Blood Engaging the Private-Sector Health Care System aware Emergency Management Agency, Lead Levels Higher After Switch to in Building Capacity to Respond to Threats to January 8, 2020. https://news.delaware. Flint River Water.” Press release: June the Nation’s Health. Washington: National gov/2020/01/08/delaware-emergen- 24, 2016. http://www.cdc.gov/media/ Academies Press, 2018. https://www.nap. cy-management-agency-earns-accredita- releases/2016/p0624-water-lead.html (ac- edu/read/25203/chapter/3#12 (accessed tion/ (accessed January 25, 2021). cessed January 25, 2021). January 25, 2021). 38 Prepared. The National Health Security Pre- 48 Iati M. “Toxic Lead, Scared Parents 30 National Academies of Sciences, Engineer- paredness Index. Princeton, NJ: Robert Wood and Simmering Anger: A Month In- ing, and Medicine. “3. Leveraging Health Johnson Foundation, June 2020. https:// side a City Without Clean Water.” Care Coalitions.” In Forum on Medical and nhspi.org/ (accessed January 25, 2021). , October 3, 2019. Public Health Preparedness for Catastrophic 39 “About Us.” In Public Health Activities and https://www.washingtonpost.com/ Events, Board on Health Sciences Policy, In- Services Tracking. https://phastdata.org/ climate-environment/2019/10/03/tox- stitute of Medicine. Preparedness, Response, about (accessed January 25, 2021). ic-lead-scared-parents-simmering-anger- and Recovery Considerations for Children and month-inside-city-without-clean-water/ Families: Workshop Summary. Washington: 40 “Profile of State and Territorial Public (accessed January 25, 2021). National Academies Press, March 21, 2014. Health.” In Association of State and Territorial https://www.ncbi.nlm.nih.gov/books/ Health Officials. https://www.astho.org/pro- 49 Mayo Clinic. Lead Poisoning. https:// NBK195866/ (accessed January 25, 2021). file/#close (accessed January 25, 2021). www.mayoclinic.org/diseases-conditions/ lead-poisoning/symptoms-causes/syc- 31 Prepared. The National Health Security 41 National Association of County and City 20354717 (Accessed February 3, 2021). Preparedness Index. Princeton, NJ: Robert Health Officials.2019 National Profile of Local Wood Johnson Foundation, June 2020. Health Departments. Washington: NACCHO, 50 Peterson M. “Paradise Residents Still https://nhspi.org/ (accessed January 25, 2020. https://www.naccho.org/uploads/ Can’t Drink the Water.” KQED, Septem- 2021). downloadable-resources/Programs/Pub- ber 30, 2019. https://www.kqed.org/ lic-Health-Infrastructure/NACCHO_2019_ science/1948232/paradise-residents-still- 32 Public Health Accreditation Board. Health Profile_final.pdf (accessed January 25, 2021). cant-drink-the-water (accessed January 25, Accreditation Board Standards and Measures: 2021). Version 1.5. Alexandria, VA: Public Health 42 Leachman M and Mcnichol E. Pandemic’s Accreditation Board, December 2013. Impact on State Revenues Less Than Earlier 51 “Water Quality Advisory—After the http://www.phaboard.org/wp-content/ Expected But Still Severe. Washington: Center Camp Fire.” In Paradise Irrigation District, uploads/SM-Version-1.5-Board-adopted- on Budget and Policy Priorities, October updated May 2020. https://pidwater. FINAL-01-24-2014.docx.pdf (accessed 30, 2020. https://www.cbpp.org/research/ com/wqadvisory (accessed January 25, January 25, 2021). state-budget-and-tax/pandemics-im- 2021). pact-on-state-revenues-less-than-earlier-ex- 33 “Why Become Accredited.” In Public Health 52 “Facts About Benzene.” In Centers for pected-but (accessed January 25, 2021). Accreditation Board. https://www.phaboard. Disease Control and Prevention, updated org/accreditation-overview/what-are-the- 43 U.S. Geological Survey. Domestic Water April 4, 2018. https://emergency.cdc. benefits/ (accessed January 25, 2021). Use. https://www.usgs.gov/mission-areas/ gov/agent/benzene/basics/facts.asp water-resources/science/domestic-wa- (accessed January 25, 2021). 34 Emergency Management Accreditation Pro- ter-use?qt-science_center_objects=0#qt-sci- gram. Applicant Guide to Accreditation, 2017. 53 “Harmful Algal Blooms: Tiny Organisms ence_center_objects (Accessed February Falls Church, VA: Emergency Management with a Toxic Punch.” In National Oceanic 3, 2021). Accreditation Program, 2017. https://www. and Atmospheric Administration, updated May emap.org/images/2017_Applicant_Guide_. 10, 2020. https://oceanservice.noaa.gov/ pdf (accessed January 25, 2021). hazards/hab/ (accessed January 25, 2021).

68 TFAH • tfah.org 54 Alexander K. “When the Power Goes 63 Pichler S and Ziebarth NR. “The Pros and 72 Bureau of Labor Statistics. “Labor Force Out, So Does the Water in Some Places.” Cons of Sick Pay Schemes: Contagious Statistics from the Current Population San Francisco Chronicle, October 9, 2019. Presenteeism and Noncontagious Survey.” Current Population Survey, U.S. https://www.sfchronicle.com/bayarea/ Absenteeism Behavior.” VOX EU CEPR Department of Labor. https://www.bls. article/When-the-power-goes-out-so-does- Policy Portal, May 12, 2018. https:// gov/cps/ (accessed January 25, 2021). the-water-in-14505539.php (accessed voxeu.org/article/pros-and-cons-sick-pay 73 Ibid. January 25, 2021). (accessed January 25, 2021). 74 Ibid. 55 Centers for Disease Control and 64 Ibid. Prevention. “Waterborne Disease and 75 Prepared. The National Health Security 65 National Partnership for Women and Outbreak Surveillance Reporting”. Preparedness Index. Princeton, NJ: Robert Families. “Paid Sick Days Improve Public https://www.cdc.gov/healthywater/ Wood Johnson Foundation, June 2020. Health.” Fact Sheet, October 2018. http:// surveillance/burden/findings.html https://nhspi.org/ (accessed January 25, www.nationalpartnership.org/research- (accessed February 4, 2021). 2021). library/work-family/psd/paid-sick-days- 56 “Private Drinking Water Wells.” In U.S. improve-our-public-health.pdf (accessed 76 National Center for Health Statistics. Environmental Protection Agency, July 15, January 25, 2021). “Table 68. Influenza Vaccination Among 2020. https://www.epa.gov/privatewells Adults Aged 18 and Over, by Selected 66 Pichler S and Ziebarth NR. The Pros (accessed January 25, 2021). Characteristics: United States, Selected and Cons of Sick Pay Schemes: Testing for Years 1989–2016.” Centers for Disease 57 Prepared. The National Health Security Contagious Presenteeism and Shirking Behavior. Control and Prevention, 2017. https://www. Preparedness Index. Princeton, NJ: Robert Cambridge, MA: National Bureau of cdc.gov/nchs/data/hus/2017/068.pdf Wood Johnson Foundation, June 2020. Economic Research, Working Paper 22530, (accessed January 25, 2021). https://nhspi.org/ (accessed January 25, August 2016. https://www.nber.org/ 2021). papers/w22530 (accessed January 25, 2021). 77 U.S. Department of Health and Human Services. “Increase proportion of peo- 58 Blau F, Koebe J, and Meyerhofer P. 67 Pichler S, Wen K, and Ziebarth NR. ple who get the flu vaccine every year.” “Essential and Frontline Workers in the “COVID-19 Emergency Sick Leave Has Healthy People 2030, Office of Disease Pre- COVID-19 Crisis.” EconoFACT, April 30, Helped Flatten the Curve in the United vention and Health Promotion (accessed 2020. https://econofact.org/essential- States.” Health Affairs, 39(12), October January 25, 2021). and-frontline-workers-in-the-covid-19-crisis 15, 2020. https://www.healthaffairs. (accessed January 25, 2021). org/doi/10.1377/hlthaff.2020.00863 78 Centers for Disease Control and Preven- (accessed January 25, 2021). tion. “2010-11 through 2018-19 Influenza 59 National Partnership for Women and Seasons Vaccination Coverage Trend Families. “Paid Sick Days Improve Public 68 Fields S. “Congress Lets Paid Sick, Family Report.” FluVaxView, National Center for Health.” Fact Sheet, October 2018. and Medical Leave Mandate Expire.” Immunization and Respiratory Diseases, http://www.nationalpartnership.org/ Marketplace, January 1, 2021. https://www. October 1, 2020. https://www.cdc.gov/ research-library/work-family/psd/paid- marketplace.org/2021/01/01/congress- flu/fluvaxview/reportshtml/trends/ sick-days-improve-our-public-health.pdf lets-paid-sick-family-and-medical-leave- index.html (accessed January 25, 2021). (accessed January 25, 2021). mandate-expire/ (accessed January 25, 2021). 79 “37% of Americans Do Not Plan to Get a 60 U.S. Bureau of Labor Statistics. “Table 31. Flu Shot This Season.” In NORC, University Leave Benefits: Access, Civilian Workers, 69 “Disability Insurance.” In State of California of Chicago, December 3, 2019. https:// March 2019.” National Compensation Survey, Employment Development Department. https:// www.norc.org/NewsEventsPublications/ March 2019. https://www.bls.gov/ncs/ data.edd.ca.gov/browse?category=Disabil- PressReleases/Pages/37-of-americans-do- ebs/benefits/2019/ownership/civilian/ ity+Insurance&utf8=%E2%9C%93 (ac- not-plan-to-get-a-flu-shot-this-season.aspx table31a.pdf (accessed January 25, 2021). cessed January 25, 2021). (accessed January 25, 2021). 61 Rho HJ, Brown H, and Fremstad S. “A 70 “Unemployment Insurance: Income 80 Piercey L (Commissioner, Tennessee De- Basic Demographic Profile of Workers Support Programs.” In Rhode Island partment of Health). Interview with Trust in Frontline Industries.” Center for Department of Labor and Training. https:// for America’s Health. December 12, 2019. Economic and Policy Research, April dlt.ri.gov/lmi/datacenter/uitdi.php 2020. https://cepr.net/wp-content/ (accessed January 25, 2021). 81 McCormick D (Division Director, Indiana uploads/2020/04/2020-04-Frontline- State Department of Health). Interview 71 The White House. “National Strategy for Workers.pdf (accessed January 25, 2021). with Trust for America’s Health, Decem- the COVID-19 Response and Pandemic ber 10, 2019. 62 Kumar S, Grefenstette JJ, Galloway D, et al. Preparedness. January 2021. https:// “Policies to Reduce Influenza in the Work- www.whitehouse.gov/wp-content/ 82 Centers for Disease Control and Prevention. place: Impact Assessments Using an Agent- uploads/2021/01/National-Strategy-for- “Flu Vaccination Coverage, United States, Based Model.” American Journal of Public the-COVID-19-Response-and-Pandemic- 2019–20 Influenza Season.”FluVaxView, Na- Health, 103(8): 1406-1411, 2013. https:// Preparedness.pdf (whitehouse.gov) tional Center for Immunization and Respira- www.ncbi.nlm.nih.gov/pubmed/23763426 (accessed February 4, 2021). tory Diseases, October 1, 2020. https://www. (accessed January 25, 2021). cdc.gov/flu/fluvaxview/coverage-1920esti- mates.htm (accessed January 25, 2021).

