Protecting Americans from Infectious Diseases2015

ISSUE REPORT Embargoed until 10:00 am ET on December 17 Outbreaks: PROTECTING AMERICANS FROM INFECTIOUS DISEASES2015

ealthcare workers in West Africa report that some personnel are able to wear Htheir PPE for only 40 minutes at a time because of high temperatures and humid conditions. Even in the United States, where management of patients with Ebola is done in air-conditioned environments, uncomfortable PPE is a common complaint and causes a burden for healthcare workers. In September 2014, President Obama announced a “Grand Challenge” to design improved PPE for use by healthcare workers during treatment of Ebola patients. CDC’s National Institute for Occupational Safety and Health (NIOSH) is partnering with other U.S. agencies on the “Fighting Ebola: A Grand Challenge for Development” to help healthcare workers on the front lines provide better care and stop the spread of Ebola. The USAID-led Grand Challenge includes developing, testing, and improving PPE to address issues of protection, heat stress, and comfort for healthcare workers. NIOSH conducts research that supports the epidemic response and the Grand Challenge and is working closely with federal partners on the Grand Challenge, including (but not limited to) participating in crowdsourcing events to promote innovation, reviewing promising ideas that can be scaled to the field, and setting performance, test, and evaluation requirements.

A NIOSH sweating thermal manikin with the PPE ensemble commonly used by Doctors Without Borders (MSF) for high 44 exposure areas. CDC artist’s rendering of the Ebola virus. There are five identified Ebola virus species, four of which are known to cause disease in humans. 10 DECEMBER 2015 Acknowledgements Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.

For more than 40 years, the Robert Wood Johnson Foundation has worked to improve the health and health care of all Americans. We are striving to build a national Culture of Health that will enable all Americans to live longer, healthier lives now and for generations to come. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook.

TFAH would like to thank RWJF for their generous support of this report.

TFAH BOARD OF DIRECTORS REPORT AUTHORS

Gail C. Christopher, DN Jeffrey Levi, PhD Dara Alpert Lieberman, MPP President of the Board, TFAH Executive Director Senior Government Relations Manager Vice President for Policy and Senior Advisor Trust for America’s Health Trust for America’s Health WK Kellogg Foundation and Professor of Health Policy Kendra May, MPH Milken Institute School of Public Health at the Cynthia M. Harris, PhD, DABT Consultant George Washington University Vice President of the Board, TFAH Rebecca St. Laurent, JD Director and Professor Laura M. Segal, MA Consultant Institute of Public Health, Florida A&M University Director of Public Affairs Trust for America’s Health Theodore Spencer Secretary of the Board, TFAH Senior Advocate, Climate Center Natural Resources Defense Council PEER REVIEWERS Robert T. Harris, MD TFAH thanks the following individuals and organizations for their time, expertise and in- Treasurer of the Board, TFAH Medical Director sights in reviewing all or portions of the report. The opinions expressed in the report do not North Carolina Medicaid Support Services CSC, Inc. necessarily represent the views of these individuals or their organizations.

David Fleming, MD Chris Aldridge, MSW Dan Hanfling, MD Vice President Senior Advisor Public Health Programs Contributing Scholar PATH National Association of County and City Health UPMC Center for Health Security Officials Arthur Garson, Jr., MD, MPH Ruth Lynfield, MD Director, Health Policy Institute John Billington State Epidemiologist Texas Medical Center Director of Healthy Policy Minnesota Department of Health Infectious Diseases Society of America Committee on Infectious Disease John Gates, JD American Academy of Pediatrics Founder, Operator and Manager James S. Blumenstock Nashoba Brook Bakery Chief Program Officer for Public Health Practice Irwin Redlener, MD Association of State and Territorial Health Officials President/Director Octavio N. Martinez, Jr., MD, MPH, MBA, FAPA Children’s Health Fund H. Dele Davies, MD, FAAP Executive Director National Center for Disaster Preparedness Hogg Foundation for Mental Health at the Vice Chancellor for Academic Affairs and Dean University of Texas at Austin for Graduate Studies Litjen (L.J) Tan, MS, PhD University of Nebraska Medical Center Chief Strategy Officer C. Kent McGuire, PhD Committee on Infectious Disease Immunization Action Coalition President and CEO American Academy of Pediatrics Southern Education Foundation Donna Hope Wegener Jonathan Fielding, MD, MPH Executive Director Eduardo Sanchez, MD, MPH Professor-in-Residence National TB Controllers Association Chief Medical Officer for Prevention UCLA Fielding School of Public Health American Heart Association Cover photos courtesy of CDC Margaret C. Fisher, MD, FAAP Medical Director The Unterberg Children’s Hospital, Monmouth Medical Center Past Member, Committee on Infectious Disease American Academy of Pediatrics

2 TFAH • RWJF Table of Contents INTRODUCTION ...... 4 Ebola lessons learned and preparing for MERS-CoV and other emerging infections . . . . .6

SECTION 1: State by State Indicators ...... 11 State Indicator Chart ...... 12 States: Indicators Map ...... 14 States: Indicators Score Overview ...... 14 Indicator 1: Public Health Funding Commitment – State Public Health Budgets ...... 16 Indicator 2: Flu Vaccination Rates ...... 17 Indicator 3: Childhood Immunization School Requirement Policies ...... 20 State school vaccination exemptions laws, preschooler immunization gaps, measles and pertussis (whooping cough) outbreaks Indicator 4: HIV/AIDS Surveillance ...... 27 HIV screening and Medicaid coverage Indicator 5: Syringe Exchange Programs ...... 29 Indicator 6: Climate Change and Infectious Disease ...... 32 Indicator 7: Reductions in Central Line-associated Bloodstream Infections ...... 35 Indicators 8 and 9: Public Health Laboratories ...... 38 Laboratory safety lapses, meaningful use Indicator 10: Food Safety ...... 42

SECTION 2: National Issues and Recommendations ...... 44 A. Increasing Resources to Maintain and Modernize Public Health Capabilities and Have Consistent and Science-Based Policies Across the Country ...... 45 Key federal infections disease program funding, key infectious disease and emergency response responsibilities, some key CDC infectious disease programs, a national blueprint for biodefense: leadership and major reform needed to optimize efforts, recommendations: Public health – leadership, foundational capabilities and funding B. Modernizing Disease Surveillance: For Detecting, Tracking and Containing Disease Trends . . 55 Recommendations: modernizing disease surveillance C. Incentivize and Support Medical Countermeasure Research, Development and Distribution . . 57 New screening tests, recommendations: improving research, development and distribution of medical countermeasures D. Address Climate Change Impact on Infectious Disease Outbreaks ...... 60 Recommendations: preventing and preparing for the adverse impact of climate change on infectious disease, One Health E. Build Community Resilience ...... 62 Recommendations: improving community resilience, guaranteed paid sick leave F. Health System Preparedness and Enhancing Surge Capacity and Infection Control . . . . . 66 Recommendations: enhancing health system preparedness for infectious diseases and surge capacity, recommendations: reducing healthcare-associated infections across the healthcare spectrum G. Improve Vaccination Rates – for Children and Adults ...... 72 Recommendations: increasing vaccination rates, vaccine preventable diseases H. Curbing Antimicrobial Resistance and Superbugs ...... 76 Antibiotic resistant threats in the United States, 2013 – CDC’s report and prioritization of threats, recommendations: reducing antibiotic and antimicrobial resistance I. Reducing Sexually Transmitted Infections and TB ...... 81 Sexually transmitted infections, recommendations: strengthening STI prevention and control, HIV/ AIDS, recommendations: HIV/AIDS prevention and control, addressing the social determinants of health inequities among gay men and other men who have sex with men in the United States, gay and lesbian teens at increased risk for injections drug use, hepatitis B and C, recommendations: viral hepatitis prevention and control, tuberculosis, TB and diabetes, recommendations: toward eliminating TB in America J. Fix Food Safety ...... 93 Recommendations: improving and aligning food safety systems APPENDIX A: Examples of Key Emerging Disease and Infections and Emergency Threats . . .95 APPENDIX B: Federal, State and Local Public Health Responsibilities ...... 98 APPENDIX C: State Public Health Budget Methodology ...... 100 ENDNOTES ...... 101 TFAH • RWJF 3 INTRODUCTION INTRODUCTION Infectious Outbreaks: Protecting Americans Diseases from Infectious Diseases 2015 Policy Report Infectious diseases — most of which are preventable — disrupt series the lives of millions of Americans each year. But the country does not sufficiently invest in basic protections that could help avoid significant numbers of outbreaks and save billions of dollars in unnecessary healthcare costs.

U.S. investments in infectious disease l Superbugs: More than two million prevention ebb and flow, where there is Americans contract antibiotic-resistant a major ramp up when a new eminent infections each year, leading to more threat emerges, but then falls back when than 23,000 deaths and $20 billion in the problem seems contained. direct medical costs and more than $35 billion in lost productivity;1 In the most recent example last year, the Ebola outbreak resulted in ephemeral l Middle East Respiratory Syndrome attention and emergency supplemental Coronavirus: While there have only funding to backfill gaps in the nation’s been two MERS-CoV cases in the ability to respond. But, lags in even United States as of fall of 2015 and emergency funding processes meant this were of individuals traveling much of the support came too late to from other locations, the novel address immediate needs in states and coronavirus that causes a severe viral in Africa. And the funding was not at respiratory disease has infected more a sufficient level to shore up ongoing than 1,600 individuals, spreading gaps, leaving the United States still from the Middle East to South Korea vulnerable for when the next emerging through international travel, causing a threat arises. significant outbreak. MERS is fatal in more than 30 percent of cases;2 Fighting infectious disease requires constant vigilance. Policies and l Foodborne Illness: More than 48 resources must be in place to allow million Americans get sick, 128,000 scientists and public health and medical are hospitalized and 3,000 die from experts to have the tools they need to: contaminated food annually; control ongoing outbreaks — such as l HIV/AIDS and Viral Hepatitis: More HIV/AIDS, antibiotic-resistant superbugs than 1.2 million Americans are living and foodborne illnesses; detect new or with HIV, and almost one in eight do reemerging outbreaks — such as Middle DECEMBER 2015 not know they are infected.3 There East Respiratory Syndrome Coronavirus has been a significant increase in new (MERS-CoV), measles and avian flu; and infections among young gay men – monitor for potential bioterrorist threats accounting for the majority of almost — such as anthrax or smallpox. 50,000 new HIV infections in 2010.4 There needs to be a fundamental Approximately 5 million Americans rethinking of the policies and priorities are infected with the hepatitis B virus that contribute to a range of outbreaks, (HBV) or hepatitis C virus (HCV), including: but two out of three people infected with HBV and 50 percent infected with HCV do not know it.5 HBV and HCV put people at risk for developing serious liver diseases and cancer.6 A recent sharp rise — more than doubling — of heroin addiction in less than a decade is contributing to a corresponding increase in HIV and hepatitis C infections.7 An estimated 29,718 new HCV infections occurred in 2013. New cases of HCV infection are predominantly among young persons who are white, live in non-urban areas (particularly in Eastern and Midwestern states), have a history of injection drug The best offense to fighting infectious and control infectious diseases and use, and previously used opioid agonists diseases is a strong and steady defense. offers recommendations for addressing such as oxycodone.8 Each person who The country needs to establish a clear, these gaps. injects drugs is projected to then infect consistent set of baseline capabilities and 20 more individuals.9 New cases of The Outbreaks report provides the provide ongoing resources to be consis- HCV are also resulting from healthcare- public, policymakers and a broad and tently ready to combat ongoing problems associated infections (HAI) — 44 diverse set of groups involved in public as well as the next emerging threat. outbreaks (of two or more cases) of health and the healthcare system with viral hepatitis related to healthcare were The Trust for America’s Health (TFAH) an objective, nonpartisan, independent reported to CDC between 2008 and and the Robert Wood Johnson Foundation analysis of the status of infectious 2014, with 95 percent (42) of those cases (RWJF) issue the Outbreaks: Protecting disease policies; encourages greater in non-hospital healthcare settings.10 Americans from Infectious Diseases report to transparency and accountability of the examine the country’s policies to respond system; and recommends ways to assure l Healthcare-associated Infections: to ongoing and emerging infectious the public health and healthcare systems Around one out of every 25 people disease threats. meet today’s needs and works across who are hospitalized each year borders to accomplish their goals. contracts a healthcare-associated To help assess policies and the capacity infection leading to around 75,000 to protect against infectious disease Protecting the country from infectious deaths a year.11 outbreaks, this report examines a range disease threats, whether bacterial, viral of infectious disease concerns. The or parasitic, is a fundamental role of l Influenza (The Flu): Between 5 percent report highlights a series of 10 indicators government, and all Americans have and 20 percent of Americans get the flu in each state that, taken collectively, offer the right to basic protections no matter each year. The severity and impact of a composite snapshot of strengths and where they live. While government is the flu can range from 3,000 to 49,000 vulnerabilities across the health system. only one partner in the fight against deaths a year, more than $10 billion in The indicators are not a comprehensive infectious diseases — along with the direct medical expenses and more than assessment or analysis but represent areas healthcare sector; pharmaceutical, $16 billion in lost earnings.12, 13 of priority infectious disease and health medical supply and technology l Global Public Health Capacity: security interests. These indicators help companies; community groups, schools Countries without an adequate public illustrate the types of policy fundamentals and employers; and families and health system that can prevent, detect that are important to have in place not individuals — government at all levels and respond to infectious disease just to prevent the spread of disease in has the ability to set policies and establish threats are more prone to outbreaks the first place but also to detect, diagnose practices based on the best science that can spread across borders and respond to outbreaks. In addition, available to better protect Americans (including to the United States) with the report examines key areas of from infectious disease threats. significant economic and health effects. concern in the nation’s ability to prevent TFAH • RWJF 5 Ebola Lessons Learned The Ebola outbreak raised domestic and international concerns and Preparing for about the need to better prepare for potential major new MERS-CoV and Other disease outbreaks. Ebola is a deadly viral hemorrhagic fever with Emerging Infections symptoms that include severe headache, muscle pain, vomiting, diarrhea and unexplained bleeding or bruising and can be transmitted through bodily fluids. There is currently no approved cure or vaccine and survival often depends on supportive care and the patient’s immune response. The current outbreak emerged in 2013 in West Africa and was largely contained by mid-2015. From 2013 through October 2015, there have been 28,635 total cases, including 11,313 deaths from Ebola in several West African nations. There were four cases diagnosed and another seven airlifted and treated in the United States with two fatalities.14

CDC’s Response to Ebola: March 2014 –July 2015 Traveler with Ebola comes to CDC organizes healthcare worker safety course US (Dallas), 2 nurses infected in Anniston, Alabama for West Africa volunteers

Spread to Nigeria and Senegal, CDC expands Ebola Rapid Isolation and Treatment of Ebola (RITE) CDC deploys 1000th CDC teams help stop the outbreak testing among US labs teams help rapidly control new outbreaks in Liberia staff member

Spread to Liberia Spread to Mali, CDC teams Liberia outbreak and Sierra Leone help stop the outbreak declared over

600

500

400 300 200

100

0 01 01 Pre-EOC Activation 1st Quarter EOC 2nd Quarter EOC 3rd Quarter EOC 4th Quarter EOC

Early reports of Ebola CDC Emergency New cases virus disease from Operations Center reported Guinea, CDC field activated, CDC CDC laboratory in Liberia Dr. Frieden CDC implements enhanced CDC works team deployed deployments surge established in Sierra Leone travels to Microplanning screening at airports, new with states Guinea, workshops with tracking program for people to improve CDC recommends CDC issues Level 3 Liberia, and county leaders coming from countries hospital reduced screening for * Approximate numbers Travel Warnings for West Africa Sierra Leone held in Liberia with Ebola outbreaks readiness passengers from Liberia

Source: CDC

6 TFAH • RWJF The outbreak demonstrated how Ebola by the Numbers quickly a new threat can arise 27,000+ 4 — and how complacency and Total number Patients diagnosed with of cases Ebola in the U.S. lapses in sustained support and 11,000+ 11 funding for preparedness can Total number U.S. Patients with Ebola of deaths treated in the U.S. leave countries and communities 24,665 650 unnecessarily vulnerable. Health workers trained U.S. healthcare workers by CDC in West Africa trained in Anniston

“Because there was so little preparation, 2,471 150,000 CDC deployments U.S. healthcare workers the world lost time … trying to answer to West Africa trained by webinars and calls EBOLA basic questions about combating Ebola. In the next epidemic, such delays could 59,665,191 result in global disaster. The problem Number of views for CDC’s Ebola website was not the fault of any single institution Source: CDC 11 — it reflects a global failure,” according to a review by Bill Gates in the New to prevent and contain emerging of what type of domestic clinical England Journal of Medicine.15 outbreaks is important as the first and response is warranted for different most effective line of defense, and types of threats — for instance, not The World Health Organization must feature a funded and maintained to overreact to an international (WHO), U.S. Centers for Disease global warning and response system, outbreak that poses limited threat to Control and Prevention (CDC), the and trained experts (including incident the wide U.S. population and not to Office of the Assistant Secretary for managers, epidemiologists and disease under-prepare for a disease that could Preparedness and Response (ASPR) intervention specialists for contact spread widely and cause severe impact. at the U.S. Department of Health and tracing), diagnostics, medicines and Infection control policies, protocols Human Services (HHS) and many other equipment must be deployed and guidelines should be regularly professional health organizations have rapidly. In 2014, the United States maintained, exercised and updated reviewed lessons learned about ways to joined the Global Health Security across the health system. better prevent and prepare for major Agenda (GHSA) with more than 40 disease outbreaks, finding:16, 17, 18, 19, 20 l All healthcare facilities should countries to work together to better have basic baseline infection l Preparedness requires constant prevent, detect and respond to control policies and protocols in vigilance — including ongoing emerging outbreaks before they become place — and that can be adapted maintenance and funding for core epidemics.21, 22 These GHSA efforts for different types of outbreaks prevention, detection and infection build on the lessons of long-standing and threats. For instance, to be control capabilities among health global health activities including prepared for an outbreak like providers and public health agencies. Global Disease Detection and the Field Ebola, healthcare facilities should Epidemiology Training Program. l Countries around the world must be part of a regionalized, tiered work together to prevent and control l Within the United States, CDC must system where patients can be outbreaks. This must include supporting act quickly to issue and regularly quickly and effectively isolated surveillance and sharing information update guidance and training for and transported to facilities with about potential outbreaks — and pooled the public and health professionals increased infection control and resources and expertise should be used — with clear, science-based treatment capabilities as needed. to mount a quick, strong response information. This should include In response to the Ebola outbreak, and containment activities. Working a scientifically-based risk assessment HHS, state health departments and

TFAH • RWJF 7 Screening by the Numbers*

18,672 203,453 Travelers who entered the Travelers screened when U.S. from Guinea, Liberia, leaving a country with and Sierra Leone widespread transmission 3,797 122,931 Guinea Guinea 9,576 35,685 Liberia Liberia 4,413 44,834 Sierra Leone Sierra Leone 13,304 150 CARE kits distributed Travelers denied boarding in countries with widespread 12,300 transmission CARE phones distributed

*10/11/2014 – 5/30/2015 Source: CDC 35

healthcare providers developed a l Plans must be maintained to regional tiered system where they ensure the recommended personal could safely transport patients— protective equipment (PPE) are after initial intake, containment and available for health professionals treatment—for more advanced care during outbreaks and that guidelines to 55 hospitals designated as Ebola for use are clearly established, treatment centers and/or one of updated and quickly communicated nine specialized bio-containment as an outbreak develops. There must units around the country. In also be processes to ensure ongoing addition, HHS designated three training in the use of PPE to ensure centers, including Emory University, equipment is used proficiently University of Nebraska Medical and that fit testing protocols are Center and Bellevue Hospital as establishes and followed. members of the National Center l All healthcare facilities should for Ebola Training for ongoing have basic procedures for the safe training and certification of other storage and disposal of hazardous institutions for preparedness against waste and contaminants. Ebola and other highly infectious diseases. These preparations should l Quarantine policies based on be maintained for future outbreaks, science should be established for regardless of the pathogen, and different types of scenarios so other plans must also be in place they are not being developed in a for an outbreak that would be reactionary context. widespread, such as a severe l The United States needs to develop pandemic flu. more measured and proportionate l Systems must be in place to strategies for screening risk in monitor citizens and healthcare international travelers and if professionals potentially exposed to and when travel restrictions may an infectious threat. be appropriate — that is more

8 TFAH • RWJF grounded in science versus perception. This is particularly HEALTH ADVISORY: important for ensuring many of the Middle East Respiratory Syndrome (MERS) resources and trained professionals Going to the Arabian Peninsula? are not diverted away from what are A new disease called MERS has been identified in often more effective and needed some countries. containment efforts. The risk to most travelers is low, but you should Symptoms include take these steps to prevent the spread of germs: l Planning must also include how fever, cough, and • Wash your hands often. to maintain ongoing public health shortness of breath. • Avoid touching your face. and healthcare needs and functions If you get sick within • Avoid close contact with sick people. 14 14 days of being in the during an emergency. Health days Arabian Peninsula, call a agencies have limited standing doctor and tell the doctor where you traveled. For more information: capacity and resources — and if all visit www.cdc.gov/travel or call 800-CDC-INFO. resources and personnel are diverted CS248339 to an emerging emergency, it leaves Source: CDC other vulnerabilities and gaps. l Effective risk communications strategies that allow for sharing HEALTH ADVISORY: MERS information with the public in a way Middle East Respiratory Syndrome that conveys accurate information Were you in the during an evolving situation and Middle East recently? avoids unnecessary panic — must • Watch for fever with cough or be better developed and in place. difficulty breathing. Communications should address • If you get sick within 14 days of multiple audiences and be culturally leaving, call a doctor. and linguistically appropriate for different communities. • Tell the doctor you traveled.

U.S. Department of l Health and Human Services Increased investments must be Centers for Disease www.cdc.gov/travel Control and Prevention made toward improving vaccine and treatments — and the ability Source: CDC to quickly and effectively distribute were more than 180 reported cases in and administer medicines--for South Korea, resulting in 36 deaths.24 infectious diseases. The United States had two reported Currently, the Middle East Respiratory cases in 2014 involving healthcare Syndrome Coronavirus is testing workers returning from Saudi Arabia. global capacity for disease prevention Trust for America’s Health, the and control. The disease was first Infectious Diseases Society of reported in Saudi Arabia in 2012. As of America (IDSA) and UPMC Center November 2015, there have been 1,618 for Health Security developed a set total cases and 579 deaths — a death of recommendations for improving rate of more than 30 percent.23 There is system-wide readiness for potential no vaccine or specific antiviral treatment emerging diseases, such as MERS, based for the disease. Most of the cases have on lessons learned from Ebola and been within or related to travel to the previous outbreaks:25 Arabian Peninsula, but in 2015, there

TFAH • RWJF 9 l Build upon Ebola and All-Hazards likely and timely diagnoses. For to reach their providers, including Preparedness in the Health System: instance, knowing which countries in language-appropriate email, text, staff The Ebola response supplemental West Africa had Ebola concerns versus meetings and/or posted signs. funding helped backfill some ongoing other locations that present the more l Modernize Disease Surveillance: A gaps and address immediate concerns likely chance of exposure to malaria or key component of infectious disease in a subset of healthcare facilities, but other concerns. prevention and control is the ability is still insufficient to build adequate l Strengthen Communication to identify new outbreaks and track and sustainable infection control Strategies: In communicating with the ongoing outbreaks. Policymakers capacity throughout the country public and healthcare workers, public should work to support real-time and improve public health systems health should take into account and interoperable disease tracking, and necessary function. Continued uncertainty of an evolving situation ensuring resources that allow and expanded support is needed and partner with trusted community public health agencies and clinical to maintain base-level infection sources in outreach to at-risk healthcare systems to incorporate control as well as the tiered, regional communities. Public health should and use new information streams response system that came out of establish relationships with media such as electronic health records the Ebola response. There needs to ahead of crises and leverage social and electronic laboratory reporting; be funding for ongoing and regular media to ensure accurate information advance new technologies like point- drilling within and between healthcare reaches the public. Communications of-care diagnostics; perform web-based facilities, public health departments strategies must prepare the public reporting to public health; and build and emergency response teams to — as well as policy makers — that enhanced baseline epidemiologic and simulate and refine local preparedness policies may shift as understanding of surveillance capabilities at the state and responses to outbreaks of the threat evolves. And CDC should and local public health level. potentially deadly infectious diseases. build bidirectional communication l Advance Shared Framework for l Routinely Take Complete Travel pathways with state and local public Isolation, Quarantine, Movement and Histories upon Intake and Be health departments on a regular basis, Monitoring Decisions: Movement Prepared to Promptly Isolate Potential not just during the outbreak. and monitoring guidance, and its Cases Needing Evaluation: Travel l Incorporate Health Alerts into appropriate application to at-risk histories should become a routine Practice: Improved systems are persons is essential to containing part of intake of patients in the needed to ensure that health agencies, potential infectious outbreaks. outpatient and inpatient systems, not hospitals and healthcare providers Federal, state and local public health just during times of crisis. Healthcare receive and acknowledge health and policy leaders should come facilities should ensure travel history alerts from CDC and state and local together and agree on a common queries are built into electronic public health agencies. Healthcare decision-making framework ahead health records and post signs in professional societies and unions, of the next outbreak to help states multiple languages that remind hospital administrators, laboratories make movement and monitoring patients to inform providers of travel and others must ensure their decisions that (1) are based upon the history and symptoms. Providers and workforce is informed and well-trained best available scientific and medical healthcare staff must also be trained on appropriate procedures for newly evidence; (2) preserve social and to understand risk patterns — such emerging and ongoing threats. Public economic continuity to the greatest as relevancy of travel history, which health and health systems should extent possible; and (3) are in the best is important to be able to prioritize also consider the most effective way interest of public health.

10 TFAH • RWJF SECTION 1 SETCION 1: STATE-BY-STATE INDICATORS State-by-State Infectious Disease State by State Prevention and Control Indicators Indicators

All Americans deserve to be protected against infectious disease threats, no matter where they live.

CDC has identified strategies and from state-to-state. To help assess fundamental capabilities that should be infectious disease control capabilities, in place to fight infectious diseases in a the Outbreaks report examines a Framework for Preventing Infectious Diseases: series of 10 indicators based on high- Sustaining the Essentials and Innovating priority areas and concerns. It is not a for the Future. Core elements of the comprehensive review; but collectively, it framework include focusing on: provides a snapshot of efforts to prevent and control infectious diseases in states l Strengthening public health and within the healthcare system. fundamentals, including infectious disease surveillance, laboratory detection The indicators were selected after and epidemiologic investigations; consulting with leading public health and healthcare officials. Each state l Identifying and implementing received a score based on these 10 high-impact strategies — such as indicators. States received one point vaccinations, infection control, rapid for achieving an indicator and zero diagnosis of disease and optimal points if they did not. Zero is the lowest treatment practices — to limit the possible score and 10 is the highest. spread of diseases and systems to The scores ranged from a high of eight reduce the diseases transmitted by in Delaware, Kentucky, Maine, New animals or insects to humans; and York and Virginia to a low of 3 in Idaho, l Developing and advancing policies such Kansas, Michigan, Ohio, Oklahoma, as integrating clinical infectious disease Oregon and Utah. preventive practices into U.S. healthcare Scores are not intended to serve as systems; educating and working with a reflection of the performance of a the public to understand how to limit specific state or local health department the spread of diseases; and working with or the healthcare system or hospitals the global health community to quickly within a state, since they reflect a much identify new diseases and reduce rates broader context, including resources, of existing diseases.26 policy environments and the health status Infectious disease control and of a community, so many of the indicators