TFAH • tfah.org 69 83 Centers for Disease Control and Preven- 91 Association of Public Health Laboratories. 101 Hamilton JJ, Turner K, and Lichtenstein tion. “2010-11 through 2019-20 Influenza Surge Capacity Planning Tool for the Labora- Cone M. “Responding to the Pandemic: Seasons Vaccination Coverage Trend tory Response Network for Biological Threats Challenges With Public Health Sur- Report.” FluVaxView, National Center for Preparedness (LRN-B). Silver Spring, MD: veillance Systems and Development Immunization and Respiratory Diseases, Association of Public Health Laboratories, of a COVID-19 National Surveillance October 1, 2020. https://www.cdc.gov/ January 2015. https://www.aphl.org/ Case Definition to Support Case-Based flu/fluvaxview/reportshtml/trends/ aboutAPHL/publications/Documents/ Morbidity Surveillance During the Early index.html (accessed January 25, 2021). PHPR_SurgeCapacityLRNB_JAN2015.pdf Response.” Journal of Public Health Man- (accessed January 25, 2021). agement and Practice, 27: S80-S86, Janu- 84 Centers for Disease Control and Preven- ary/February 2021. https://journals. tion. “Flu Vaccination Coverage, United 92 Ibid. lww.com/jphmp/Fulltext/2021/01001/ States, 2018–19 Influenza Season.”FluVax - 93 “Responding to the Coronavirus Disease Responding_to_the_Pandemic__Chal- View, National Center for Immunization (COVID-19) Pandemic.” In Association lenges_With_Public.14.aspx (accessed and Respiratory Diseases, September 26, of Public Health Laboratories. June 4, January 25, 2021). 2020. https://www.cdc.gov/flu/fluvax- 2020. https://www.aphl.org/programs/ view/coverage-1819estimates.htm (ac- 102 “Developing a Financing System to preparedness/Crisis-Management/ cessed January 25, 2021). Support Public Health Infrastruc- COVID-19-Response/Pages/default.aspx ture.” In Resolve, Public Health Leader- 85 “Study Suggests Medical Errors Now (accessed January 25, 2021). ship Forum. https://www.resolve.ngo/ Third Leading Cause of Death in the 94 Ibid. site-healthleadershipforum/develop- U.S.” In Johns Hopkins Bloomberg School of ing-a-financing-system-to-support-pub- Public Health, May 3, 2016. https://www. 95 “The Data: Total for the US.” In The lic-health-infrastructure.htm (accessed hopkinsmedicine.org/news/media/ COVID Tracking Project at The Atlantic. January 25, 2021). releases/study_suggests_medical_errors_ https://covidtracking.com/data/national now_third_leading_cause_of_death_in_ (accessed January 25, 2021). 103 Funding for PHEP was $939 million in the_us (accessed January 25, 2021). FY 2003 and $695 million in FY 2021. 96 “COVID-19 Projections Using Machine 86 “Errors, Injuries, Accidents, Infections.” Learning.” In COVID-19 Projections. 104 Funding for HPP was $515 million in FY In Leapfrog Hospital Safety Grade. http:// https://covid19-projections.com/ (ac- 2003 and $280 million in FY 2021. www.hospitalsafetygrade.org/what-is-pa- cessed January 25, 2021). 105 “Public Health Infrastructure Saves Lives tient-safety/errors-injuries-accidents-infec- Act.” In Trust for America’s Health, Fact tions (accessed January 25, 2021). 97 Emory Health News. “Viral sequencing can reveal how SARS-COV-2 spreads Sheet, September 20220. https://www.tfah. 87 Richterman A, Meyerowitz EA, and and evolves”. EurekAlert!/AAAS. Viral org/wp-content/uploads/2020/09/PHI_ Cevik M. “Hospital-Acquired SARS-CoV-2 sequencing can reveal how SARS-CoV-2 FactSheet.pdf (accessed January 25, 2021). Infection: Lessons for Public Health.” spreads and evolves | EurekAlert! Science 106 U.S. Government Accountability Of- JAMA, 324(21): 2155-2156, 2020. https:// News (accessed February 5, 2021). fice.COVID-19: Federal Efforts Could Be jamanetwork.com/journals/jama/fullarti- Strengthened by Timely and Concerted Actions. cle/2773128 (accessed January 25, 2021). 98 Association of Public Health Laboratories. Surge Capacity Planning Tool for the Labora- GAO-20-701. Washington: Government 88 Leapfrog Group. Leapfrog Hospital Safety tory Response Network for Biological Threats Accountability Office, September 21, Grade: Scoring Methodology, Spring 2020. Preparedness (LRN-B). Silver Spring, MD: 2020. https://www.gao.gov/reports/GAO- Washington: Leapfrog Hospital Safety Association of Public Health Laboratories, 20-701/ (accessed January 25, 2021). Grade, April 14, 2020. https://www.hospital- January 2015. https://www.aphl.org/ 107 Devine R. “The White House Releases its safetygrade.org/media/file/HospitalSafe- aboutAPHL/publications/Documents/ 2019 Global Health Security Strategy.” tyGrade_ScoringMethodology_Spring2020. PHPR_SurgeCapacityLRNB_JAN2015.pdf Homeland Security Digital Library, May 10, pdf (accessed January 25, 2021). (accessed January 25, 2021). 2019. https://www.hsdl.org/c/the-white- 89 “How Safe Is Your Hospital.” In Leapfrog 99 Samuel Abrams (Senior Public house-releases-its-2019-global-health- Hospital Safety Grade. https://www.hospital- Health Preparedness and Response security-strategy/ (accessed January 25, safetygrade.org/your-hospitals-safety-grade/ Specialist, Association of Public Health 2021). state-rankings (accessed January 25, 2021). Laboratories). Interview with Trust for 108 Cutler DM and Summers LH. “The America’s Health, December 2, 2020. 90 “About Public Health Laboratories.” In As- COVID-19 Pandemic and the $16 Tril- sociation of Public Health Laboratories. https:// 100 Kliff S and Sanger-Katz M. “Bottleneck lion Virus.” JAMA, 324(15):1495-1496, www.aphl.org/aboutAPHL/Pages/about- for U.S. Coronavirus Response: The 2020. https://jamanetwork.com/jour- phls.aspx (accessed January 25, 2021). Fax Machine.” The New York Times, nals/jama/fullarticle/2771764#:~:tex- July 13, 2020. https://www.nytimes. t=The%20estimated%20cumulative%20 com/2020/07/13/upshot/coronavi- financial%20costs,domestic%20prod- rus-response-fax-machines.html (ac- uct%20of%20the%20US (accessed Janu- cessed January 25, 2021). ary 25, 2021).