prevention is a concern in every state. are impacted by factors beyond the direct DECEMBER 2015 However, policies and programs vary control of health officials. STATE INDICATORS (6) (1) (2) (3) (4) (5) (7) (8) (9) (10) Climate Change Public Health Funding: Flu Vaccination Rates: Childhood Immunization School HIV/AIDS Surveillance: Syringe Excahnge Central Line-Associated Public Health Public Health Laboratories: Food Safety: and Infectious State increased or State vaccinated at least half Requirement Policies: State requires reporting of all Programs: Bloodstream Infections: Laboratories: State laboratories provided biosafety State met the national Disease: Total maintained funding for of their population (ages 6 State law either excludes philosophical (detectable and undetectable) CD4 State explicitly State reduced the standardized State laboratories reported training and/or information about performance target of testing State currently has Score public health from months and older) for the exemptions entirely or requires a parental (a type of white blood cell) and HIV authorizes syringe infection ratio (SIR) for central having a biosafety courses for sentinel clinical labs in 90 percent of reported climate change FY 2013 to 2014 and seasonal flu from Fall 2014 notarization or affidavit to achieve a religious or viral load data to their state HIV exchange programs line-associated blood stream professional from July 1, their jurisdiction from July 1, 2014 Escherichia coli (E. coli) O157 adaptation plans FY 2014 to 2015. to Spring 2015. philosophical exemption for school attendance. surveillance program (as of July 2013). (SEP). infections between 2012 to 2013. 2014 to June 30, 2015. to June 30, 2015. cases within four days. completed. Alabama 3 Alabama 3 3 3 4 Alaska 3 3 3 Alaska 3 3 3 3 7 Arizona 3 3 Arizona 3 3 3 5 Arkansas 3 3 3 3 Arkansas 3 3 6 California 3 3 3 California 3 3 3 3 7 Colorado 3 3 3 Colorado 3 3 5 Connecticut 3 3 Connecticut 3 3 3 5 Delaware 3 3 3 3 3 Delaware 3 3 3 8 D.C. 3 3 3 D.C. 3 4 Florida 3 3 Florida 3 3 4 Georgia 3 3 3 Georgia 3 3 5 Hawaii 3 3 3 3 Hawaii 3 5 Idaho 3 Idaho 3 3 3 Illinois 3 3 Illinois 3 3 3 3 6 Indiana 3 Indiana 3 3 3 4 Iowa 3 3 3 3 Iowa 3 3 6 Kansas Kansas 3 3 3 3 Kentucky 3 3 3 3 Kentucky 3 3 3 3 8 Louisiana 3 3 Louisiana 3 3 4 Maine 3 3 3 Maine 3 3 3 3 3 8 Maryland 3 3 3 3 Maryland 3 3 3 7 Massachusetts 3 3 3 Massachusetts 3 3 3 3 7 Michigan 3 3 Michigan 3 3 Minnesota 3 3 3 3 Minnesota 3 3 3 7 Mississippi 3 3 Mississippi 3 3 3 5 Missouri 3 3 Missouri 3 3 3 5 Montana 3 3 3 Montana 3 3 5 Nebraska 3 3 3 3 Nebraska 3 3 3 7 Nevada 3 3 Nevada 3 3 4 New Hampshire 3 3 3 New Hampshire 3 3 3 6 New Jersey 3 3 3 New Jersey 3 3 3 6 New Mexico 3 3 3 New Mexico 3 3 3 6 New York 3 3 3 New York 3 3 3 3 3 8 North Carolina 3 3 3 North Carolina 3 3 3 6 North Dakota 3 3 3 North Dakota 3 3 3 6 Ohio 3 Ohio 3 3 3 Oklahoma 3 Oklahoma 3 3 3 Oregon 3 3 Oregon 3 3 Pennsylvania 3 3 Pennsylvania 3 3 3 5 Rhode Island 3 3 3 3 Rhode Island 3 5 South Carolina 3 3 South Carolina 3 3 4 South Dakota 3 3 3 South Dakota 3 4 Tennessee 3 3 Tennessee 3 3 4 Texas 3 3 3 Texas 3 3 5 Utah 3 3 Utah 3 3 Vermont 3 3 Vermont 3 3 3 3 6 Virginia 3 3 3 3 Virginia 3 3 3 3 8 Washington 3 3 Washington 3 3 3 5 West Virginia 3 3 3 3 West Virginia 3 3 6 Wisconsin 3 3 Wisconsin 3 3 3 3 6 Wyoming 3 3 Wyoming 3 3 4 Total 34 States +D.C. 18 States 20 States 43 States + D.C. 16 States + D.C. 15 States 9 States 36 States 35 States 39 States+ D.C. 12 TFAH • RWJF STATE INDICATORS (6) (1) (2) (3) (4) (5) (7) (8) (9) (10) Climate Change Public Health Funding: Flu Vaccination Rates: Childhood Immunization School HIV/AIDS Surveillance: Syringe Excahnge Central Line-Associated Public Health Public Health Laboratories: Food Safety: and Infectious State increased or State vaccinated at least half Requirement Policies: State requires reporting of all Programs: Bloodstream Infections: Laboratories: State laboratories provided biosafety State met the national Disease: Total maintained funding for of their population (ages 6 State law either excludes philosophical (detectable and undetectable) CD4 State explicitly State reduced the standardized State laboratories reported training and/or information about performance target of testing State currently has Score public health from months and older) for the exemptions entirely or requires a parental (a type of white blood cell) and HIV authorizes syringe infection ratio (SIR) for central having a biosafety courses for sentinel clinical labs in 90 percent of reported climate change FY 2013 to 2014 and seasonal flu from Fall 2014 notarization or affidavit to achieve a religious or viral load data to their state HIV exchange programs line-associated blood stream professional from July 1, their jurisdiction from July 1, 2014 Escherichia coli (E. coli) O157 adaptation plans FY 2014 to 2015. to Spring 2015. philosophical exemption for school attendance. surveillance program (as of July 2013). (SEP). infections between 2012 to 2013. 2014 to June 30, 2015. to June 30, 2015. cases within four days. completed. Alabama 3 Alabama 3 3 3 4 Alaska 3 3 3 Alaska 3 3 3 3 7 Arizona 3 3 Arizona 3 3 3 5 Arkansas 3 3 3 3 Arkansas 3 3 6 California 3 3 3 California 3 3 3 3 7 Colorado 3 3 3 Colorado 3 3 5 Connecticut 3 3 Connecticut 3 3 3 5 Delaware 3 3 3 3 3 Delaware 3 3 3 8 D.C. 3 3 3 D.C. 3 4 Florida 3 3 Florida 3 3 4 Georgia 3 3 3 Georgia 3 3 5 Hawaii 3 3 3 3 Hawaii 3 5 Idaho 3 Idaho 3 3 3 Illinois 3 3 Illinois 3 3 3 3 6 Indiana 3 Indiana 3 3 3 4 Iowa 3 3 3 3 Iowa 3 3 6 Kansas Kansas 3 3 3 3 Kentucky 3 3 3 3 Kentucky 3 3 3 3 8 Louisiana 3 3 Louisiana 3 3 4 Maine 3 3 3 Maine 3 3 3 3 3 8 Maryland 3 3 3 3 Maryland 3 3 3 7 Massachusetts 3 3 3 Massachusetts 3 3 3 3 7 Michigan 3 3 Michigan 3 3 Minnesota 3 3 3 3 Minnesota 3 3 3 7 Mississippi 3 3 Mississippi 3 3 3 5 Missouri 3 3 Missouri 3 3 3 5 Montana 3 3 3 Montana 3 3 5 Nebraska 3 3 3 3 Nebraska 3 3 3 7 Nevada 3 3 Nevada 3 3 4 New Hampshire 3 3 3 New Hampshire 3 3 3 6 New Jersey 3 3 3 New Jersey 3 3 3 6 New Mexico 3 3 3 New Mexico 3 3 3 6 New York 3 3 3 New York 3 3 3 3 3 8 North Carolina 3 3 3 North Carolina 3 3 3 6 North Dakota 3 3 3 North Dakota 3 3 3 6 Ohio 3 Ohio 3 3 3 Oklahoma 3 Oklahoma 3 3 3 Oregon 3 3 Oregon 3 3 Pennsylvania 3 3 Pennsylvania 3 3 3 5 Rhode Island 3 3 3 3 Rhode Island 3 5 South Carolina 3 3 South Carolina 3 3 4 South Dakota 3 3 3 South Dakota 3 4 Tennessee 3 3 Tennessee 3 3 4 Texas 3 3 3 Texas 3 3 5 Utah 3 3 Utah 3 3 Vermont 3 3 Vermont 3 3 3 3 6 Virginia 3 3 3 3 Virginia 3 3 3 3 8 Washington 3 3 Washington 3 3 3 5 West Virginia 3 3 3 3 West Virginia 3 3 6 Wisconsin 3 3 Wisconsin 3 3 3 3 6 Wyoming 3 3 Wyoming 3 3 4 Total 34 States +D.C. 18 States 20 States 43 States + D.C. 16 States + D.C. 15 States 9 States 36 States 35 States 39 States+ D.C. TFAH • RWJF 13 MAJOR INFECTIOUS THREATS WA AND KEY FINDINGS T T R H W A W T R A A J H A T W A T A AR A A Scores Color T A 3 4 F A 5 H 6 7 8

SCORES BY STATE 8 7 6 5 4 3 (5 states) (6 states) (11 states) (12 states) (9 states & D.C.) (7 states) Delaware Alaska Arkansas Arizona Alabama Idaho Kentucky California Illinois Colorado D.C. Kansas Maine Maryland Iowa Connecticut Florida Michigan New York Massachusetts New Hampshire Georgia Indiana Ohio Virginia Minnesota New Jersey Hawaii Louisiana Oklahoma Nebraska New Mexico Mississippi Nevada Oregon North Carolina Missouri South Carolina Utah North Dakota Montana South Dakota Vermont Pennsylvania Tennessee West Virginia Rhode Island Wyoming Wisconsin Texas Washington

INDICATOR SUMMARY Indicator Finding 1. Public Health Funding Commitment 34 states and Washington, D.C. increased or maintained funding for public health from Fiscal Year (FY) 2013 to 2014 to FY 2014 to 2015. 2. Vaccinations 18 states vaccinated at least half of their population (ages 6 months and older) against the seasonal flu from fall 2014 to spring 2015. 3. Vaccinations 20 states’ laws either exclude philosophical exemptions entirely for vaccinations or require a parental notarization or affidavit to achieve a religious or philosophical exemption for school attendance. 4. HIV/AIDS Surveillance 43 states and Washington, D.C. require reporting of all (detectable and undetectable) CD4 (a type of white blood cell) and HIV viral load data to their state HIV surveillance program (as of July 2013). 5. Syringe Exchange Programs 16 states and Washington, D.C. explicitly authorize syringe exchange programs. 6. Climate Change and Infectious Disease 15 states currently have completed climate change adaption plans that include the impact on human health. 7. Healthcare-Associated Infection Control Between 2012 and 2013, the standardized infection ratio (SIR) for central line associated blood stream infections decreased significantly in nine states. 8. Public Health Laboratories 36 state laboratories reported having a biosafety professional (between July 1, 2014 and June 30, 2015). 9. Public Health Laboratories 35 state laboratories reported providing biosafety training and/or information about biosafety training courses for sentinel clinical labs in their jurisdiction (between July 1, 2014 and June 30, 2015). 10. Food Safety 39 states met the national performance target of testing 90 percent of reported Escherichia coli (E.coli) O157 cases within four days.

14 TFAH • RWJF NATIONAL HEALTH SECURITY PREPAREDNESS INDEX

The National Health Security The NHSPI was developed by the Preparedness Index™ (NHSPI) was Association of State and Territorial developed as a new way to measure Health Officials (ASTHO) in partnership and advance the nation’s readiness with CDC and more than 20 development to protect people during a disaster partners — including TFAH and RWJF — including major infectious disease — and was first released in 2013. The outbreaks caused by nature or acts of 2014 version included 194 measures bioterrorism. The NHSPI measures the from more than 35 sources — and health security preparedness of the reviewed six domains for preparedness, nation by looking collectively at existing including Health Security Surveillance, state-level data from a wide variety Community Planning and Engagement, of sources. Uses of the Index include Incident and Information Management, guiding quality improvement, informing Healthcare Delivery, Countermeasure policy and resource decisions, and Management and Environmental and encouraging shared responsibility for Occupational Health. In 2015, RWJF, preparedness across a community. The in collaboration with the University of National Health Security Preparedness Kentucky, took the lead for managing and Index aims to provide an accurate maintaining the Index. portrayal of how prepared our nation In 2014, the total national average is to both prevent health incidents and for the indicators was a 7.3 out of a effectively respond should an incident possible 10. The state scores ranged occur. The Index is a tool for advancing from 6.5 in Alaska to 8.1 in Utah and health security preparedness — our Virginia. The index is available at: www. ability to serve and protect our nation’s nhspi.org. greatest asset, its people.

TFAH • RWJF 15 INDICATOR 1: PUBLIC 34 states and Washington, D.C. increased or main- 16 states cut public health funding from FY 2013 to tained public health funding from FY 2013 to 2014 2014 to FY 2014 to 2015. (0 points.) HEALTH FUNDING to FY 2014 to 2015. (1 point.) COMMITMENT — STATE Alaska (19.1%) Missouri (1.9%) Alabama (-0.5%)^ New Mexico (-1.6%) Arizona (4.2%) Montana (0.0%) California (-13.3%) North Carolina (-2.3%)^ PUBLIC HEALTH BUDGETS Arkansas (0.8%) Nebraska (8.6%) Connecticut (-1.4%) Ohio (-6.1%)^ Colorado (9.8%) Nevada (14.3%) Indiana (-1.0%)^ Oklahoma (-0.8%) Delaware (3.6%) New Jersey (4.3%) Kansas (-1.1%)^ Tennessee (-3.2%) KEY FINDING: 34 states and D.C. (11.7%) New York (0.1%) Massachusetts (-11.6%) Texas (-1.9%) Washington, D.C. increased or Florida (6.1%) North Dakota (14.5%) Mississippi (-0.7%) Vermont (-3.5%) Georgia (3.3%) Oregon (25.4%) New Hampshire (-3.7%) Washington (-11.1%)^ maintained funding for public Hawaii (1.8%) Pennsylvania (1.7%) Idaho (6.7%) Rhode Island (4.5%) health from Fiscal Year (FY) 2013 Illinois (4.6%) South Carolina (1.6%) to 2014 to FY 2014 to 2015. Iowa (5.3%) South Dakota (14.6%) Kentucky (3.4%) Utah (7.9%) Louisiana (28.3%) Virginia (3.2%) Maine (0.1%) West Virginia (19%) Maryland (7.3%) Wisconsin (15.3%) Michigan (2.2%) Wyoming (3.5%) Minnesota (2.3%) Notes: Bolded states did not respond to a data check conducted in the fall of 2015; the most recent publicly available information was used for the states that did not reply or supply additional information. *Budget decreased for second year in a row. ^Budget decreased for third year in a row.

This indicator illustrates a state’s with the exception of Medicaid, CHIP or to carry out all of their responsibilities. commitment and ability to provide comparable health coverage programs It is important to note that several states funding for public health programs that for low-income residents. that received points for this indicator support the infrastructure and workforce Based on this analysis (adjusted for may not have actually increased their needed to improve health in each state, inflation), 16 states made cuts in their spending on public health programs. including the ability to prevent and public health budgets. Six states cut their For instance, the ways some states report control infectious disease outbreaks. budget for two or more years in a row. The their budgets, by including federal Every state allocates and reports its median spending in FY 2014 to FY 2015 was funding in the totals or including public budget in different ways. States also $35.77 per capita — up from FY 2013 to FY health dollars within healthcare spending vary widely in the budget details they 2014 levels of $31.06 — around the same totals, make it very difficult to determine provide. This makes comparisons rates as six years ago in FY 2008 ($33.71). “public health” as a separate item. across states difficult. For this analysis, Public health funding is discretionary This indicator is limited to examining TFAH examined state budgets and spending in most states and, therefore, whether states’ public health budgets appropriations bills for the agency, is at high risk for significant cuts during increased or decreased; it does not assess department, or division in charge of tight fiscal climates. States rely on a if the funding is adequate to cover public public health services for FY 2013 to 2014 combination of federal, state and local health needs in the states, and it should and FY 2014 to 2015, using a definition funds to support public health activities, not be interpreted as an indicator or as consistent as possible across the including infectious disease prevention, surrogate for a state’s overall performance. analyses of the two budget cycles, based immunization services and preparedness on how each state reports data. TFAH For additional information on the methodology activities. The overall infrastructure of defined “public health services” broadly of the budget analysis, please see Appendix C: public health programs supports the ability to include all state-level health spending Methodology for Select State Indicators.

16 TFAH • RWJF 18 states vaccinated at least half of their popula- 32 states and Washington, D.C. did not vaccinate half of INDICATOR 2: FLU tion (ages 6 months and older) for the seasonal flu their population (ages 6 months and older) for the sea- from fall 2014 to spring 2015. (1 point.) sonal flu from fall 2014 to spring 2015. (0 points.) VACCINATION RATES Arkansas (50.5%) New Hampshire Alabama (45.8%) Missouri (49.1%) Connecticut (52.8%) (52.1%) Alaska (44.0%) Montana (44.4%) Delaware (53.3%) North Carolina (52.4%) Arizona (41.6%) Nevada (39.7%) KEY FINDING: 18 states Hawaii (52.0%) North Dakota (51.0%) California (44.2%) New Jersey (46.8%) vaccinated at least half of their Iowa (53.8%) Pennsylvania (50.3%) Colorado (49.0%) New Mexico (49.6%) Maryland (52.1%) Rhode Island (58.7%) D.C. (46.7%) New York (48.6%) population (ages 6 months and Massachusetts South Dakota (59.6%) Florida (39.2%) Ohio (46.1%) (54.9%) Texas (50.1%) Georgia (44.1%) Oklahoma (49.1%) older) for the seasonal flu from Minnesota (51.9%) Virginia (51.8%) Idaho (42.2%) Oregon (44.3%) fall 2014 to spring 2015.27 Nebraska (54.0%) West Virginia (51.1%) Illinois (41.9%) South Carolina (48.3%) Indiana (44.7%) Tennessee (48.8%) Kansas (48.0%) Utah (46.9%) Kentucky (48.3%) Vermont (49.9%) Louisiana (44.7%) Washington (49.5%) Maine (49.5%) Wisconsin (44.1%) Michigan (44.3%) Wyoming (40.4%) Mississippi (44.9%) Source: CDC, Flu Vaccination Coverage, United States, 2014-2015 Influenza Season

Vaccination is the best prevention The highest vaccination rate was in against the seasonal flu. CDC South Dakota at 59.6 percent and the recommends all Americans ages 6 lowest was in Florida at 39.2 percent.30 months and older get vaccinated, yet Eighteen states vaccinated 50 percent fewer than half of Americans ages 6 of their population or higher and 48 months and older were vaccinated states and D.C. vaccinated 40 percent against the flu in the last three flu or higher. Nationally, 47.1 percent of seasons (2012 to 2013, 2013 to 2014 and Americans ages 6 months and older 2014 to 2015).28 were vaccinated.

In addition to protecting Americans l Rates are significantly higher for from the seasonal flu, establishing a children (59.3 percent) compared to cultural norm of annual flu vaccinations adults (43.6 percent). can help ensure the country has a l The lowest numbers are among adults strong mechanism in place to be better ages 18 to 64 at just 38.0 percent. able to vaccinate all Americans quickly Traditionally, there has been a much during a new pandemic or unexpected stronger focus on encouraging seniors disease outbreak. and children to get vaccinated, since This indicator examines if at least half they often have more severe illnesses (50 percent) of a state’s population along with the flu and have more (ages 6 months and older) was interaction with the healthcare system. Source: CDC vaccinated against the flu during the If all seniors received a newly available 2014 to 2015 season. HHS has set a goal high-dose version of the flu shot, flu for the nation to vaccinate 70 percent of cases among this vulnerable population adults and 70 percent of children as part could drop 25 percent.31 of the Healthy People 2020 initiative.29

TFAH • RWJF 17 Is it Flu or Ebola?

Flu (influenza) Ebola

The flu is a common contagious respiratory illness caused by flu viruses. Ebola is a rare and deadly disease caused by The flu is different from a cold. infection with an Ebola virus. Sporadic outbreaks have occurred in some African Flu can cause mild to severe illness, and countries since 1976. complications can lead to death.

How Flu Germs Are Spread How Ebola Germs are Spread

People get Ebola by direct contact with The flu is spread mainly by droplets made • The body fluids of a person who is sick with when people who have flu cough, sneeze, or has died from Ebola. or talk. Viruses can • Objects contaminated with body fluids of a also spread on surfaces, but this is person sick with Ebola or who has died less common. of Ebola. People with flu can spread the • Infected fruit bats and primates (apes and monkeys) virus before and during their illness. • And, possibly from contact with semen from a man who has recovered from Ebola (for example, by having oral, vaginal, or anal sex)

Who Gets The Flu? • Who Gets Ebola?

People most at risk of getting Ebola are Anyone can get the flu. • People with a travel history to countries with widespread transmission or exposure Some people—like very young to a person with Ebola. children, older adults, and people with • Healthcare providers taking care of some health conditions—are at high risk of patients with Ebola. serious complications. • Friends and family who have had unprotected direct contact with blood or body fluids of a person sick with Ebola.

Signs and Symptoms of Flu Signs and Symptoms of Ebola

The signs and symptoms of Ebola can appear 2 to 21 days after exposure. The The signs and symptoms of flu usually average time is 8 to 10 days. Symptoms develop within 2 days after exposure. of Ebola develop over several days and Symptoms come on quickly and all at once. become progressively more severe. • People with Ebola cannot spread the virus until symptoms appear.

• Fever or feeling feverish • Fever • Headache • Severe headache • Muscle or body aches • Muscle pain • Feeling very tired (fatigue) • Feeling very tired (fatigue) • Cough • Vomiting and diarrhea develop • Sore throat after 3–6 days • Runny or stuffy nose • Weakness (can be severe) • Stomach pain • Unexplained bleeding or bruising

For more information about the flu and Ebola, visit www.cdc.gov/flu and www.cdc.gov/ebola. May 4, 2015

CS252296-1 Source: CDC 18 TFAH • RWJF Each year, between 5 percent and days (83.9 percent) and lowest among 20 percent of Americans get the flu. personnel working in settings where Between 3,000 and 49,000 Americans vaccine was neither required, promoted, die each year from the flu and more nor offered on-site (44 percent).39 than 220,000 are hospitalized.32, 33 CDC estimates that during the 2013 to Between 2004 and 2012, 830 children 2014 flu season, vaccination resulted between 6 months and 18-years-old in over 90,000 fewer hospitalizations died from flu complications; 43 percent than otherwise would have occurred. of these children were otherwise Overall, 16.9 percent of adverse completely healthy.34 In the 2014 health outcomes associated with to 2015 flu season, there were 145 influenza were prevented.40 By influenza-associated pediatric deaths.35 preventing hospitalizations, influenza immunizations can save $80 per year, In addition to its health effects, flu has per person vaccinated.41 a serious impact in terms of healthcare and worker absenteeism costs. Seasonal The historically low demand for flu can often result in a half day to five seasonal vaccinations has translated into days of work missed, which affects both making flu vaccine development a low the individual and his or her employer. priority — without a steady demand, Indirect Costs of the Flu Annually, the flu leads to approximately incentives to manufacture and research $10.4 billion in direct costs for new influenza vaccines are reduced. $76.7 billion hospitalizations and outpatient visits and Under the Affordable Care Act (ACA), $76.7 million in indirect costs.36 all vaccines routinely recommended Nearly one-quarter (22.7 percent) of by the Advisory Committee on healthcare workers were not vaccinated Immunization Practices (ACIP), against the flu during the 2014 to 2015 including flu shots, are covered when season.37 Healthy People 2020 has provided by in-network providers in set a goal of 90 percent of healthcare group and individual health plans and workers vaccinated each flu season.38 for the Medicaid expansion population Direct Costs of the Flu Vaccination coverage was highest with no co-payments or cost sharing, $10.4 billion among healthcare personnel working but states are still able to determine in hospitals (90.4 percent) and lowest coverage and cost-sharing for their among those working in long-term care traditional Medicaid population. As settings (63.9 percent). Rates were of 2013, 38 states and D.C. required higher among healthcare professionals Medicaid coverage of flu shots with no- whose employers required that they be copay, while six states required a co-pay vaccinated (96 percent). In settings (Alaska, Colorado, Kentucky, Mississippi, with no employer requirement for Missouri and Montana).42 Medicare vaccination, coverage was higher where Part B covers annual flu vaccinations for vaccination was offered on-site at no cost beneficiaries with no co-pay. for one day (73.6 percent) or multiple

TFAH • RWJF 19 INDICATOR 3: CHILDHOOD 20 states’ laws either exclude philosophical 30 states and Washington, D.C. laws do not either exemptions entirely or require a parental exclude philosophical exemptions entirely or require a IMMUNIZATION SCHOOL notarization or affidavit to achieve a religious or parental notarization or affidavit to achieve a religious philosophical exemption from school immunizations or philosophical exemption from school immunizations REQUIREMENT POLICIES requirements for school attendance. (1 point.) requirements for school attendance. (0 points.) Alaska Nebraska Alabama Missouri KEY FINDING: Twenty Arkansas New Hampshire Arizona Nevada California** New Jersey Colorado New York states’ laws either exclude Delaware New Mexico Connecticut North Dakota Georgia North Carolina D.C. Ohio philosophical exemptions Iowa Tennessee Florida Oklahoma entirely for vaccinations or Kentucky Texas Hawaii Oregon Minnesota Vermont** Idaho Pennsylvania require a parental notarization Mississippi* Virginia Illinois Rhode Island Montana West Virginia* Indiana South Carolina or affidavit to achieve a religious Kansas South Dakota or philosophical exemption for Louisiana Utah Maine Washington school attendance. Maryland Wisconsin Massachusetts Wyoming Michigan Source: CDC’s State School Vaccination Exemptions Laws (as of March 2015) Note: *Mississippi and West Virginia do not allow nonmedical exemptions.43 **Effective July 1, 2015, California repealed religious and philosophical exemptions and Vermont repealed philosophical exemptions.

This indicator examines how challenging states make opting out of mandated childhood vaccinations requirements for school attendance for nonmedical reasons. States receive a point for the indicator if they have a law that either excludes philosophical exemptions entirely or require a parental notarization or affidavit to achieve a religious or philosophical exemption. Twenty states meet this threshold.44 Every state in the nation allows parents to opt out of vaccine requirements for their children for medical reasons — e.g., suppressed immune systems or a history of reactions like anaphylaxis or Guillain-Barré Syndrome.45 States may also have different definitions for medical providers, where states with broad definitions of providers can impact the ability of families to get a medical exemption. States that allowed Source: CDC for philosophical exemptions as well as religious exemptions had more than 2.5 times higher opt-out rates.46

20 TFAH • RWJF Depending on the number of children foregoing vaccinations, National childhood vaccination rates remain these exemptions can threaten herd immunity (general immunity of an high, but children still at risk for disease infection within a population) and put communities at risk. Not only are Knowing the vaccination rates in your the unvaccinated children themselves community is important. at risk, their status threatens others, Unvaccinated people tend to cluster including infants too young to be and put communities at risk for outbreaks of diseases like measles. vaccinated, children not yet old enough to receive the entire series, or

WA those with certain medical conditions. VT Many states are making vaccination D OR M MA Y data available online so you can see Experts report that herd immunity MI IA T local vaccine coverage and vaccine protections require 90 percent or A UT IL S Y VA exemption data. higher vaccination rates. The national A AL median for kindergartener vaccination T  States that report local-level coverage and exemption data online as of 2015. L rates for key recommended vaccinations is: 94 percent against measles, mumps and rubella ((MMR) — 2 doses); 94.2 To find out if your state percent against pertussis/whooping makes this information available, check with cough (94.2 percent — 5 doses of DTaP your state health *April 2015, Arizona (diptheria, tentanus and pertussis)); department or visit: Department of Health Services and 93.6 percent against chicken www.cdc.gov/vaccines/schoolvaxview-states/ pox (varicella — 2 doses).47 While Know the rates in your many states are below 90 percent on a community and protect your particular vaccine, only Arkansas and child by vaccinating according Colorado have rates below 89 percent to the recommended schedule. for the three vaccinations. Published August 27, 2015 Source: CDC, Vaccination Coverage Among Children in Kindergarten — United States, 2014–15 School Year. MMWR; 2015;64:897–904 In recent years, there have been a www.cdc.gov/mmwr/preview/mmwrhtml/mm6433a2.htm number of outbreaks in community U.S. Department of Health and Human Services clusters, including in some communities www.cdc.gov/vaccines/parents Centers for Disease Control and Prevention with high levels of religious-based NCIRDig526 | 08.27.2015 vaccine exemptions in Texas, Florida and Brooklyn, New York.48, 49, 50