70 TFAH • tfah.org 109 Goldstein-Street J. “Cost of Washington’s 116 Centers for Disease Control and Preven- 124 Auerbach J, Gracia JN, Farberman R, Measles Outbreak Tops $1M.” Associated tion. Antibiotic Use in the United States, 2017: et al. A Blueprint for the 2021 Admin- Press, February 23, 2019. https://www.ap- Progress and Opportunities. Atlanta: Centers istration and Congress: The Promise of news.com/a88d9198385a4e04a3491c9e8 for Disease Control and Prevention, 2017. Good Health for All: Transforming Public dc6404e (accessed January 25, 2021). https://www.cdc.gov/antibiotic-use/stew- Health in America. Washington: Trust ardship-report/pdf/stewardship-report. for America’s Health, October 2020. 110 Garfield R, Orgera K, and Damico A. pdf (accessed January 25, 2021). https://www.tfah.org/wp-content/up- The Uninsured and the ACA: A Primer—Key loads/2020/10/2021BluePrintRpt.pdf Facts about Health Insurance and the Unin- 117 “Core Elements of Antibiotic Steward- (accessed January 25, 2021). sured Amidst Changes to the Affordable Care ship.” In Centers for Disease Control and Act. San Francisco: Kaiser Family Foun- Prevention. https://www.cdc.gov/antibi- 125 Lustig A and Cabrera M. Promoting Health dation, January 25, 2019. https://www. otic-use/core-elements/index.html (ac- and Cost Control in States: How States Can kff.org/report-section/the-uninsured- cessed January 25, 2021). Improve Community Health & Well-being and-the-aca-a-primer-key-facts-about- Through Policy Change. Washington: Trust 118 “National Healthcare Safety Network.” In health-insurance-and-the-uninsured- for America’s Health, February 2019. Centers for Disease Control and Prevention, amidst-changes-to-the-affordable-care- https://www.tfah.org/report-details/pro- updated August 15, 2019. https://www. act-how-many-people-are-uninsured/ moting-health-and-cost-control-in-states/ cdc.gov/nhsn/index.html (accessed Jan- (accessed January 25, 2021). (accessed January 25, 2021). uary 25, 2021). 111 Vaccine Awareness Campaign to Cham- 126 “CDC COVID-19 Response Health 119 “Infectious Diseases Society of America’s pion Immunization Nationally and En- Equity Strategy: Accelerating Progress Policy on State Immunization Mandates.” In hance Safety Act of 2019. U.S. House of Towards Reducing COVID-19 Disparities Infectious Diseases Society of America, June 23, Representatives, May 21, 2019. https:// and Achieving Health Equity.” In Center 2012. https://www.idsociety.org/globalas- www.congress.gov/bill/116th-congress/ for Disease Control and Prevention, updated sets/idsa/policy--advocacy/current_topics_ house-bill/2862/all-info?r=5&s=1 (ac- August 21, 2020. https://www.cdc.gov/ and_issues/immunizations_and_vaccines/ cessed January 25, 2021). coronavirus/2019-ncov/community/ statements/062312-idsa-policy-state- health-equity/cdc-strategy.html (accessed 112 Adult Vaccines Now. “Financial Barriers ment-on-state-immunization-mandates.pdf January 25, 2021). to Adult Immunization.” Medicare Finan- (accessed January 25, 2021). cial Barriers Fact Sheet, 2017. http://www. 127 Louissaint N. “Building Community 120 Wingfield AH. “The Disproportionate adultvaccinesnow.org/wp-content/up- Resilience Through Health Equity.” Impact of COVID-19 on Black Health loads/2017/03/avac_financial_barriers_ Domestic Preparedness, April 5, 2017. Care Workers in the U.S.” Harvard Busi- FINAL_.pdf (accessed January 25, 2021). https://www.domesticpreparedness. ness Review, May 14, 2020. https://hbr. com/healthcare/building-community- 113 Center for Value-Based Insurance org/2020/05/the-disproportionate-im- resilience-through-health-equity/ Design. “Cost-Sharing for Immu- pact-of-covid-19-on-black-health-care-work- (accessed January 25, 2021). nizations in Medicare: Impacts on ers-in-the-u-s (accessed January 25, 2021). Beneficiaries and Recommenda- 128 Mental Health America. 2021 State of Mental 121 Carroll N. “The Backstory: Pollution. tions for Policymakers.” University Health in America. Alexandria, VA: Mental Poor health care. Crowded housing. of Michigan. http://vbidcenter.org/ Health America, 2020. https://www.mhana- High-risk jobs. Prejudice. Why people of cost-sharing-for-immunizations-in-medi- tional.org/issues/state-mental-health-amer- color are dying of COVID-19.” USA Today, care-impacts-on-beneficiaries-and-recom- ica (accessed January 25, 2021). October 23, 2020. https://www.usatoday. mendations-for-policymakers/ (accessed com/story/opinion/2020/10/23/covid- 129 Czeisler ME, Lane RI, Petrosky E, et al. January 25, 2021). racism-communities-color-have-high- “Mental Health, Substance Use, and 114 Stewart AM, Lindley MC, Chang er-rates-covid-here-why/3727325001/ Suicidal Ideation During the COVID-19 KHM, et al. “Vaccination Benefits and (accessed January 25, 2021). Pandemic—United States, June 24–30, Cost-Sharing Policy for Non-Institu- 2020.” Morbidity and Mortality Weekly 122 Louissaint N. “Building Community tionalized Adult Medicaid Enrollees Report, 69(32): 1049-1057, August 14, Resilience Through Health Equity.” Do- in the United States.” Vaccine, 32(5): 2020. https://www.cdc.gov/mmwr/vol- mestic Preparedness, April 5, 2017. https:// 618-623, January 23, 2014. https://www. umes/69/wr/mm6932a1.htm (accessed www.domesticpreparedness.com/ sciencedirect.com/science/article/pii/ January 25, 2021). healthcare/building-community-resil- S0264410X13015843 (accessed January ience-through-health-equity/ (accessed 130 Alter A and Yeager C. “The Consequences 25, 2021). January 25, 2021). Of Covid-19 On The Overdose Epidemic: 115 World Health Organization. WHO Guide- Overdoses Are Increasing.” Overdose Detec- 123 Substance Abuse and Mental Health Ser- lines on Use of Medically Important Antimi- tion Mapping Application Program, May 13, vices Administration. “Greater Impact: crobials in Food-Producing Animals. Geneva: 2020. http://www.odmap.org/Content/ How Disasters Affect People of Low Socio- WHO, 2017. http://www.who.int/food- docs/news/2020/ODMAP-Report- economic Status.” SAMHSA Disaster Tech- safety/publications/cia_guidelines/en/ May-2020.pdf (accessed January 25, 2021). nical Assistance Center Supplemental Research (accessed January 25, 2021). Bulletin, July 2017. https://www.samhsa. gov/sites/default/files/dtac/srb-low- ses_2.pdf (accessed January 25, 2021).

TFAH • tfah.org 71 131 “FAQs: Provision of Methadone and Bu- 138 Center for Health Security. “Implications 146 Toner E, Schoch-Spana M, Waldhorn prenorphine for the Treatment of Opioid of Clade X for National Policy.” In Johns R, et al. A Framework for Healthcare Di- Use Disorder in the COVID-19 Emer- Hopkins Bloomberg School of Public Health, saster Resilience: A View to the Future. gency.” In Substance Abuse and Mental Health Clade X: A Pandemic Exercise. http://www. Baltimore: Center for Health Security, Services Administration, April 21, 2020. centerforhealthsecurity.org/our-work/ 2018. http://www.centerforhealthse- https://www.samhsa.gov/sites/default/ events/2018_clade_x_exercise/pdfs/ curity.org/our-work/pubs_archive/ files/faqs-for-oud-prescribing-and-dispens- Clade-X-policy-statements.pdf (accessed pubs-pdfs/2018/180222-frame- ing.pdf (accessed January 25, 2021). January 25, 2021). work-healthcare-disaster-resilience.pdf (accessed January 25, 2021). 132 “Telehealth: Delivering Care Safely 139 Centers for Disease Control and Preven- During COVID-19.” In U.S. Department of tion. 2015-2016 National Report of Medical 147 “Regional Disaster Health Response Sys- Health and Human Services, updated July Countermeasure Readiness: Key Findings. tem: An Overview.” In Public Health Emer- 15, 2020. https://www.hhs.gov/corona- Atlanta: Centers for Disease Control and gency, updated October 5, 2020. https:// virus/telehealth/index.html (accessed Prevention. https://www.cdc.gov/cpr/ www.phe.gov/Preparedness/planning/ January 25, 2021). readiness/2015-2016_KeyFindings.html RDHRS/Pages/rdhrs-overview.aspx (ac- (accessed January 25, 2021). cessed January 25, 2021). 133 Juliano C, Castrucci B, and Fraser MR. “COVID-19 and Public Health: Look- 140 National Academies of Science, Engi- 148 “Emergency Management.” In The Joint ing Back, Moving Forward.” Journal of neering and Medicine. The Nation’s Med- Commission. https://www.jointcommis- Public Health Management and Practice, ical Countermeasure Stockpile: Opportunities sion.org/resources/patient-safety-topics/ 27: S1-S4, January/February 2021. to Improve the Efficiency, Effectiveness, and emergency-management/ (accessed Jan- https://journals.lww.com/jphmp/ Sustainability of the CDC Strategic National uary 25, 2021). Fulltext/2021/01001/COVID_19_and_ Stockpile: Workshop Summary. Washing- 149 Harvey M. “Using the Energy Sector As Public_Health__Looking_Back,_Mov- ton: National Academies Press, June 28, a Model for Healthcare Reliability.” U.S. ing.1.aspx (accessed January 25, 2021). 2016. http://www.nationalacademies. Department of Homeland Security, pre- org/hmd/Reports/2016/nations-med- 134 National Association of County and City sentation at 2019 National Healthcare Pre- ical-countermeasure-stockpile-ws.aspx Health Officials.National Profile of Local paredness Conference, December 5, 2019. (accessed January 25, 2021). Health Departments: 2019 Profile Study. Wash- 150 NPR. Planet Money Newsletter. How the ington: NACCHO, May 2020. https:// 141 U.S. Government Accountability Of- Crisis is Making Racial Inequity Worse. www.naccho.org/resources/lhd-research/ fice.COVID-19: Federal Efforts Could Be May 26, 2020. How The COVID-19 Crisis national-profile-of-local-health-depart- Strengthened by Timely and Concerted Actions. Is Making Racial Inequality Worse : Planet ments (accessed January 25, 2021). GAO-20-701. Washington: Government Money : NPR (accessed February 3, 2021) Accountability Office, September 21, 135 “Public Health Emergency Medical 2020. https://www.gao.gov/reports/GAO- 151 Aron-Dine A. “House Bill Would Help Countermeasures Enterprise.” In Public 20-701/ (accessed January 25, 2021). Millions Get Health Coverage, Cut Costs Health Emergency, updated December 30, for Millions More.” Center on Budget 2020. https://www.phe.gov/Prepared- 142 Webber T and Hollingsworth H. “‘Very and Policy Priorities, June 29, 2020. ness/mcm/phemce/Pages/default.aspx Dark Couple of Weeks’: Morgues and https://www.cbpp.org/ blog/house-bill- (accessed January 25, 2021). Hospitals Overflow.”Associated Press, De- would-help-millions-gethealth-coverage- cember 1, 2020. https://apnews.com/ 136 “What are Medical Countermeasures?” cut-costs-for-millions-more (accessed article/pandemics-coronavirus-pandem- In U.S. Food and Drug Administration, January 25, 2021). ic-2d8758a7bac85cd136248d5ce85533ed June 1, 2020. https://www.fda.gov/ (accessed January 25, 2021). 152 Toner E, Schoch-Spana M, Waldhorn emergency-preparedness-and-response/ R, et al. A Framework for Healthcare Di- about-mcmi/what-are-medical-counter- 143 Werner RM, Hoffman AK, and Coe NB. saster Resilience: A View to the Future. measures#:~:text=Medical%20counter- “Long-Term Care Policy after Covid-19 Baltimore: Center for Health Security, measures,%20or%20MCMs,%20 — Solving the Nursing Home Crisis.” New 2018. http://www.centerforhealthse- are%20FDA-regulated%20products%20 England Journal of Medicine, 383: 903-905, curity.org/our-work/pubs_archive/ (biologics,,radiological/nuclear%20 September 3, 2020. https://www.nejm. pubs-pdfs/2018/180222-frame- material,%20or%20a%20naturally%20 org/doi/full/10.1056/NEJMp2014811 work-healthcare-disaster-resilience.pdf occurring%20emerging%20disease (ac- (accessed January 25, 2021). (accessed January 25, 2021). cessed January 25, 2021). 144 Glauser TA, Williamson C, Berger L, et 153 “The EMS Compact.” In National Registry 137 Dall C. “As Pandemic Rages, PPE Sup- al. “Impact of Covid-19 on Outpatient of Emergency Medical Technicians. https:// ply Remains a Problem.” CIDRAP News, Clinical Practices: A Survey of Physi- www.nremt.org/rwd/public/document/ Center for Infectious Disease Research cians and Practice Administrators in replica (accessed January 25, 2021). and Policy, University of Minnesota, July the United States.” Policy and Medicine, 29, 2020. https://www.cidrap.umn.edu/ June 15, 2020. https://www.policymed. 154 “Uniform Emergency Volunteer Health news-perspective/2020/07/pandem- com/wp-content/uploads/2020/06/ Practitioners Act.” In The American College ic-rages-ppe-supply-remains-problem COVID-19-manuscript-06.15.2020.pdf of Surgeons. https://www.facs.org/advo- (accessed January 25, 2021). cacy/state/uevhpa (accessed January 25, 145 https://nhspi.org/indicator/hd-health- 2021). care-delivery/ (accessed January 25, 2021).

72 TFAH • tfah.org 155 “Topic Collection: Crisis Standards of 165 Statista. “Distribution of COVID-19 172 CDC. Morbidity and Mortality Report. Care.” In ASPR Tracie Technical Resources, Deaths in the United States as of January COVID-19 Associated Multisystem U.S. Department of Health and Human 27, 2021, by race”. https://www.statista. Inflammatory Syndrome in Children - Services, updated January 28, 2021. com/statistics/1122369/covid-deaths-dis- United States, March - July 2020. COVID- https://asprtracie.hhs.gov/technical-re- tribution-by-race-us/ (Accessed February 19–Associated Multisystem Inflammatory sources/63/crisis-standards-of-care/0 1, 2021). Syndrome in Children — United States, (accessed January 28, 2021). March–July 2020 | MMWR (cdc.gov) (Ac- 166 Van Beusekom M. “Studies Explore cessed February 1, 2021). 156 “Crisis Standards of Care.” In National Asymptomatic COVID-19 Cases, Racial Academies of Sciences Engineering and Med- Inequities.” CIDRAP News, Center for In- 173 “What We Know About Long-Term icine. https://www.nationalacademies. fectious Disease Research and Policy, Uni- Effects of COVID-19.” In World Health org/our-work/crisis-standards-of-care- versity of Minnesota, September 22, 2020. Organization, updated September 9, successes-and-challenges-from-the-past- https://www.cidrap.umn.edu/news-per- 2020. https://www.who.int/docs/ ten-years--a-workshop (accessed January spective/2020/09/studies-explore-asymp- default-source/coronaviruse/risk-com- 28, 2021). tomatic-covid-19-cases-racial-inequities ms-updates/update-36-long-term-symp- (accessed January 25, 2021). toms.pdf?sfvrsn=5d3789a6_2 (accessed 157 Crimmins A, Balbus J, Gamble JL, et al. The January 25, 2021). Impacts of Climate Change on Human Health 167 Lake S. “COVID-19 Death Toll Under- in the United States: A Scientific Assessment. reported, Study Finds.” Virginia Business, 174 U.S. Department of Health and Human Washington: U.S. Global Change Research July 1, 2020. https://www.virginiabusi- Services. “HHS Announces Partnership Program, 2016. https://health2016.global- ness.com/article/covid-19-death-toll- with Morehouse School of Medicine to change.gov/ (accessed January 28, 2021). underreported-study-finds/ (accessed Fight COVID-19 in Racial and Ethnic January 25, 2021). Minority and Vulnerable Communities.” 158 “Health and Climate Change: Account- Press release: HHS, June 23, 2020. https:// ing for Costs.” In Natural Resources Defense 168 Samuels M. “U.S. COVID Deaths May www.hhs.gov/about/news/2020/06/23/ Council, November 2011. https://www. be Undercounted by 36 Percent.” Bos- hhs-announces-partnership-morehouse- nrdc.org/sites/default/files/accounting- ton University School of Public Health, school-medicine-fight-covid-19-racial- costs.pdf (accessed January 28, 2021). 2020. https://www.bu.edu/sph/news/ ethnic-minority.html (accessed January articles/2020/us-covid-deaths-may-be- 159 Ibid. 25, 2021). undercounted-by-36-percent/ (accessed 160 “CDC COVID Data Tracker: United January 25, 2021). 175 “Fact Sheet: Explaining Operation Warp States COVID-19 Cases and Deaths Speed.” In U.S. Department of Health and 169 Lange SJ, Ritchey MD, Goodman AB, by State.” In Centers for Disease Control Human Services, updated January 21, et al. “Potential Indirect Effects of and Prevention. https://covid.cdc.gov/ 2021. https://www.hhs.gov/coronavirus/ the COVID-19 Pandemic on Use of covid-data-tracker/#cases_totalcases (ac- explaining-operation-warp-speed/index. Emergency Departments for Acute cessed January 25, 2021). html (accessed January 25, 2021). Life-Threatening Conditions—United 161 “WHO Coronavirus Disease (COVID-19) States, January–May 2020.” Morbidity and 176 “COVID-19 Vaccines.” In The U.S. Food Dashboard.” In World Health Organization, Mortality Weekly Report, 69(25): 795–800, and Drug Administration. Updated Jan- updated January 25, 2021. https://covid19. 2020. https://www.cdc.gov/mmwr/vol- uary 14, 2021. https://www.fda.gov/ who.int (accessed January 25, 2021). umes/69/wr/mm6925e2.htm (accessed emergency-preparedness-and-response/ January 25, 2021). coronavirus-disease-2019-covid-19/covid- 162 “COVID-19 Dashboard by the Center 19-vaccines (accessed January 25, 2021). for Systems Science and Engineering 170 National Institutes of Health. “Scientists (CSSE) at Johns Hopkins University Discover Genetic and Immunologic 177 “Frequently Asked Questions about (JHU).” In John Hopkins University & Underpinnings of Some Cases of Severe COVID-19 Vaccination.” In Centers for Medicine, Coronavirus Resource Center. COVID-19.” Press release: National Insti- Disease Control and Prevention, updated https://coronavirus.jhu.edu/map.html tute of Allergy and Infectious Diseases, January 25, 2021. https://www.cdc. (accessed January 25, 2021). September 24, 2020. https://www.nih. gov/coronavirus/2019-ncov/vaccines/ gov/news-events/news-releases/scien- faq.html#:~:text=The%20federal%20 163 “CDC COVID Data Tracker: Demo- tists-discover-genetic-immunologic-un- government%20will%20oversee,be%20 graphic Trends of COVID-19 Cases and derpinnings-some-cases-severe-covid-19 ordered%20through%20CDC (accessed Deaths in the US Reported to CDC.” In (accessed January 25, 2021). January 25, 2021). Centers for Disease Control and Prevention, updated January 24, 2021. https://covid. 171 “For Parents: Multisystem Inflammatory 178 Chokshi N. “Airlines Gear Up to Trans- cdc.gov/covid-data-tracker/#demo- Syndrome in Children (MIS-C) associ- port Vaccines That Could Revive Travel.” graphics. (accessed January 25, 2021). ated with COVID-19.” In Centers for Dis- The New York Times, December 10, 2020. ease Control and Prevention, updated May https://www.nytimes.com/2020/12/10/ 164 “The COVID Racial Data Tracker: 20, 2020. https://www.cdc.gov/coro- business/airlines-vaccines-coronavirus. COVID-19 Is Affecting Black, Indige- navirus/2019-ncov/daily-life-coping/ html (accessed January 25, 2021). nous, Latinx, and Other People of Color children/mis-c.html (accessed January The Most.” In The COVID Tracking Project 25, 2021). at The Atlantic. https://covidtracking. com/race. (accessed January 25, 2021).