Exemptions and the ease of obtaining disease outbreaks. For example, in vaccinations can help predict increased 2013, researchers compared geographic disease risk among exempted children clusters of the 2010 pertussis outbreak themselves and others in their in California (9,120 cases) with the community.51 Comparing opt-out number of exemptions in those areas policies with surveillance data shows and found that communities in an correlations between states with easier exemption cluster were 2.5 times more opt-out policies and vaccine-preventable likely to be in a pertussis cluster.52

TFAH • RWJF 21 In addition, in Colorado, which has the departments of health and education have lowest reported estimated rates in the not had the statutory authority to enforce country of kindergarteners receiving whether or not local schools document if recommended vaccination for measles, students have received a vaccination or an mumps and rubella (86.9 percent), exemption or bar attendance for students pertussis/whooping cough (84.3 percent) who have not provided documentation.53 and chickenpox (85.4 percent), the state Currently, parents in the state seeking non-medical exemptions from school and child-care vaccine requirements only Reported Pertussis Cases by Month and Year with Projected Baseline and Epidemic Thresholds, Colorado, 2005‐2015 (provisional) had to submit the request once during 400 a student’s tenure. Also, there is no Number of cases per month 5 Year Epidemic Threshold (2010‐2014) enforcement for schools to document 350 3 Year Epidemic Threshold (2012‐2014) 10 Year Epidemic Threshold (2005‐2014) and report on whether or not students are

300 vaccinated or exempt — and many schools do not track status or bar students from 250 school who are not in compliance. The state Board of Health passed new rules, 200 which go into effect in July 2016, requiring

150 schools to report students’ immunization and status rates — and that information 100 will be made publicly available, and

50 students will be required to submit information about their immunization 0 status or file an exemption every school Jul Jul Jul Jul Jul Jul Jan Jan Jan Jan Jan Jan Sep Sep Sep Sep Sep Sep

Nov Nov Nov Nov Nov Nov Mar Mar Mar Mar Mar Mar May May May May May May 2014 2015 2010 2011 2012 2013 year. The state will not, however, withhold funds or take action against schools not Source: Colorado Department of Public Health & Environment Updated 9/9/2015 in compliance. Colorado had more than double the national rate — and the

Pertussis Cases by Month of Report, Colorado second highest rate among states — of Provisional 2015 (year-to-date) vs. Epidemic Average (2012 - 2014) vs. 5-Year Baseline Average (2007-2011) whooping cough in the nation in 2014, at 54 160 24.3 per 100,000 people.

2015 140 CDC’s 2015 examination of state Epidemic average (2012 - 2014) exemption laws highlights the varieties 5 yr baseline average (2007-2011) 120 of ways states try to protect their residents. During outbreaks, some states 100 will not honor exemptions and will

80 require students be immunized (Hawaii and Kentucky), while others will not 60 umberof Cases N N allow the unvaccinated to attend school

40 (Arkansas, Georgia and Wyoming). Others do not allow permanent medical 20 exemptions — students’ medical status must be periodically evaluated to 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec determine whether an exemption is still medically necessary (Connecticut and Month of Report November 30, 2015 55 Source: Colorado Department of Public Health & Environment New Mexico).

22 TFAH • RWJF State School Vaccination Exemptions Laws as of March 2015

A few states have made changes to laws in 2015. Effective July 1, 2015, philosophical exemptions are no longer permitted in Cali- fornia and Vermont. California also no longer permits religious exemptions.56 In 2015, a new law was passed in California requiring workers and volunteers at daycare centers to be vaccinated against flu, pertussis and measles starting in the fall of 2016.57

Source: CDC

Estimated percentage of children enrolled in kindergarten who have been exempted from receiving one or more vaccines,* by state† — United States, 2014–15 school year

WA T T R H W A W T R A A J H A T W A T A AR * Exemptions might not reflect a child’s vacci- A ≥4% (N=11) A nation status. Children with an exemption who 2% to <4% (N=9) T A did not receive any vaccines are indistinguish- 1% to 2% (N=20) able from those who have an exemption but are <1% (N= 6) F up-to-date for one or more vaccines. A Data not H available (N= 5) † Seven states used a sample for exemption data: Colorado, Delaware, Hawaii, Nevada, South Carolina, Virginia, and Wisconsin. Source: CDC

TFAH • RWJF 23 PRESCHOOLER IMMUNIZATION GAPS (2014)

In general, vaccination rates among polio, hepatitis B, varicella, DTaP, children entering kindergarten are pneumococcal conjugate vaccine (PCV) high. For the 2014-2015 school year, and Haemophilus influenzae type b median vaccination coverage was (Hib)) for 19- to 35-month-old children 94.0 percent for 2 doses of measles, ranged from 63.4 percent in West mumps, and rubella vaccine; 94.2 Virginia to 84.7 percent in Maine. percent for the local requirements Improved vaccination registries and edu- for diphtheria, tetanus, and acellular cation to parents, child and daycare pro- pertussis vaccine (DTaP); and 93.6 viders (including home-based child care) percent for 2 doses of varicella vaccine and healthcare providers about the im- among the 39 states and Washington, portance and safety of vaccines are im- D.C. with a 2-dose requirement.58 portant steps for increasing rates. This However, there is a much bigger gap should include encouraging providers in preschooler vaccination rates. The to check patients’ vaccinations records failure to vaccinate all preschoolers with whenever they go for other doctor visits all of the recommended immunizations or emergency care — and updating vac- on time leaves more than 2 million cinations when there are gaps. Vacci- young children unnecessarily vulnerable nation of patients should be considered to preventable illnesses.59 There is as a quality performance measure for also wide geographic variation. The pediatricians and other providers as 2014 coverage rates for the combined part of delivery of value-based care. childhood vaccine series (MMR,

Recommended Vaccination (by 13 months unless otherwise noted) % NOT Receiving Childhood full series 4:3:1:3:3:1:4 28.4% Rotavirus 28.3% Pneumococcal – ≥3 doses 7.4% DTaP – 4+ doses 15.8% Hepatitis B – 3 doses* 8.4% Varicella 9.0% MMR 8.5% Polio 6.7% *Note: The first vaccination dose of hepatitis B is recommended to be administered at birth (before discharge); many children receive their first dose after the recommended schedule. By preschool age, there is a recommendation children should have received 3 scheduled doses of the vaccine

24 TFAH • RWJF MEASLES AND PERTUSSIS (WHOOPING COUGH) OUTBREAKS In recent years, there have been a number of outbreaks of vaccine-preventable diseases among children, including measles and whooping cough.

Measles Measles is a highly contagious, viral illness that can lead to health complications, including pneumonia, encephalitis and eventually death. Those infected can carry the virus for up to three weeks before a rash develops.60 Prior to routine vaccination, measles infected approximately three to four million Americans each year and killed 400 to 500 individuals. In addition, 48,000 individuals were hospitalized and another 1,000 developed chronic disability from measles encephalitis. Wide- spread use of measles vaccine has led to a greater than 99 percent reduction in measles cases in the United States compared with the pre-vaccine era.61

In 2000, measles was declared eliminated in the United States, with subse- quent reported cases each year due to travelers. In 2014, there were more than 600 measles cases reported in the United States in 27 states — a total of 23 outbreaks according to the CDC.62 In 2015, (as of September 18), a total of 189 measles cases from 24 states and Washington, D.C. have been reported to CDC — the largest outbreak being associated with Disney theme parks in southern California. More than half of the individuals whose infections were associated with the outbreak at Disney were young adults. Measles outbreaks place a tremendous strain on state and local public health. The total economic burden on state and local public health institutions that dealt with the 16 outbreaks in 2011 was estimated between $2.7 million and $5.3 million.63 On July 2, 2015, Washington State Department of Health confirmed a measles-related death; prior to that, the last reported measles-related death was in 2003.64

Unvaccinated individuals are far more likely to contract measles than those who have been vaccinated. Because measles is still endemic in many parts of the world, individuals traveling from outside the country continually import the disease, and outbreaks can occur in communities with low vaccination coverage.65 There may be missed or delayed diagnosis because many clinicians in the United States have never seen a measles case due to our high vaccination rates and rapid response to outbreaks.

TFAH • RWJF 25 Pertussis (Whooping Cough) Pertussis, commonly known as whooping cough, is a highly contagious bacterial respiratory infection that can be fatal in infants. Early symptoms mirror those of a cold, but infection progresses into a severe cough that can affect breathing. The best way to prevent pertussis is through vaccination. However, young infants who are the group at highest risk for severe disease, do not even begin their primary series of pertussis vaccination until 2 months of age. CDC recommends that pregnant women and all individuals who will have contact with a newborn be vaccinated.66

Pertussis does not only sicken infants. In the past several years, infections have increased in children ages 7 to 10 and in adolescents ages 13 to 14.67 In 2014, nearly 33,000 cases of pertussis were reported to CDC — with the largest number of cases from California (8,723), Texas (2,576) and Wisconsin (1,515).68

Outbreaks can strain health departments because of the manpower required to identify and ensure treatment or vaccination of contacts. In one outbreak, the direct costs to a local health department for response to a whooping cough outbreak was estimated at $2,200 per case, compared to a few dollars spent per dose of vaccine.69, 70

Getting your whooping cough vaccine in your 3rd trimester...

helps protect your baby from the start.

Outbreaks of whooping cough are happening across the United States. This disease can cause your baby to have coughing fits, gasp for air, and turn blue from lack of oxygen. It can even be deadly. When you get the whooping cough vaccine (also called Tdap) during your third trimester, you’ll pass antibodies to your baby. This will help keep him protected during his first few months of life, when he is most vulnerable to serious disease and complications. Talk to your doctor or midwife about the whooping cough vaccine.

Born with protection against whooping cough. www.cdc.gov/whoopingcough

February 2015

15_255220

26 TFAH • RWJF 43 states and Washington, D.C. require reporting 7 states do not require reporting of all CD4 and (detect- INDICATOR 4: HIV/AIDS of all CD4 and (detectable and undetectable) HIV able and undetectable) HIV viral load data (as of July viral load data (as of July 2013). (1 point.) 2013). (0 points.) SURVEILLANCE Alabama Missouri Connecticut Alaska Montana Idaho Arizona Nebraska Kansas KEY FINDING: Forty-three states Arkansas New Hampshire Nevada and Washington, D.C. require California New Mexico New Jersey Colorado New York Pennsylvania reporting of all (detectable and D.C. North Carolina Vermont Delaware North Dakota undetectable) CD4 (a type of Florida Ohio white blood cell) and HIV viral load Georgia Oklahoma* Hawaii Oregon data to their state HIV surveillance Illinois Rhode Island Indiana South Carolina program (as of July 2013). Iowa South Dakota Louisiana Tennessee Kentucky Texas Maine Utah Maryland Virginia Massachusetts Washington Michigan West Virginia Minnesota Wisconsin Mississippi Wyoming Source: CDC’s Prevention Status Report and HIV State Laws review * Required reporting as of September 2014.

More than 1.2 million Americans are living with HIV, and almost one in eight do not know they are infected. Since the epidemic began, more than 658,000 Americans have died due to AIDS.71 While overall diagnoses of HIV declined 19 percent between 2005 and 2014 – driven largely by declines among heterosexuals (35 percent), people who inject drugs (63 percent) and Black women (42 percent) -- there continues to be an alarming rise in new HIV diagnoses among young gay men of color (ages 13 to 24).72 l There are around 50,000 new HIV diagnoses each year. l Between 2005 and 2014, there was an 87 percent increase in diagnoses among young Black gay and bisexual men, and a 24 percent increase among Latino gay and bisexual men.73 l Blacks represent nearly half of Americans living with AIDS. Young gay Black men (ages 13 to 24), are at the highest risk for new HIV infections — seven times that of White men, twice that of Latino men, and nearly three times that of Black women.74 l According to CDC, half of young people with HIV do not know they are infected. l Worldwide, an estimated 36.9 million people are living with HIV/AIDS, nearly half of whom are women — with 2 million new HIV infections and 1.2 million deaths attributable from AIDS in 2014 alone.75 TFAH • RWJF 27 This indicator examines whether a state requires reporting dropped out of care.79 National analyses to monitor progress of all CD4 and HIV viral load results (detectable and against HIV are only effective if all HIV-related CD4 and viral load undetectable) to the state HIV surveillance program test results are reported by every state and jurisdiction. — currently, 43 states and Washington, D.C. have this Nationally, CDC estimates that only 30 percent of those living requirement, which is an increase from 36 states and with HIV are virally suppressed.80 Jurisdictions where high Washington, D.C. in 2012.76, 77 rates of viral load suppression are achieved have seen declines CDC and the Council of State and Territorial Epidemiologists in infection rates, in contrast to national trends. (CSTE) recommend reporting both detectable and undetectable viral loads. An HIV viral load test measures the amount of virus in a person’s blood, while a CD4 lymphocyte test measures his or her immune function and can determine 1 in 8 people with HIV the stage and progression of HIV infection. The results are don’t know they have it. often used to monitor disease progression and guide timing for clinical care, as well as assessing testing and prevention efforts.78

These data are critical to the health of people living with HIV, because they help ensure that individuals are linked to HIV medical Get the facts. Get Tested. Get involved. Find out more about HIV, including where to get tested, at gettested.cdc.gov care and retained in care, and a number of health departments have begun using the data to help re-engage individuals who have IN 2011 AFRICAN AMERICANS HIV and Latinos

490,000OVER LIVING WITH HIV Did you know not all Latinos with HIV are getting the care they need? Of Latinos diagnosed with HIV:

DIA ENG PRE VIR G A SC SUP A N G R P L R L O E I E D B Y S S E S E I E

C 8083.0%.3% 54.54.8%4% 44.43.3%4% 3635.6%.9%

85% 40% A 36% 28% virally

T R linked to care retainedretained in carecare prescribedprescribed ARARTT

E linked to care supprsuppressedessed**

*virus at low enough levels www.cdc.gov/oneconversation to stay healthy and VIRAL SUPPRESSION KEEPS PEOPLE HEALTHY AND REDUCES TRANSMISSION. reduce transmission risk

www.cdc.gov/hiv GET EDUCATED. GET TESTED. GET TREATED. Get Tested. Get in Care. Stay in Care. Live Well.