TFAH • tfah.org 73 179 Vergun D. “DOD Officials Announce 186 Centers for Disease Control and Preven- 195 Centers for Disease Control and Prevention. Distribution Plan for Initial Batch of tion. COVID-19 Vaccination Program Interim “Weekly Influenza Surveillance Report: Key COVID-19 Vaccine.” Defense News, U.S. Playbook for Jurisdiction Operations. Atlanta: Updates for Week 51, Ending December 21, Department of Defense, December 9, Centers for Disease Control and Preven- 2019.” Flu View, updated January 22, 2021. 2020. https://www.defense.gov/Ex- tion, October 29, 2020. https://www.cdc. https://www.cdc.gov/flu/weekly/index. plore/News/Article/Article/2440577/ gov/vaccines/imz-managers/downloads/ htm (accessed January 25, 2021). dod-officials-announce-distribution-plan- COVID-19-Vaccination-Program-Interim_ 196 “Widespread Person-to-Person Outbreaks for-initial-batch-of-covid-19-vaccine/ (ac- Playbook.pdf (accessed January 25, 2021). of Hepatitis A Across the United States.” In cessed January 25, 2021). 187 CBS News. “Biden vows to distribute 100 Centers for Disease Control and Prevention, up- 180 Centers for Disease Control and Pre- million vaccine doses in first 100 days”. dated January 25, 2021. https://www.cdc. vention. COVID-19 Vaccination Program December 8, 2020. https://www.cbsnews. gov/hepatitis/outbreaks/2017March-Hep- Interim Playbook for Jurisdiction Operations. com/news/biden-covid-vaccine-100-mil- atitisA.htm (accessed January 25, 2021). Atlanta: Centers for Disease Control and lion-doses-first-100-days/ (accessed Febru- 197 Ibid. Prevention, October 29, 2020. https:// ary 4, 2021). www.cdc.gov/vaccines/imz-managers/ 198 Doshani M, Weng M, Moore KL, et al. 188 Centers for Disease Control and Pre- downloads/COVID-19-Vaccination-Pro- “Recommendations of the Advisory vention. “COVID-19 Vaccinations in the gram-Interim_Playbook.pdf (accessed Committee on Immunization Practice for U.S.” CDC COVID Data Tracker (accessed January 25, 2021). People Experiencing Homelessness.” Mor- February 4, 2021). bidity and Mortality Reports, 68(6):153-156, 181 Dooling K, Marin M, Wallace M, et al. 189 Nambi Ndugga, et al. Kaiser Family February 15, 2019. https://www.cdc.gov/ “The Advisory Committee on Immu- Foundation. “Early State Vaccination Data mmwr/volumes/68/wr/mm6806a6.htm. nization Practices’ Updated Interim Raise Warning Flags for Racial Equity”. Recommendation for Allocation of 199 “Hepatitis A Outbreaks in the United January 21, 2021. https://www.kff.org/ COVID-19 Vaccine—United States, De- States.” In Centers for Disease Control policy-watch/early-state-vaccination-da- cember 2020.” Morbidity and Mortality and Prevention, updated July 28, 2020. ta-raise-warning-flags-racial-equity/ (Ac- Weekly Report, 69(51-52): 1657, January 1, https://www.cdc.gov/hepatitis/out- cessed February 1, 2021). 2021. https://www.cdc.gov/mmwr/vol- breaks/hepatitisaoutbreaks.htm (ac- umes/69/wr/pdfs/mm695152e2-H.pdf 190 Centers for Disease Control and Preven- cessed January 25, 2021). (accessed January 25, 2021). tion. “Flu Activity & Surveillance: Find 200 “Widespread Person-to-Person Out- COVID-19 Surveillance Data.” Flu View, 182 Frosch D, Findell E, and Loftus P. “As breaks of Hepatitis A Across the United updated July 8, 2020. https://www.cdc. Covid-19 Vaccines Roll Out, States to De- States.” In Centers for Disease Control and gov/flu/weekly/fluactivitysurv.htm (ac- termine Who Gets Shots First.” The Wall Prevention, updated January 25, 2021. cessed January 25, 2021). Street Journal, December 9, 2020. https:// https://www.cdc.gov/hepatitis/out- www.wsj.com/articles/as-covid-19-vac- 191 “Estimated Influenza Illnesses, Medical breaks/2017March-HepatitisA.htm (ac- cines-roll-out-states-to-determine-who- Visits, Hospitalizations, and Deaths in cessed January 25, 2021). gets-shots-first-11607509801 (accessed the United States—2019–2020 Influenza 201 “Measles Cases and Outbreaks.” In Cen- January 25, 2021). Season.” In Centers for Disease Control and ters for Disease Control and Prevention, up- Prevention, updated October 6, 2020. 183 Stanley-Baker I. “Shots Are Slow to Reach dated December 2, 2020. https://www. https://www.cdc.gov/flu/about/bur- Arms as Trump Administration Leaves cdc.gov/measles/cases-outbreaks.html den/2019-2020.html (accessed January Final Steps of Mass Vaccination to Belea- (accessed January 25, 2021). 25, 2021). guered States.” The Washington Post, Decem- 202 Ibid. ber 30, 2020. https://www.washingtonpost. 192 Ibid. com/health/2020/12/30/covid-vaccine-de- 203 “Complications of Measles.” In Centers 193 Centers for Disease Control and Preven- lay/ (accessed January 25, 2021). for Disease Control and Prevention, updated tion. “Flu Vaccination Coverage, United November 5, 2020. https://www.cdc. 184 Feuer W. “Dr. Fauci Says Slow COVID States, 2019–20 Influenza Season.”Flu gov/measles/symptoms/complications. Vaccine Rollout Has Been Disappointing.” Vax View, updated January 21, 2021. html (accessed January 25, 2021). CNBC, December 31, 2020. https://www. https://www.cdc.gov/flu/fluvaxview/ cnbc.com/2020/12/31/dr-fauci-says-slow- (accessed January 25, 2021). 204 Paules CI, Marston HD, and Fauci AS. covid-vaccine-rollout-has-been-disappoint- “Measles in 2019—Going Backward.” New 194 “Estimated Influenza Illnesses, Medical ing.html (accessed January 25, 2021). England Journal of Medicine, 380: 2185- Visits, and Hospitalizations Averted 2187, June 6, 2019. https://www.nejm. 185 Sun LH, Stanley-Becker I, Sellers FS, et al. by Vaccination in the United States — org/doi/full/10.1056/NEJMp1905099 “Vaccines Were a Chance to Redeem Fail- 2019–2020 Influenza Season.” InCenters (accessed January 25, 2021). ures in the U.S. Coronavirus Response. for Disease Control and Prevention, updated What Went Wrong?” The Washington October 6, 2020. https://www.cdc.gov/ 205 “Measles Cases and Outbreaks: Measles Post, January 11, 2021. https://www. flu/about/burden-averted/2019-2020. Cases in 2019.” In Centers for Disease Con- washingtonpost.com/health/covid-vac- htm (accessed January 25, 2021). trol and Prevention, updated December cine-slow-rollout/2021/01/11/2e804898- 2, 2020. https://www.cdc.gov/measles/ 5100-11eb-bda4-615aaefd0555_story.html cases-outbreaks.html (accessed January (accessed January 25, 2021). 25, 2021). 74 TFAH • tfah.org 206 “Worldwide Measles Deaths Climb 215 “Cholera: Cholera Outbreaks.” World 224 “Statement on the Second Meeting of 50% from 2016 to 2019 Claiming Over Health Organization, November 2019. the International Health Regulations 207,500 Lives in 2019.” In Measles & http://www.emro.who.int/health-topics/ (2005) Emergency Committee Regard- Initiative. https://measles- cholera-outbreak/cholera-outbreaks. ing the Outbreak of Novel Coronavirus rubellainitiative.org/measles-news/ html (accessed January 25, 2021). (2019-nCoV).” In World Health Organiza- worldwide-measles-deaths-climb-50- tion, January 30, 2020. https://www.who. 216 “Cholera.” In World Health Organization. from-2016-to-2019-claiming-over- int/news/item/30-01-2020-statement-on- https://www.who.int/health-topics/choler- 207500-lives-in-2019/ (accessed January the-second-meeting-of-the-international- a#tab=tab_1 (accessed January 25, 2021). 25, 2021). health-regulations-(2005)-emergency- 217 World Health Organization. How Do committee-regarding-the-outbreak-of- 207 “Immunization Analysis and Insights: Provi- Vaccines Work? https://www.who.int/ novel-coronavirus-(2019-ncov) (accessed sional Monthly Measles and Rubella Data.” news-room/feature-stories/detail/how- January 25, 2021). In World Health Organization. https:// do-vaccines-work (who.int) (Accessed www.who.int/teams/immunization-vac- 225 World Health Organization. “WHO February 1, 2021). cines-and-biologicals/immunization-analy- Director-General remarks at media brief- sis-and-insights/surveillance/monitoring/ 218 “Polio Vaccination Campaigns Restart in Af- ing, , 2020. WHO Director-Gen- provisional-monthly-measles-and-rubel- ghanistan and Pakistan After COVID-19 Hi- eral’s opening remarks at the media la-data (accessed January 25, 2021). atus.” In UN News, August 11, 2020. https:// briefing on COVID-19 - 11 March 2020 news.un.org/en/story/2020/08/1069972 (accessed February 4, 2021). 208 “Emergency Call to Action for Measles (accessed January 25, 2021). and Polio Outbreak Prevention and 228 Wilhelm B. and Egar WT. “Congressional Response.” In World Health Organization 219 “Foodborne Outbreaks.” In Centers for Oversight Provisions in the Coronavi- and UNICEF, November 2020. http:// Disease Control and Prevention, updated rus Aid, Relief, and Economic Security polioeradication.org/wp-content/up- January 13, 2021. https://www.cdc.gov/ (CARES) Act (P.L. 116-136).” Congres- loads/2020/11/Call-To-Action-20201105. foodsafety/outbreaks/index.html (ac- sional Research Service, April 17, 2020. pdf (accessed January 25, 2021). cessed January 25, 2021). https://fas.org/sgp/crs/misc/R46315. pdf (accessed January 25, 2021). 209 “2020 Democratic Republic of the 220 Centers for Disease Control and Preven- Congo, Equateur Province.” In Centers tion. “Foodborne Germs and Illnesses” 229 “CARES Act Provider Relief Fund.” In for Disease Control and Prevention, updated March 18, 2020. https://www.cdc.gov/ U.S. Department of Health and Human November 18, 2020. https://www.cdc. foodsafety/foodborne-germs.html (Ac- Services, updated January 21, 2021. gov/vhf/ebola/outbreaks/drc/2020- cessed February 3, 2021). https://www.hhs.gov/coronavirus/ june.html (accessed January 25, 2021). cares-act-provider-relief-fund/index. 221 “Foodborne Germs and Illnesses.” In html#:~:text=The%20Provider%20 210 “Latest Ebola outbreak in DR Congo is de- Centers for Disease Control and Prevention Relief%20Fund%20supports,lines%20 clared over, with lessons for COVID-19.” updated March 14, 2020. https://www. of%20the%20coronavirus%20response In UN News, November 18, 2020. https:// cdc.gov/foodsafety/foodborne-germs. (accessed January 25, 2021). news.un.org/en/story/2020/11/1077912 html (accessed January 25, 2021). (accessed January 25, 2021). 230 “Policy Changes During COVID-19.” In 222 U.S. Department of Health and Human Telehealth.HHS.gov, updated January 19, 211 Nett JE. “Candida auris: An Emerging Services. “Secretary Azar Declares Public 2021. https://telehealth.hhs.gov/pro- Pathogen ‘Incognito’?” PLoS Pathogens, Health Emergency for United States for viders/policy-changes-during-the-covid- 15(4): e1007638, April 8, 2019. https:// 2019 Novel Coronavirus.” Press release, 19-public-health-emergency/ (accessed journals.plos.org/plospathogens/arti- HHS, January 31, 2020. https://www. January 25, 2021). cle?id=10.1371/journal.ppat.1007638 hhs.gov/about/news/2020/01/31/sec- (accessed January 25, 2021). retary-azar-declares-public-health-emer- 231 Cohen J and van der Meulen Rodgers gency-us-2019-novel-coronavirus.html Y. “Contributing Factors to Personal 212 “Tracking Candida auris: CDC Works (accessed January 25, 2021). Protective Equipment Shortages During With Global Partners to End Cholera.” the COVID-19 Pandemic.” Preventative In Centers for Disease Control and Preven- 223 “Another Coronavirus Emerges: U.S. Do- Medicine, 141: 106263, December 2020. tion, updated January 15, 2021. https:// mestic Response to 2019-nCoV.” In Every- https://www.ncbi.nlm.nih.gov/pmc/ar- www.cdc.gov/fungal/candida-auris/ CRSReport, January 29, 2020. https://www. ticles/PMC7531934/ (accessed January tracking-c-auris.html (accessed January everycrsreport.com/reports/IN11212. 25, 2021). 25, 2021). html (accessed January 25, 2021). 232 Ranney ML, Griffeth V, and Jha AK. 213 Centers for Disease Control and Pre- “Critical Supply Shortages—The Need for vention. “Candia auris Outbreak in a Ventilators and Personal Protective Equip- COVID-19 Specialty Care Unit – Florida, ment during the COVID-19 Pandemic.” July – August 2020”. https://www.cdc. New England Journal of Medicine, 382: e41, gov/mmwr/volumes/70/wr/mm7002e3. April 30, 2020. https://www.nejm.org/ htm July–August 2020 | MMWR (cdc. doi/full/10.1056/NEJMp2006141 (ac- gov) (accessed February 4, 2021). cessed January 25, 2021). 214 Ibid.

TFAH • tfah.org 75 233 “Supply Shortages Impacting COVID-19 240 U.S. Department of Health and Human 247 U.S. Food and Drug Administration. FDA and Non-COVID Testing.” In American Services. “HHS Awards $2.24 Billion Approves Only Drug in U.S. to Treat Severe Society for , January 19, 2021. in Grants to Help Americans Access Malaria. May 26, 2020. https://www.fda. https://asm.org/Articles/2020/Septem- HIV/AIDS Care, Support Services, gov/news-events/press-announcements/ ber/Clinical-Microbiology-Supply-Short- and Medication.” Press release: October fda-approves-only-drug-us-treat-severe- age-Collecti-1#:~:text=Those%20 1, 2020. https://www.hhs.gov/about/ malaria Accessed February 3, 2021. responding%20this%20week%20 news/2020/10/01/hhs-awards-2.24-bil- 248 Centers for Disease Control and Preven- report,tips%20reagent%20bins%20 lion-in-grants-to-help-americans-access-- tion. Parasites - Malaria. January 26, 2021. (41.2%25) (accessed January 25, 2021). aids-care-support-services-and-medication. https://www.cdc.gov/parasites/malaria/ html (accessed January 25, 2021). 234 U.S. Department of Health and Human index.html (Accessed February 3, 2021) Services. “Secretary Azar Statement on 241 National Institutes of Health. “NIH 249 National Institutes of Health. “First New Defense Production Act Orders.” Press establishes Centers for Research in Human Trial of Monoclonal Antibody release: April 3, 2020. https://www.hhs.gov/ Emerging Infectious Diseases.” Press to Prevent Malaria Opens.” Press release: about/news/2020/04/03/secretary-azar- release: August 27, 2020. https://www. January 27, 2020. https://www.nih.gov/ statement-on-new-defense-production-act- nih.gov/news-events/news-releases/ news-events/news-releases/first-human-tri- orders.html (accessed January 25, 2021). nih-establishes-centers-research-emerg- al-monoclonal-antibody-prevent-malar- ing-infectious-diseases (accessed January 235 “National Organizations Call for Action ia-opens (accessed January 25, 2021). 25, 2021). to Implement Crisis Standards of Care 250 Bavarian Nordic. “Bavarian Nordic An- During COVID-19 Surge.” In National 242 “Viral Hepatitis National Strategic Plan.” nounces Topline Results from Phase 1 Academy of Medicine, December 18, 2020. In U.S. Department of Health and Human Clinical Trial of Equine Encephalitis https://nam.edu/national-organiza- Services, October 9, 2020. https://www. Virus Vaccine.” Press release: June 8, 2020. tions-call-for-action-to-implement-crisis- hhs.gov/hepatitis/viral-hepatitis-nation- https://www.bavarian-nordic.com/ standards-of-care-during-covid-19-surge/ al-strategic-plan/index.html (accessed investor/news/news.aspx?news=6058 (accessed January 25, 2021). January 25, 2021). (accessed January 25, 2021). 236 Tyson A, Johnson C, and Funk C. “U.S. 243 “U.S. National Action Plan for Combat- 251 U.S. Department of Health and Human Public Now Divided Over Whether to Get ing Antibiotic-Resistant Bacteria (Na- Services. “HHS Secretary Azar Statement COVID-19 Vaccine.” Pew Research Center, tional Action Plan).” In Centers for Disease on First FDA Approval of Ebola Therapeu- September 17, 2020. www.pewresearch. Control and Prevention, updated October tic.” Press release: October 14, 2020. https:// org/science/2020/09/17/u-s-public-now- 9, 2020. https://www.cdc.gov/drugresis- www.hhs.gov/about/news/2020/10/14/ divided-over-whether-to-get-covid-19-vac- tance/us-activities/national-action-plan. hhs-secretary-azar-statement-first-fda-ap- cine/ (accessed January 25, 2021). html (accessed January 25, 2021). proval-ebola-therapeutic.html (accessed 237 Trust for America’s Health. “Building 244 Huang, P. “Trump Sets Date To End January 25, 2021). Trust in and Access to a COVID-19 Vac- WHO Membership Over Its Handling 252 Abbasi J. “FLU-v, a Universal Flu Vaccine cine Within Communities of Color and Of Virus.” NPR, July 7, 2020. https:// Candidate, Advances in Trial.” JAMA, Tribal Nations.” Policy Brief, December www.npr.org/sections/goatsand- 323(14): 1336, April 14, 2020. https:// 2020. https://www.tfah.org/report-de- soda/2020/07/07/888186158/ jamanetwork.com/journals/jama/arti- tails/trust-and-access-to-covid-19-vaccine- trump-sets-date-to-end-who-membership- cle-abstract/2764436 (accessed January within-communities-of-color/ (accessed over-its-handling-of-virus (accessed Janu- 25, 2021). January 25, 2021). ary 25, 2021). 253 Pleguezuelos O, James E, Fernandez A, 238 “FY 2020 Appropriations for Federal 245 Food and Drug Administration. “FDA et al. Efficacy of FLU-v, a broad-spectrum HIV/AIDS Programs.” In The AIDS In- Launches New Era of Smarter Food influenza vaccine, in a randomized phase stitute, November 4, 2019. https://www. Safety Initiative, Releases Blueprint and IIb human influenza challenge study. npj theaidsinstitute.org/sites/default/files/ Pilot Study.” Press release: July 13, 2020. Vaccines, 5(22), March 13, 2020. https:// attachments/FY2020%20ABAC%20 https://www.fda.gov/news-events/ doi.org/10.1038/s41541-020-0174-9 (ac- Chart%2011.04.19%20(1).pdf (accessed press-announcements/fda-launches-new- cessed January 25, 2021). January 25, 2021). era-smarter-food-safety-initiative-releas- es-blueprint-and-pilot-study (accessed 254 Bliss J. “Inside the Storm.” Nashville 239 “Budget.” In HIV.gov, May 12, 2020. January 25, 2021). Tennessean, April 4, 2020. https:// https://www.hiv.gov/federal-response/ www.tennessean.com/in-depth/news/ funding/budget (accessed January 25, 246 “New Era Of Smarter Food Safety: FDA’s local/2020/04/03/tennessee-torna- 2021). Blueprint for the Future.” In Food and does-weather-science/5025110002/ (ac- Drug Administration, July 2020. https:// cessed January 25, 2021). www.fda.gov/media/139868/download (accessed January 25, 2021).