HIV SCREENING AND MEDICAID COVERAGE

According to a survey conducted by the HIV screening is considered particularly Experts believe that providing Kaiser Family Foundation’s Commission important so those who may not know they screening services for Medicaid on Medicaid and the Uninsured, pub- are infected can receive treatment as soon beneficiaries is particularly important lished in February 2014, 34 states and as possible and can take action to prevent since these Americans include many of Washington, D.C. reported coverage of spreading the infection to others. An es- the lowest-income and most vulnerable routine HIV screening under their Medic- timated 30 percent of new HIV infections in terms of quality of health and aid programs, while 16 states reported are from people living with HIV who are un- risk for HIV infection. In 30 states, coverage of testing only when it is con- aware of their infection, and more than 90 more than 20 percent of individuals sidered “medically necessary.”81 percent of new HIV infections in the United diagnosed with HIV are covered by States could be averted by diagnosing peo- Medicaid, and in 12 states, more than The U.S. Preventive Services Task Force ple living with HIV and ensuring they receive 30 percent of individuals with HIV are (USPSTF) and CDC recommend routine HIV prompt, ongoing care and treatment.82 covered by Medicaid.83 screening for all adolescents and adults.

28 TFAH • RWJF 16 states and Washington, D.C., explicitly authorize 34 states do not explicitly authorize syringe exchange INDICATOR 5: SYRINGE syringe exchange programs. (1 point.) programs. (0 points.) EXCHANGE PROGRAMS California Maryland Alabama Nebraska Colorado Massachusetts Alaska New Hampshire Connecticut Nevada Arizona North Carolina KEY FINDING: Sixteen states D.C. New Jersey Arkansas North Dakota Delaware New Mexico Florida Ohio and Washington, D.C. explicitly Hawaii New York Georgia Oklahoma Kentucky Rhode Island Idaho Oregon authorize syringe exchange Maine Vermont Illinois Pennsylvania programs (SEPs). Washington Indiana* South Carolina Iowa South Dakota Kansas Tennessee Louisiana Texas Michigan Utah Minnesota Virginia Mississippi West Virginia Missouri Wisconsin Montana Wyoming Source: LawAtlasSM, April 201584 Note: *Due to a recent outbreak of HIV (increase from fewer than 5 cases to 79 cases in a three month period in Scott County Indiana), Indiana passed a law in 2015 identifying short-term syringe exchange programs in counties with a declared public health emergency.85, 86

One of the most effective, scientifically- l Nationally, new acute hepatitis C C virus infection. A majority of these based methods for reducing HIV/AIDS infections have increased by 151.5 people do not know they are infected and viral hepatitis is syringe exchange percent in reported cases from 2010 because they do not look or feel sick. programs.87, 88 These programs, however, to 2013 (increases are attributed to l The number of HCV-related deaths have been at the center of political both real incidence and heightened has increased from 15,601 in 2007 debates, many of which are based on detection efforts).90 Of the 39 states that to 19,368 in 2013 — and the acute some long-held misperceptions, creating reported data in both 2010 and 2013, disease and death rates are expected a challenge for the medical community 28 states had an increase in persons to continue to rise significantly as Baby and policymakers. newly infected with HCV. According to Boomers — who do not know they CDC, the increase has predominantly A recent escalation of heroin use and other have a chronic infection — age into been among young adults (under injection drug use — related to people the symptoms of the disease.95, 96 30-years-old) who are white, live in transitioning from using prescription non-urban areas, particularly in the l There are around 50,000 new HIV opioid painkillers to heroin (also an East and Midwest, and have a history of infections each year.97 People who opioid), which is cheaper and more easily injection drug use and previously used inject drugs represented 15 percent of available in some communities — has prescription painkillers.91, 92 people living with HIV in 2011. More contributed to a significant rise in hepatitis than 1.2 million Americans are living C infections and the potential for increases l In Kentucky, Tennessee, Virginia and with HIV/AIDS, and nearly one in eight in HIV/AIDS. Many policymakers are West Virginia, acute HCV infections do not know they are infected.98 The reexamining SEPs as an effective strategy increased by 364 percent from 2006 rate of new infections is expected to for helping to reduce rates. to 2012 — a majority of those infected increase as injection drug use increases have been white adolescents and l Heroin use has grown 63 percent in the — including in places where HIV rates adults under 30 who inject drugs.93 past decade (from 2002-2004 to 2011- have traditionally been low, such as in 2013), with more than half a million l There were nearly 30,000 acute HCV Appalachia.99 Americans using the drug in 2013, infections in 2013.94 An estimated 2.7 leading to more than 8,200 deaths.89 million Americans have chronic hepatitis TFAH • RWJF 29 Syringe programs are public health l An analysis of people who inject drugs programs where people who inject in New York City showed that those who drugs are provided with new, sterile did not participate in SEPs were three syringes, needles and other supplies, times more likely to become infected or can exchange used needles for with HIV than those who did;106 clean ones, so the disease is not passed l Washington, D.C. saw a 70 percent from one drug user to another. SEPs drop in newly diagnosed HIV help control the spread of disease cases within 2 years following the and reduce accidental needle sticks establishment of its SEP;107 and among law enforcement and the public by providing safe disposal of used l SEPs help link people who inject syringes. In addition, many SEPs are drugs to services and care, which can part of a comprehensive prevention help decrease drug use and related program for people who inject drugs to problems.108 These services often provide resources or connect them with include on-site medical care; screening services that help target the underlying and counseling for HIV, hepatitis C, problems and/or refer individuals to and sexually transmitted infections; substance use treatment or other health distribution of condoms, food, and and social services and job programs. clothing; and referrals to substance misuse treatment. SEPs have been endorsed by the Institute of Medicine (IOM), World Preventing new infections saves money. Health Organization, American A recent calculation showed that Academy of Pediatrics (AAP), American expanding SEP coverage to 10 percent of Medical Association (AMA), American people who inject drugs would prevent Nurses Association (ANA), the nearly 500 new HIV infections annually. American Public Health Association This service expansion would cost an (APHA), Infectious Diseases Society estimated $64 million — significantly less of America (IDSA), HIV Medicine that the estimated $193 million lifetime Association (HIVMA) and a range of cost of treating 500 new HIV infections.109 leading experts.100, 101, 102 The national Syringe access is governed by a set organization, Drug Policy Alliance, also of state and and local laws across the recommends that the United States end country. Currently, federal funding of state policies that criminalize syringe SEPs is banned in the United States. possession and limit sterile syringe The ban was put in place in 1988, distribution, lift the ban on federal repealed in 2009, and reinstated by funding for syringe access programs, Congress in 2011.110 The President’s expand syringe exchange services, FY 2016 budget includes a request that and permit over-the-counter sales of communities be allowed to make the syringes.103 Research has shown that decision to use federal funding for SEPs decrease rates of infection and syringe exchange in conjunction with needle sharing, and do not increase local law and health authorities. Draft neighborhood crime.104 For instance: appropriations measures from Congress l CDC has found SEPs lower the maintain the ban on federal funds for incidence of HIV/AIDS among people purchase of syringes; the House and who inject drugs by 80 percent;105 Senate Appropriations Committees

30 TFAH • RWJF included language in the FY 2016 appropriations reports that would allow use of federal funding for related program elements, such as substance use counseling, if the state or local health department and CDC determine there is a risk or significant increase of hepatitis C or HIV infections due to injection drug use.

This indicator examines whether states specifically authorize SEPs. According to a 2015 analysis by LawAtlasSM, 16 states and Washington, D.C. authorize such programs, which provide people who inject drugs access to clean syringes and needles in efforts to stem the transmission of HIV and other bloodborne diseases like hepatitis B and C. Having a law to explicitly authorize SEPs is important for establishing the ability to protect the public health of citizens. This does not reflect other states that have removed legal barriers to syringe programs but do not directly authorize them.

In 2015, following the escalation of new HCV and HIV infections, Kentucky and Indiana both passed legislation allowing counties to establish syringe programs.111 Kentucky’s first SEP opened in June 2015.112 While Indiana’s SEP is temporary, according to assessments, it distribution in prescription and can vary. Some include requiring has contributed to decreases in people paraphernalia laws. adults to have a prescription to purchase syringes, some limit how who inject drugs who shared syringes l Fourteen states have removed many syringes can be purchased at one from 18 percent at their first recorded visit syringes from their definition of 113 time, some limit sales to pharmacies to 5 percent at their most recent visit. drug paraphernalia by removing and some require retailers to ask for terms such as needles, syringes, Among the states that explicitly authorize buyer information, such as the buyer’s and injection from the definitions SEPs, variations exist, such as whether name and purpose of the syringe. syringe exchanges must be approved section, amending lists of illegal drug locally or if programs are limited to paraphernalia to explicitly exclude Even without legislative authorization, 1-for-1 exchanges. Other measures some syringes, or providing exceptions many states and localities operate SEPs. states have taken to reduce potential to allow distribution of syringes to According to the North American Syringe harm and use include:114 prevent bloodborne diseases. Exchange Network, as of May 2015, there are 228 syringe exchange programs in 35 l l Some states require prescriptions for Twenty-eight states have limited states and Washington, D.C.115 or removed barriers to syringe the retail sale of syringes, but these

TFAH • RWJF 31 INDICATOR 6: CLIMATE 15 states currently have climate change adaptation 35 states and Washington, D.C. do not currently have CHANGE AND INFECTIOUS plans that are completed. (1 point.) complete climate change adaptation plans. (0 points.) Alaska New York Alabama Missouri DISEASE California Oregon Arizona** Montana Connecticut Pennsylvania Arkansas Nebraska Florida Vermont Colorado** Nevada KEY FINDING: 15 states Maine Virginia Delaware* New Jersey* Maryland Washington D.C.** New Mexico currently have completed Massachusetts Wisconsin Georgia North Carolina** climate change adaption plans New Hampshire Hawaii* North Dakota Iowa** Ohio that include the impact on Idaho Oklahoma Illinois Rhode Island* human health. Indiana South Carolina** Kansas South Dakota Kentucky Tennessee Louisiana Texas Michigan** Utah** Minnesota* West Virginia Mississippi Wyoming Source: Center for Climate and Energy Solutions Note: *Plans in progress. **Adaptation Plan Recommended in the Climate Action Plan.

This indicator examines which states have communities prepare for the adverse comprehensive climate adaptation plans, effects of climate change, given their which includes a plan by a governmental role in building healthy communities. body that has at least two sections. These Different regions of the country can include planning for changing risk face different health threats due to of emerging and reemerging infectious climate change — including those diseases due to changing temperatures related to sea-level rise and associated and weather patterns, and issues such as flooding, prolonged drought and water vector control, air quality and food and insecurity, hurricanes and other severe water safety. weather, and extreme heat events.117 According to reviews by the Center Climate change will require enhanced for Climate and Energy Solutions monitoring of potential disease vectors (C2ES), 15 states currently have and outbreaks. Factors like potential comprehensive climate adaptation plans, changes in water quantity and quality, and four additional states have plans in air quality, average and extreme progress.116 While the existence of a plan temperatures and insect control are does show consideration of concerns all important public health concerns. by a state, it does not necessarily mean Certain zoonotic and vector-borne a state is currently following or has diseases, as well as food and waterborne invested in supporting the plan. diseases, may increase in incidence and spread as changes in temperature Health departments, the healthcare and weather patterns allow pathogens systems and community partners have to expand into different geographic an important role to play in helping regions. For instance:

32 TFAH • RWJF l The presence and number of rodents, West Nile virus neuroinvasive disease incidence reported to ArboNET, by mosquitoes, ticks and other insects county, United States, 2014 and animals that can carry infectious diseases (disease vectors) rise in warmer temperatures. So as extreme temperatures increase in severity and duration, the geographic and spatiotemporal patterns of diseases ranging from West Nile virus to Lyme and other tick-borne diseases to encephalitis are expected to shift.118 l Climate change may have an effect on the timing of migration of wild birds. Wild birds are a concern for public health because they can be infected by a number of microbes that can be transmitted to humans. In addition, birds migrating across national and intercontinental borders Source: ArboNET, Arboviral Diseases Branch, Centers for Disease Control and Prevention can become long-range carriers of West Nile virus neuroinvasive disease incidence maps present data reported by state and local health any bacteria, virus or parasite they departments to CDC's ArboNET surveillance system. This map shows the incidence of human neuroinvasive disease (e.g., meningitis, encephalitis, or acute flaccid paralysis) by county for 2014 with shading ranging from harbor. Birds were the source of the 0.01‐0.99, 1.0‐2.49, 2.50‐9.99, and greater than 10.0 per 100,000 population. rapid spread of West Nile virus after Counties from the following states reported neuroinvasive disease cases to ArboNET in 2014: Arizona, Arkansas, it was first identified in 1999, and by California, Colorado, Connecticut, District of Columbia, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, 2012 the virus had been reported in New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, humans, mosquitoes, and birds in 48 South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, and Wisconsin. states. In addition to West Nile virus, migratory birds were reported to be one possible source of the 2006 global outbreak of the H5N1 avian influenza virus.119 Since December 2014, the United States has experienced highly pathogenic avian influenza incidents among poultry flocks and wild bird.120 l Annual influenza seasons and potential epidemics occur primarily during cold weather, while meningococcal meningitis is associated with dry climates. Changing weather patterns put people in different regions at increased risk for both diseases.121, 122