76 TFAH • tfah.org 255 Cappucci M. “Last Month Was the 263 “2020 Atlantic Hurricane Season Fast 272 “Declared Disasters 2020.” In FEMA. Second-Most Active April For Torna- Facts.” In CNN, November 23, 2020. https://www.fema.gov/disasters/ does.” The Washington Post, May 5, 2020. https://www.cnn.com/2020/05/11/ disaster-declarations?field_dv2_state_ https://www.washingtonpost.com/ us/2020-atlantic-hurricane-sea- territory_tribal_value=All&field_year_val- weather/2020/05/05/april-2020-was-sec- son-fast-facts/index.html (accessed Janu- ue=2020&field_dv2_declaration_type_ ond-most-active-such-month-tornadoes/ ary 25, 2021). value=DR&field_dv2_incident_type_tar- (accessed January 25, 2021). get_id_selective=49121 (accessed January 264 “2020 Atlantic Hurricane Season.” In 25, 2021). 256 Beddoes M. “Ranking the Easter 2020 Center for Disaster Philanthropy, December Tornado Outbreak Versus the Worst 1, 2020. https://disasterphilanthropy. 273 Miller S. “‘This Season Is Off the Charts’: Outbreaks in History.” WHSV, April 22, org/disaster/2020-atlantic-hurricane-sea- Colorado Fights the Worst Wildfires in 2020. https://www.whsv.com/content/ son/ (accessed January 25, 2021). its Recent History.” The Guardian, Octo- news/Ranking-the-Easter-2020-out- ber 30, 2020. https://www.theguardian. 265 “2020 Atlantic Hurricane Season Fast break-versus-the-worst-outbreaks-in- com/us-news/2020/oct/30/colora- Facts.” In CNN, November 23, 2020. history-569861941.html%20target= do-fires-cameron-peak-east-troublesome https://www.cnn.com/2020/05/11/ (accessed January 25, 2021). (accessed January 25, 2021). us/2020-atlantic-hurricane-sea- 257 Newberger E. “Heatwaves Are Becoming son-fast-facts/index.html (accessed Janu- 274 “Top 20 Largest California Wildfires.” More Deadly As Nights Warm Faster ary 25, 2021). In Cal Fire, November 3, 2020. https:// Than Days.” CNBC, September 12, 2020. www.fire.ca.gov/media/4jandlhh/top20_ 266 “2020 Atlantic Hurricane Season.” In https://www.cnbc.com/2020/09/12/ acres.pdf (accessed January 25, 2021). Center for Disaster Philanthropy, December climate-change-why-heatwaves-are-more- 1, 2020. https://disasterphilanthropy. 275 “Stats and Events.” In Cal Fire. https:// deadly-as-nights-warm-faster.html (ac- org/disaster/2020-atlantic-hurricane-sea- www.fire.ca.gov/stats-events/ (accessed cessed January 25, 2021). son/ (accessed January 25, 2021). January 25, 2021). 258 Rice D. “If You Thought July Was Hot, 267 “2020 Atlantic Hurricane Season Fast Facts.” 276 Bay Area News. “Map: 33 People You Were Right: It Was One of Earth’s In CNN, November 23, 2020. https://www. Killed in California Wildfires, 2020 Hottest Months Ever Recorded.” cnn.com/2020/05/11/us/2020-atlan- Season.” The Mercury News, November USA Today, August 13, 2020. https:// tic-hurricane-season-fast-facts/index.html 18, 2020. https://www.mercurynews. www.usatoday.com/story/news/ (accessed January 25, 2021). com/2020/10/02/map-31-people-killed- nation/2020/08/13/july-2020-re- in-california-wildfires-2020-season/ (ac- cord-heat-one-hottest-months-ever-re- 268 “2020 Atlantic Hurricane Season.” In cessed January 25, 2021). corded/3366762001/ (accessed January Center for Disaster Philanthropy, December 25, 2021). 1, 2020. https://disasterphilanthropy. 277 Borunda A. “Climate Change Is Con- org/disaster/2020-atlantic-hurricane-sea- tributing to California’s Fires.” Na- 259 Di Liberto T. “September 2020: An- son/ (accessed January 25, 2021). tional Geographic, October 25, 2019. other Record-Setting Month for Global https://www.nationalgeographic.com/ Heat.” Climate.gov, October 16, 2020. 269 “2020 Atlantic Hurricane Season Fast science/2019/10/climate-change-cal- https://www.climate.gov/news-features/ Facts.” In CNN, November 23, 2020. ifornia-power-outage/?utm_ features/september-2020-another-re- https://www.cnn.com/2020/05/11/ source=All+Members+List_New+web- cord-setting-month-global-heat (accessed us/2020-atlantic-hurricane-sea- site&utm_campaign=c8855162b1-Cli- January 25, 2021). son-fast-facts/index.html (accessed Janu- mateChange_2018_1-9_COPY_01&utm_ ary 25, 2021). 260 Patel K. “California Heatwave Fits a medium=email&utm_term=0_5ae- Trend.” Earth Observatory, September 6, 270 “Over 400,000 Need Urgent Aid in c46f054-c8855162b1-206919617&mc_ 2020. https://earthobservatory.nasa. Central America: Rights Group.” In cid=c8 (accessed January 25, 2021). gov/images/147256/california-heat- Al Jazeera, December 9, 2020. https:// 278 DiGiovanna S. “Spring Rain and -fits-a-trend (accessed January 25, www.aljazeera.com/news/2020/12/9/ Add Up to Heavy Vegetation Growth 2021). refugee-group-over-400000-in-need-of- and a Potentially Explosive Fire Sea- aid-in-central-america (accessed January 261 Penney V. “2020 Had the Warmest Sep- son.” NBC Los Angeles, May 5, 2020. 25, 2021). tember on Record, Data Shows.” The New https://www.nbclosangeles.com/news/ York Times, October 7, 2020. https:// 271 Schwartz MS. “Iowa Derecho this Au- california-wildfires/california-wild- www.nytimes.com/2020/10/07/climate/ gust Was Most Costly Thunderstorm fires-rain-vegetation-spring-fire-sea- hottest-september.html (accessed Janu- Event in Modern U.S. History.” NPR, son-prepare/2350979/ (accessed ary 25, 2021). October 18, 2020. https://www.npr. January 25, 2021). org/2020/10/18/925154035/iowa- 262 Allen G. “Too Many Storms, Not 279 Rand J. “La Nina Forms in the Pa- derecho-this-august-was-most-costly- Enough Names.” Morning Edition, NPR, cific—Here’s What That Means For thunderstorm-event-in-modern-u-s-histor November 30, 2020. https://www.npr. California’s Rain and Fire Seasons.” (accessed January 25, 2021). org/2020/11/30/937986687/too-ma- ABC7, September 12, 2020. https:// ny-storms-not-enough-names (accessed abc7.com/la-nina-california-wild- January 25, 2021). fires--what-is/6419469/ (ac- cessed January 25, 2021).