Source: CDC TFAH • RWJF 33 l The rise in extreme weather events and actions for federal agencies to take to natural disasters also leads to a more prevent and mitigate the impacts of fertile environment for the spread of climate change.131 And in 2014, HHS infectious diseases and germs. For released a Climate Adaption Plan, which instance, cryptosporidiosis outbreaks includes the ability to provide healthcare — which cause diarrheal disease — are and programs during emergency associated with heavy rainfall, which climate-related emergencies.132 In 2015, can overwhelm sewage treatment U.S. Surgeon General Vivek Murthy plants or cause lakes, rivers and streams highlighted the public health impacts to become contaminated by runoff of climate change during a White containing waste from infected animals. House Summit on Climate Change and Experts also believe that an El Niño Health, and the Obama administration occurrence may have contributed to announced actions to support resilience increases of cholera.123 Communities to climate change, including early recovering from a disaster may see warning systems and climate change food or waterborne illnesses associated medical education.133 with power outages or flooding, as well CDC’s Climate-Ready States and Cities as infectious disease transmission in Initiative in FY 2014 awarded $4.5 emergency shelters. million in grants to 16 states and two CDC, the Environmental Protection cities to conduct planning and build Agency (EPA), IOM, the National resilience to the health impacts of Institutes of Health (NIH) and the climate change using the Building Federal Emergency Management Resilience Against Climate Effects Agency (FEMA) have worked to identify (BRACE) framework.134 CDC will assist potential threats and ways to help adapt awardees in developing and using to and mitigate against the problems models to more accurately anticipate climate change may pose to the health of health impacts, monitor health effects, Americans.124, 125, 126, 127, 128, 129 In addition, and identify the most vulnerable areas in 2013, the President issued an Executive in their region. Awardees include Order to prepare for the effects of departments of health in Arizona, climate change, including how increases California, Florida, Illinois, Maine, in excessively high temperatures, heavy Maryland, Massachusetts, Michigan, downpours, wildfires, severe droughts, Minnesota, New Hampshire, New York permafrost thawing, ocean acidification City, New York State, North Carolina, and sea-level rise affect communities and Oregon, Rhode Island, San Francisco, public health.130 In 2014, an updated Vermont and Wisconsin.135 National Climate Assessment laid out

34 TFAH • RWJF Between 2012 and 2013, 9 states reduced the 41 states and Washington, D.C. had either the same or INDICATOR 7: number of central line-associated blood stream more central line-associated blood stream infections be- infections. (1 point.) tween 2012 and 2013. (0 points.) REDUCTIONS IN CENTRAL Alaska Alabama Nebraska LINE-ASSOCIATED Connecticut Arkansas Nevada Illinois Arizona New Hampshire BLOODSTREAM Kentucky California New Mexico INFECTIONS Maine Colorado North Carolina Mississippi Delaware North Dakota New Jersey D.C. Ohio KEY FINDING: Between 2012 New York Florida Oklahoma Tennessee Georgia Oregon and 2013, the standardized Hawaii Pennsylvania infection ratio (SIR) for central Idaho Rhode Island Indiana South Carolina line-associated bloodstream Iowa South Dakota Kansas Texas infections decreased Louisiana Utah significantly in 9 states. Maryland Vermont Massachusetts Virginia Michigan Washington Minnesota West Virginia Missouri Wisconsin Montana Wyoming Source: CDC, National and State Healthcare-Associated Infections: Progress Report Note: Puerto Rico’s central line-associated blood stream SIR was reduced between 2012 and 2013.

Approximately 1 out of every 25 the national standard infection ratio hospitalized patients will contract (SIR), and found that 17 states had a healthcare-associated infection, rates that were statistically significantly which is an infection patients can get better: Alaska, California, Hawaii, Idaho, while receiving medical treatment in Illinois, Michigan, Minnesota, Missouri, a healthcare facility.136 Healthcare- New Hampshire, Ohio, Oklahoma, associated infections not only happen Oregon, Pennsylvania, South Dakota, in hospitals but can also occur in Tennessee, Vermont and West Virginia. outpatient surgery centers, nursing A central line is a tube that is typically homes and other long-term care inserted in a patient’s large vein, usually facilities, rehabilitation centers, in the neck, chest, arm or groin, to give community clinics or physicians’ offices. important medical treatment. When This indicator examines one form of not put in correctly or kept clean, HAI — central line associated blood central lines can become a freeway stream infections (CLABSI) — and for germs to enter the body and cause whether a state reduced infection deadly infections in the blood. These rates from 2012 to 2013. According to infections are usually serious, often CDC’s National and State Healthcare- resulting in the prolongation of hospital Associated Infections: Progress Report, stay and increased cost and risk of nine states and Puerto Rico met this mortality.138 Nationally, the number of objective.137 In addition, CDC reviewed CLABSI infections has decreased overall how states performed compared to — by 46 percent — from 2008, when

TFAH • RWJF 35 the standard infection ratio benchmark was established (0.54) to be able to track HEALTHCARE - ASSOCIATED WHAT PATIENTS CAN DO INFECTIONS progress overtime.139, 140

A person’s risk for an HAI, which BE INFORMED. BE EMPOWERED. BE PREPARED. WAYS TO BE A SAFE PATIENT includes a range of antibiotic-resistant 6 infections, increases if they are having invasive surgery, if they have a catheter in a vein or their bladder, 1 or if they are on a ventilator or are on SPEAK UP. a prolonged course of antibiotics as Talk to your doctor about part of their care.141, 142 In 2011, there all questions or worries you have. Ask them what they 2 are doing to protect you. were an estimated 722,000 HAIs and KEEP HANDS CLEAN. 75,000 patients with HAIs died during If you have a catheter, Be sure everyone cleans their their hospitalizations in the United ask each day if it is hands before touching you. States.143 Of the infections, 157,500 necessary. were from pneumonia; 157,500 from Ask your doctor how he/she prevents surgical site infections. Also ask how surgical site infections; 123,100 from you can prepare for surgery to reduce gastrointestinal illness; 93,300 from your infection risk. 3 urinary tract infections; 71,900 from GET SMART ABOUT ANTIBIOTICS. primary bloodstream infections; and Ask if tests will be done to make sure 118,500 from other types of infections.144 the right antibiotic is prescribed. Clostridium difficile, which caused 12.1 percent of HAIs, was the most commonly reported pathogen. 4 HAIs cost the country $28 to $33 billion KNOW THE SIGNS AND SYMPTOMS in preventable healthcare expenditures OF INFECTION. each year.145 A 2013 meta-analysis found Some skin infections, such as MRSA, that CLABSIs were the most costly HAIs appear as redness, pain, or drainage at an 5 IV catheter site or surgery site. Often these at $45,814 per case.146 According to symptoms come with a fever. Tell your WATCH OUT FOR DEADLY DIARRHEA. (AKA C. difficile) CDC, if 20 percent of these infections doctor if you have these symptoms. Tell your doctor if you have 3 or more diarrhea were prevented, healthcare facilities episodes in 24 hours, especially if you have been taking an antibiotic. could save nearly $6 to $7 billion, and reducing infections by 70 percent could result in $25 to $32 billion in savings.147

Prevention and education efforts have been helping to decrease the rates of 6 HAIs. CDC, the Centers for Medicare PROTECT YOURSELF. and Medicaid Services (CMS), states Get vaccinated against flu and other infections to avoid complications. 245525-E and medical providers have launched

36 TFAH • RWJF a series of provider education and prevention initiatives.148, 149 In addition, How CDC Helps Resolve Outbreaks in 2008, Medicare provided an incentive in Healthcare Facilities to reduce infections by adopting a “no Milestones in an Epi-Aid Investigation pay” rule for infections acquired during a hospital stay, requiring the hospitals themselves to cover any costs incurred CDC receives a call or e-mail from a facility or health department by these infections.150 According to a 2012 survey, 80 percent of infection- CDC epidemiologist gathers initial information and provides control professionals believe the rules consultation on case finding, lab testing and infection control have resulted in a greater focus on reducing HAIs. The ACA also requires Health department extends a formal invitation for CDC to in-patient hospitals to report certain help lead an on-site team infections to National Healthcare CDC Epidemic Intelligence Service Officers arrive on-siteand Safety Network (NHSN) in order to help gather additional information from interviews, case/chart receive their full payment updates, reviews, observations and environmental sampling and the information is available on the 151 The team analyzes this information to identify risk factors for CMS’ Hospital Compare website. infection and help develop control measures The NHSN is the largest healthcare- associated infection reporting system CDC recommends new or revised measures and steps to in the United States, serving more than prevent more patients from becoming infected or harmed 17,000 healthcare facilities of all types.152 Health department and facility implement recommendations and Many states are seeing decreases in check to ensure the control measures are working HAIs. Between 2008 and 2013, there were 46 percent fewer central line- Following the conclusion of the on-site investigation, group communications continue to review what has worked and associated bloodstream infections and make adjustments as needed 19 percent fewer surgical site infections related to 10 surgical procedures in in-patient healthcare settings.153 There CDC reviews the were an estimated 30,800 fewer invasive situation for lessons Methicillin-resistant Staphylococcus learned and takes aureus (MRSA) infections in the steps to prevent United States from 2005 to 2011, with similar outbreaks hospital-onset MRSA decreasing by CS257322B more than 60 percent.154 Hospital- onset MRSA decreased 8 percent between 2011 and 2013.155

TFAH • RWJF 37 INDICATORS 8 AND 9: 36 state laboratories reported having a biosafety 15 state laboratories and in Washington, D.C. reported professional from July 1, 2014 to June 30, 2015. not having a biosafety professional. (0 points.) PUBLIC HEALTH (1 point.) LABORATORIES Alabama Missouri Arkansas Alaska Montana Colorado Arizona Nebraska Connecticut KEY FINDING: 36 state California New Jersey D.C. Delaware New Mexico Florida laboratories reported having a Georgia New York Hawaii biosafety professional (from July Idaho North Carolina Mississippi Illinois North Dakota Nevada 1, 2014 to June 30, 2015.) Indiana Ohio New Hampshire Iowa Pennsylvania Oklahoma Kansas South Carolina Oregon Kentucky Texas Rhode Island Louisiana Vermont South Dakota Maine Virginia Tennessee Maryland Washington Utah Massachusetts West Virginia Washington Michigan Wisconsin Minnesota Wyoming Source: Association of Public Health Laboratories 2015 survey

36 state laboratories provided biosafety train- 14 state laboratories and in Washington, D.C. did not KEY FINDING: 35 state ing and/or information about biosafety training provide biosafety training and/or information about bio- courses for sentinel clinical labs in their jurisdic- safety training courses for sentinel clinical labs in their laboratories provided biosafety tion from July 1, 2014 to June 30, 2015. (1 point.) jurisdiction. (0 points.). training and/or provided Alabama Missouri Alaska Arizona Montana Connecticut information about biosafety Arkansas Nebraska^ D.C California^ Nevada^ Florida training courses for sentinel Colorado* New Hampshire* Hawaii clinical labs in their jurisdiction Delaware New Jersey Maryland Georgia New Mexico* Michigan from July 1, 2014 to June 30, Idaho^ New York^ Ohio Illinois* North Carolina* Oregon 2015. Indiana^ North Dakota Pennsylvania Iowa^ Oklahoma^ Rhode Island Kansas^ South Carolina Tennessee Kentucky^ South Dakota Utah Louisiana^ Texas^ Washington Maine^ Vermont^ West Virginia Massachusetts Virginia* Wyoming Minnesota Wisconsin Mississippi^ Source: Association of Public Health Laboratories 2015 survey Note: * State provided training and information about training. ^ State provided information about training courses only.

38 TFAH • RWJF Public health laboratories are essential to were being received through ELR quickly identifying and diagnosing new compared to 54 percent in 2012.

characterizatio outbreaks and tracking ongoing outbreaks. definitive CDC’s Epidemiology and Laboratory Labs require highly expert staffing, Capacity for Infectious Diseases (ELC) extensive safety measures, specialized n Cooperative Agreements provide equipment, reagents and other biological confir state, local and territorial health

testin materials to use for testing, and enough mator department grantees with financial

g capacity to test for a large threat or y and technical resources to strengthen multiple threats at once. They have epidemiological, laboratory and health recognize

r ongoing responsibilities, such as testing ule-out information systems to detect, prevent ref water and environmental conditions, as er and control infectious diseases. The well as responding to emergencies and ELC cooperative agreements totaled 158 novel threats, such as an outbreak of Source: CDC $110 million in awards in FY 2015. Salmonella or a suspicious white powder These indicators examine two that could potentially be used during an referral of specimens. They are made important components of ensuring act of bioterrorism. up of more than 100 state and local public health, military, international, safety in laboratories. First, according Since 2001, public health labs have veterinary, agriculture, and food- and to an annual survey conducted by created networks to be more efficient water-testing laboratories; and the Association of Public Health and effective, so that every state has a Laboratories (APHL), 36 state labs baseline of capabilities but does not l Sentinel laboratories, which provide reported that they have a professional have to invest the resources required to routine diagnostic services, rule-out committed to biosafety on staff (from maintain every type of state-of-the-art and referral steps in the identification July 1, 2014 to June 30, 2015). Second, equipment or staffing expertise. For process. While these laboratories may 35 state labs reported they provided example, samples can be shipped to not be equipped to perform the same biosafety training and/or information facilities with the needed expertise as tests as LRN Reference laboratories, about biosafety training courses for quickly and safely as possible. they can test samples. sentinel clinical labs in their jurisdiction (with 20 providing training, 21 The Laboratory Response Network Labs not only help detect and diagnose providing information about courses for Biological Threat Preparedness problems, the information they provide and six providing both (Colorado, (LRN-B) includes labs with a hierarchy helps public health officials track the Illinois, New Hampshire, New Mexico, of different capabilities, so labs with emergence and spread of different North Carolina and Virginia)). increased capabilities provide support outbreaks and is an essential part for other labs, consisting of:156 of monitoring disease threats and According to the Occupational Safety understanding how to control them. and Health Administration (OSHA), l National laboratories — including those there are over 500,000 lab workers in operated by CDC, U.S. Army Medical In 2010, CDC began funding 57 state, the United States. These workers can Research Institute for Infectious local and territorial health departments be exposed to a range of chemical, Diseases (USAMRIID), and the Naval to encourage increased electronic biological and radiological hazards. Medical Research Center (NMRC) — reporting of lab results to help make 157 While lab safety is governed by myriad are responsible for specialized strain reporting faster and more complete. regulations at the national, state and characterizations, bioforensics, select Data collected since then show various local level, OSHA has developed agent activity and handling highly improvements. By the end of July 2013, 54 of the 57 jurisdictions were standards and published guidance over infectious biological agents; 159 getting some laboratory reports through the years to improve safety. l Reference laboratories, which are Electronic Laboratory Reporting (ELR), responsible for investigation and/or and 62 percent of laboratory reports