TFAH • tfah.org 77 280 Urness Z. “Oregon’s 2020 Wildfire Season 288 “Public Health Emergency Declarations.” 295 “Outbreak of Lung Injury Associated Brought a New Level of Destruction. It In Public Health Emergency, updated Jan- with the Use of E-Cigarette, or Vaping, Could Be Just the Beginning.” Salem States- uary 12, 2021. https://www.phe.gov/ Products.” In Centers for Disease Control man Journal, October 30, 2020. https:// emergency/news/healthactions/phe/ and Prevention, updated February 25, www.statesmanjournal.com/story/ Pages/default.aspx (accessed January 25, 2020. https://www.cdc.gov/tobacco/ news/2020/10/30/climate-change-or- 2021). basic_information/e-cigarettes/se- egon-wildfires-2020/6056170002/ (ac- vere-lung-disease.html#latest-outbreak-in- 289 U.S. Department of Health and Human cessed January 25, 2021). formation (accessed January 25, 2021). Services. “HHS Secretary Azar Declares 281 Worthington D. “Video Shows Damage Public Health Emergencies in Louisiana 296 “Gun Violence Archive.” In Gun Violence at Rocky Mountain National Park After and Texas due to Hurricane Laura.” Archive. https://www.gunviolencearchive. Wildfires Burned 30,000 Acres.”The Press release: August 26, 2020. https:// org (accessed January 25, 2021). Denver Post, November 16, 2020. https:// www.hhs.gov/about/news/2020/08/26/ 297 Ibid. theknow.denverpost.com/2020/11/16/ hhs-secretary-azar-declares-public-health- rocky-mountain-national-park-dam- emergencies-in-louisiana-and-texas- 298 Santilli A, O’Connor Duffany K, Car- age-east-troublesome-cameron-peak-wild- due-to-hurricane-laura.html (accessed roll-Scott A, et al. “Bridging the Re- fires/248942/ (accessed January 25, January 25, 2021). sponse to Mass Shootings and Urban 2021). Violence: Exposure to Violence in New 290 U.S. Department of Health and Human Haven, Connecticut.” American Journal 282 Worthington D. “Rocky Mountain Na- Services. “HHS Awards $79 Million to of Public Health, 107(3): 374-379, March tional Park Loses Several Historic Struc- Support Health Center Response to 2017. https://www.ncbi.nlm.nih.gov/ tures in East Troublesome Fire.” The Emergencies.” Press release: September pmc/articles/PMC5296698/ (accessed Denver Post, November 6, 2020. https:// 8, 2020. https://www.hhs.gov/about/ January 25, 2021). theknow.denverpost.com/2020/11/06/ news/2020/09/08/hhs-awards-79-million- rocky-mountain-national-park-east-trou- to-support-health-center-response-to-emer- 299 Jeong Y and Hineman B. “Downtown blesome-fire-damage/248479/ (accessed gencies.html (accessed January 25, 2021). Nashville Explosion an Intentional Act, January 25, 2021). Police Say.” Tennessean, December 25, 291 Dos Passos Coggin D. “In the Eastern 2020. https://www.tennessean.com/story/ 283 “National Preparedness Level.” In Na- U.S., Tropical Storms that Were Once news/local/2020/12/25/downtown-nash- tional Interagency Fire Center, December Major Hurricanes Pose Greatest Threat of ville-explosion-christmas/4044635001/ 4, 2020. https://www.nifc.gov/fireInfo/ Extreme Rain.” Climate.gov, June 29, 2020. (accessed January 25, 2021). nfn.htm (accessed January 25, 2021). https://www.climate.gov/news-features/ featured-images/eastern-us-tropical- 300 Jones SG, Doxsee C, and Harrington 284 Liedtke M. “Q&A: Why California is storms-were-once-major-hurricanes-pose- N. “The War Comes Home: The Evo- facing power outages, rolling blackouts greatest (accessed January 25, 2021). lution of Domestic Terrorism in the again.” Desert Sun, August 19, 2020. United States.” CSIS Briefs, October 22, https://www.desertsun.com/story/news/ 292 Federal Emergency Management 2020. https://www.csis.org/analysis/ environment/wildfires/2020/08/19/ Agency. “FEMA Releases National Risk war-comes-home-evolution-domestic-ter- california-power-outages-roll- Index: New Online Data Shows Natural rorism-united-states (accessed January ing-blackouts-why-they-happen- Hazards Risks for Communities.” Press 25, 2021). ing-again/5612003002/ (accessed release: November 16, 2020. https:// January 25, 2021). www.fema.gov/press-release/20201116/ 301 Galford C. “DHS Transferring Own- fema-releases-national-risk-index-new-on- ership of National Bio and Agro-De- 285 Ibid. line-data-shows-natural-hazards (accessed fense Facility to USDA for Research, 286 Wetsman N. “California’s Black- January 25, 2021). Vaccine Development.” Homeland outs Reveal Health Care’s Preparedness News, September 9, 2020. 293 “Climate Reports.” In United Nations. Fragile Power System.” The Verge, Oc- https://homelandprepnews.com/ https://www.un.org/en/climatechange/ tober 28, 2019. https://www.theverge. stories/55275-dhs-transferring-owner- reports (accessed January 25, 2021). com/2019/10/28/20932780/califor- ship-of-national-bio-and-agro-defense-fa- nia-blackout-healthcare-electricity-fires 294 McKillop M, Links JM, Latshaw MW, et cility-to-usda-for-research-vaccine-devel- (accessed January 25, 2021). al. Climate Change & Health: Assessing opment/ (accessed January 25, 2021). State Preparedness. Washington: Trust 287 U.S. Department of Health and Human 302 Galford C. “DARPA Deploys Automated for America’s Health, December 2020. Services. “HHS Secretary Azar Declares Radiation Detection System to Port https://climateandhealthreport.org/ Public Health Emergency for Puerto Authority of New York and New Jersey.” assets/pdfs/JHU-004_Climate_Change_ Rico Following Earthquakes.” Press re- Homeland Preparedness News, September 9, and_Health_Report_FINAL_112520.pdf lease: January 8, 2020. https://www.hhs. 2020. https://homelandprepnews.com/ (accessed January 25, 2021). gov/about/news/2020/01/08/hhs-secre- stories/55268-darpa-deploys-automat- tary-azar-declares-public-health-emergen- ed-radiation-detection-system-to-port-au- cy-for-puerto-rico-following-earthquakes. thority-of-new-york-and-new-jersey/ html (accessed January 25, 2021). (accessed January 25, 2021).

78 TFAH • tfah.org 303 Clark D. “DHS Initiates NG911 Systems 308 Government Accountability Office. 314 Office of Senator Lamar Alexander. “Sen- Viability Testing.” Homeland Preparedness “Biomedical Research: HHS Has Not Yet ate Health Committee Chairman Alexan- News, August 6, 2020. https://homeland- Used New Authorities to Improve Re- der Says Congress Should Prepare This prepnews.com/stories/53427-dhs-ini- cruitment and Retention of Scientists.” Year for the Next Pandemic.” Press release: tiates-ng911-systems-viability-testing/ GAO-20-531R, May 8, 2020. https:// June 9, 2020. https://www.alexander.sen- (accessed January 25, 2021). www.gao.gov/products/GAO-20-531R ate.gov/public/index.cfm/pressreleas- (accessed January 25, 2021). es?ID=74C40CDB-CE78-4CC2-9A93-72DD 304 U.S. Department of Health and Human 16F659CD (accessed January 25, 2021). Services. Strategic Plan for 2020-2023. 309 Trust for America’s Health. A Blueprint Washington: Office of the Assistant Sec- for the 2021 Administration and Congress: 315 U.S. Senate Committee on Health, Ed- retary for Preparedness and Response, The Promise of Good Health for All – Trans- ucation, Labor and Pensions. “Senate 2020. https://medicalcountermeasures. forming Public Health in America. Washing- Health Chairman Alexander Introduces gov/media/37185/2020-aspr-strate- ton: Trust for America’s Health, October Bill to Prepare for the Next Pandemic.” gic-plan.pdf (accessed January 25, 2021). 6, 2020. https://www.tfah.org/report-de- Press release: July 20, 2020. https://www. tails/blueprint2021/ (accessed January help.senate.gov/chair/newsroom/press/ 305 King A. “Embattled Public Health 25, 2021). senate-health-chairman-alexander-intro- Workers Leaving At ‘Steady And Alarm- duces-bill-to-prepare-for-the-next-pan- ing’ Rate.” All Things Considered, NPR, 310 Center for Disease Control and Preven- demic (accessed January 25, 2021). November 25, 2020. https://www.npr. tion Healthcare-related Infections. Clostrid- org/2020/11/25/938873547/embattled- ioides difficile Infection. Clostridioides 316 Hess B. “Recap: 2020 Preparedness public-health-workers-leaving-at-steady- difficile Infection | HAI | CDC November Summit.” National Association of County and-alarming-rate (accessed January 25, 13, 2019. (Accessed February 3, 2021). and City Health Officials, August 28, 2020. 2021). https://www.naccho.org/blog/articles/ 311 Public Health Emergency “Two Novel recap-2020-preparedness-summit (ac- 306 Association of State and Territorial Investigational Drugs Targeting Anti- cessed January 25, 2021). Health Officials, “New Data on State biotic-Resistant Infections Move into Health Agencies Shows Shrinking Advanced Development with HHS.” Press 317 U.S. Senate Committee on Health, Educa- Workforce and Decreased Funding release, September 30, 2020. https://www. tion, Labor and Pensions. “Health Equity: Leading up to the COVID-19 Pan- phe.gov/Preparedness/news/Pages/ Amid COVID-19 Pandemic, New Report demic.” Press release: September 24, carbX-grads-30sept2020.aspx (accessed From Senator Murray Outlines Roots of 2020. https://astho.org/Press-Room/ January 25, 2021). Systemic Racism and Inequality in U.S. New-Data-on-State-Health-Agencies- Health Care, Lays Out Recommendations 312 Srisuknimit V. “Fighting Fire with Fire: Kill- Shows-Shrinking-Workforce-and- For Congressional Action.” Press release: ing Bacteria with Virus.” Science in the News, Decreased-Funding-Leading-up-to- September 30, 2020. https://www.help. Harvard University, February 1, 2018. the-COVID-19-Pandemic/09-24-20/ senate.gov/ranking/newsroom/press/ http://sitn.hms.harvard.edu/flash/2018/ (accessed January 25, 2021). health-equity-amid-covid-19-pandemic- bacteriophage-solution-antibiotics-prob- new-report-from-senator-murray-outlines- 307 National Association of County and lem/ (accessed January 25, 2021). roots-of-systemic-racism-and-inequality- City Health Officials “NACCHO’s 2019 313 Center for Disease Research and Pol- in-us-health-care-lays-out-recommenda- Profile Study: Changes in Local Health icy. “FDA approves cefiderocol for tions-for-congressional-action (accessed Department Workforce and Finance Ca- hospital-acquired, ventilator-associated January 25, 2021). pacity Since 2008.” Research brief, May pneumonia.” News Scan, University of 2020. https://www.naccho.org/uploads/ 318 Trust for America’s Health. Ready or Not: Minnesota, September 28, 2020. https:// downloadable-resources/2019-Pro- Protecting the Public’s Health from Diseases, www.cidrap.umn.edu/news-perspec- file-Workforce-and-Finance-Capacity.pdf Disasters and Bioterrorism, 2019. Washing- tive/2020/09/news-scan-sep-28-2020 (accessed January 25, 2021). ton: Trust for America’s Health, 2019. (accessed January 25, 2021). https://www.tfah.org/report-details/ ready-or-not-protecting-the-publics-health- from-diseases-disasters-and-bioterror- ism-2019/ (accessed January 28, 2021).

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