TFAH • RWJF 39 Source: CDC 40 TFAH • RWJF Many workers handle a variety of LABORATORY SAFETY LAPSES biological hazards, including blood borne agents, research animals and In 2014, safety lapses in the handling of plague and encephalitis samples at ad- federally regulated biological agents dangerous pathogens were identified at ditional labs. Samples labeled as dead (e.g., viruses, bacteria, fungi, prions) multiple U.S. government laboratories. or weakened do not require the personal and toxins that have the potential to CDC hired a top laboratory safety official protective equipment when handling that pose a severe threat to public health in 2015 to provide agency-wide leadership live samples do and can put lab workers and safety. These select agents or toxins and accountability for laboratory safety at risk. No illnesses have been caused by must be properly stored and handled and quality, and FDA hired a safety official these safety lapses so far, but the Penta- to ensure the safety of the worker, his to address gaps in FDA labs.163, 164, 165 gon has ordered a freeze on all operations or her immediate environment and the in the nine U.S. labs that work with the In 2015, additional incidents were identi- larger public as a whole. most dangerous agents.168 fied in military laboratories. In September, A biosafety program requires consistent anthrax bacteria was found on the floors While no staff were sickened and the pub- use of good microbiological practices, of two military laboratories in a Utah facil- lic was never at risk, these incidents and use of primary containment equipment ity, outside the designated containment their potential for harm is troubling. They and proper containment facility area.166 This facility had inadvertently highlight a lack of training, oversight, and design.160 One of the primary elements sent live anthrax spores — instead of de- failures of safety protocol by individuals. of lab safety is personal protective activated samples — to all 50 states and Laboratory safety is critical not just to pro- equipment — the protective gear nine countries for research and testing.167 tect laboratorians and the public, but to workers wear to keep them safe as they CDC inspectors found labeling errors in enable lifesaving research to continue. carry out their jobs. These include respirators, goggles and disposable gloves. In working with the select agents and toxins that are regulated federally, MEANINGFUL USE workers must use PPE and agents must be properly stored and handled. Meaningful Use is defined as “the use One public health objective for meaning- PPE is selected based on the hazard of certified electronic health record ful use is electronic lab reporting –trans- to the worker and must be properly (EHR) technology in a meaningful man- mitting laboratory reports to public health fitted, maintained in accordance with ner (for example electronic prescribing); agencies on reportable conditions. Its manufacturing specifications, and ensuring that the certified EHR tech- benefits include improved timeliness, properly removed and disposed of or nology is connected in a manner that reduction of manual data entry errors, cleaned to avoid contaminating the provides for the electronic exchange and reports that are more complete. The worker, others or the environment.161 of health information to improve the vision for ELR — as determined by a task quality of care; and that in using certi- force comprised of experts from CDC, Properly maintained Biosafety Cabinets fied EHR technology the provider must the Council of State and Territorial Epide- (BSCs) are another key component submit to the Secretary of Health & miologists and the Association of Public of laboratory safety; they provide an Human Services information on quality Health Laboratories — is that “all labs effective containment system for safe of care and other measures.” Through (public and private) conducting clinical manipulation of Biosafety Level 2 (BSL- its “Medicare and Medicaid Programs: testing identify laboratory results that in- 2) and 3 (BSL-3) agents. BSCs protect Electronic Health Records Incentive dicate a potential reportable condition for lab workers and the immediate lab Program,” CMS is providing incentive the jurisdictions they serve, format the environment from infectious aerosols payments to eligible hospitals, providers information in a standard manner, and generated within the cabinet and must and critical access hospitals that adopt transmit appropriate messages to the re- be certified when installed, whenever and successfully demonstrate meaning- sponsible jurisdiction; all jurisdictions can they are moved and at least annually.162 ful use of certified EHR technology.169 and do receive and utilize the data.”170

TFAH • RWJF 41 INDICATOR 10: FOOD 39 states met the national performance target of testing 11 states did not meet the national performance 90 percent of reported E. coli O157 cases within four target of testing 90 percent of reported E. coli O157 SAFETY days (in 2013). (1 point.) cases within four days (in 2013). (0 points.) Alabama (100%) Missouri (97%) Georgia (81%) Alaska (100%) Nebraska (100%) Idaho (73%) KEY FINDING: 39 states met Arizona (100%) Nevada (100%) Iowa (88%) the national performance Arkansas (100%) New Hampshire (100%) Louisiana (0%)** California (97%) New Mexico (94%) Michigan (86%) target of testing 90 percent of Colorado (98%) New York (99%) Montana (85%) Connecticut (100%) North Carolina (97%) New Jersey (79%) reported Escherichia coli O157 D.C. (N/A)* North Dakota (100%) Oregon (38%) cases within four days. Delaware (100%) Ohio (100%) South Carolina Florida (100%) Oklahoma (100%) (80%) Hawaii (95%) Pennsylvania (91%) South Dakota (89%) Illinois (92%) Rhode Island (100%) Texas (75%) Indiana (100%) Tennessee (99%) Kansas (100%) Utah (96%) Kentucky (90%) Vermont (100%) Maine (100%) Virginia (98%) Maryland (97%) Washington (93%) Massachusetts (100%) West Virginia (100%) Minnesota (91%) Wisconsin (90%) Mississippi (100%) Wyoming (100%) Source: CDC, National Snapshot of Public Health Preparedness, 2015. Note: *Data were not available for Washington, D.C. ** State did not report.

Annually, around 48 million Americans cases within four days. Nine states tested suffer from foodborne illnesses. between 60 percent and 89.9 percent Around one million of those who are of reported cases and two states tested stricken in a given year will suffer from fewer than 60 percent.174, 175 Quickly long-term chronic complications, such detecting E. coli O157 contamination as kidney failure and brain and nerve serves as a marker for the ability of damage.171, 172 Foodborne illnesses are states to protect their populations and responsible for around 128,000 hospital the nation from foodborne illness. visits and kill approximately 3,000 E. coli is a diverse group of bacteria that individuals each year.173 Virtually all live harmlessly in the guts of humans of these illnesses could be prevented and animals. However, some pathotypes if stronger measures were taken to of E. coli can cause acute gastro-intestinal improve the U.S. food safety system. illness that may lead to systemic disease. This indicator examines how quickly Most reported outbreaks are caused by states test reported cases of Escherichia Shiga toxin-producing E. coli (STEC) coli O157 — one of the most common O157, which is primarily transmitted foodborne illnesses in the United through the fecal-oral route. People can States. Thirty-nine states met CDC’s be sickened by consuming contaminated national performance target of testing leafy greens, raw dairy products and 90 percent of reported E. coli O157 undercooked meat.176

42 TFAH • RWJF Problem: Multistate foodborne outbreaks are serious and hard to solve.

Multistate outbreaks can be hard to detect. Contaminated food can be hard to trace to the source. ■ Contaminated food grown or produced in a single place ■ Companies may not have complete records of the can wind up in kitchens across America. source or destination of foods. ■ People in many states may get sick from a contaminated ■ Imported food can be even harder to trace to its source, food, making it difficult to spot the outbreak. and imports to the US are increasing. ■ Detecting that an outbreak is happening requires ■ Many different farms may produce the beef in a single specialized testing of germs in laboratories across burger or the fresh vegetables sold in a single crate. the country. Innovative methods are helping detect and solve Multistate outbreaks can be hard to investigate. more multistate outbreaks. ■ Investigators depend on sick people to remember what ■ New DNA sequencing technology is improving public they ate several weeks earlier. health’s ability to link germs found in sick people and in ■ If the problem is a contaminated ingredient, people may contaminated foods. unknowingly eat it in many different foods. ■ Information technology is helping investigators in many ■ Unexpected foods have been linked to recent multistate places work together. outbreaks, such as caramel apples and chia powder. ■ Efforts by food industries are helping trace contaminated foods to their source. Government and food industries need to work together to make food safer. More multistate outbreaks are being found Multistate outbreaks: less common, but more serious Why? Better methods to detect and Why? The deadly germs Salmonella, E. coli and investigate, and wider food distribution. Listeria cause 91% of multistate outbreaks.

. 120 of sicknesses Only 3% 11% 79 of all US foodborne outbreaks are multistate, of hospitaliations 51 but they cause more than their share of 34% 34 outbreak sicknesses, hospitalizations Number of outbreaks of deaths and deaths: 56% 1995-1999 2000-2004 2005-2009 2010-2014 SOURCE: CDC National Outbreak Reporting System, 1995-2014. SOURCE: CDC Vital Signs MMWR, November 2015.

CDC’s National Snapshot of Public impact. Food safety surveillance faces Health Preparedness and Prevention the additional challenge of culture Status Report highlight practices independent diagnostics, which provide recommended by the Council to a quick diagnosis, but do not provide Improve Foodborne Outbreak Response a PFGE isolate that often are used to that can help states prevent or reduce enable public health officials to identify foodborne illness. One practice is an outbreak. increasing the speed of pulsed-field According to the U.S. Department gel electrophoresis (PFGE) testing of Agriculture’s (USDA) Economic (DNA fingerprinting) of reportedE. Research Service, E. coli costs the coli O157 cases. According to the CDC, country over $271 million a year.179 “Speed of PFGE testing is defined as the annual proportion of E. coli O157 In 2015, CDC was notified of 546 ill PFGE patterns reported to CDC…within persons with confirmed Cyclospora four working days of receiving the infection from 31 states. Previous U.S. isolate in the state public health PFGE outbreaks of Cyclosporiasis have been lab.”177, 178 Detecting outbreaks quickly linked to imported fresh produce, not only prevents new cases of illness, including cilantro from the Puebla but can help the food industry identify region of Mexico. gaps and minimize adverse economic

TFAH • RWJF 43 SECTION 2: SECTION National National Issues and Issues Recommendations 2: NATIONAL ISSUES AND RECOMMENDATIONS & Recommendations Successes in fighting infectious diseases — due to vaccines, antibiotics and vigilant public health practices — have been dramatic, but have also contributed to a national complacency. This has resulted in a lack of sufficient support to maintain and grow the defenses needed to address them.

Overuse of antibiotics and underuse of be consistently maintained and regularly vaccines — and limited incentives for a updated with advances in technology. research and development pipeline — Key areas of recommendation include to: along with inadequate and fluctuating resources for core infectious disease A. Increase Resources to Maintain and prevention practices have resulted in Modernize Public Health Capabilities major gaps in the country’s ability to and Have Consistent and Science- detect, diagnose, treat and contain the Based Policies Across the Country spread of illnesses.180 This puts the B. Modernize Disease Surveillance nation at unnecessary risk when new — For Detecting, Tracking and threats emerge — like Ebola, MERS, Containing Disease Threats a new strain of pandemic flu or new foodborne illness outbreak — and C. Incentivize and Support Medical hampers the ability to tackle ongoing Countermeasure Research, problems — like HIV, antibiotic-resistant Development and Distribution infections or even the seasonal flu. D. Address Climate Change Impact on Most infectious diseases are preventable Infectious Disease Outbreaks — and millions of Americans become unnecessarily sick or die each year, and E. Build Community Resilience infectious diseases cost the country F. Improve Health System Preparedness, more $120 billion each year, but the Including Enhancing Surge Capacity country has not maintained a sustained and Infection Control commitment to address them.181 G. Improve Vaccination Rates Without sufficient attention and resources, much of the nation’s approach H. Combat Antibiotic Resistance to fighting infectious disease has not been I. Reduce Sexually Transmitted modernized in decades. Moving forward, Infections (STIs) and TB DECEMBER 2015 the country should make it a priority to define baseline capabilities — that must J. Fix Food Safety A. Increase Resources to Maintain and Modernize Public Health Capabilities and Have Consistent and Science-Based Policies Across the Country Stable, sufficient, dedicated funding is essential to assure that states and communities around the country have the basic capabilities needed to prevent and contain disease outbreaks. Infectious disease control requires constant vigilance — and inadequate and fluctuating resources leave gaps in the ability to quickly detect, diagnose, treat and contain the spread of illnesses.

Preparedness is at a higher baseline l Some significant never-well-addressed than it was prior to the September 11th gaps: Coordinated, interoperable, and anthrax tragedies, but it remains real-time biosurveillance; the ability a long way from the identified goals to provide mass care in emergencies; of what is needed to maintain basic maintaining a stable medical capabilities to protect against a range of countermeasure (MCM) strategy to potential infectious disease and other continue research and development health threats on an ongoing basis. of vaccines; antiviral medications and After 2001, significant investments were antibiotics; chemical and radiation made — and important progress was laboratory services, and the ability achieved in many areas — but many of to help communities become more the goals were never fully addressed, resilient to cope with and recover and as attention and resources have from emergencies. waned, some of the accomplishments l Cuts to preparedness — resulting that were made have also eroded. in eroding capabilities: The major l Some key areas of accomplishment: source of support for public health Emergency operations planning preparedness in states — the Public and coordination; public health Health Emergency Preparedness laboratories; vaccine manufacturing; (PHEP) Cooperative Agreement the Strategic National Stockpile Funding — has been cut from a (SNS); pharmaceutical and high of nearly $1 billion in FY 2006 medical equipment distribution to $644 million in FY 2015; Hospital and administration; surveillance Preparedness Program (HPP) has and epidemiologic investigation; been cut by more than half — from information sharing, and $515 million in FY 2004 to $255 communications; legal and liability million in FY 2015;182 funds for the protections; increasing and upgrading Strategic National Stockpile have not public health staffing trained to been sufficient to replenish medicines, prevent and respond to emergencies; vaccines, diagnostics and equipment, and limited improvements in medical it addresses a limited number of surge capacity. infectious diseases and many of the

TFAH • RWJF 45 countermeasures for communicable place, emergency supplemental funds diseases are in shortage, high- are needed. The emergency funds are cost and/or are no longer sold or often too late to support the immediate produced in the United States; and crisis — so scarce dollars are diverted health departments in 48 states, two from ongoing public health concerns. U.S. territories and Washington, D.C. And, the cost of ramping up quickly have reported budget cuts, and state during an emergency is significantly and local health departments have lost higher than if a solid foundation is 19 percent of their workforce — or maintained — so, once they are available 51,000 jobs — since 2008.183 for use, the emergency funds help to pay back expenditures in the aftermath of a The 2014 Ebola outbreak served as the crisis — but little is left to pay for future most recent illustration of the dynamic needs or to fill in costs incurred from where a new threat exposes ongoing diverting resources and staff to other gaps and vulnerabilities in the system. In public health responsibilities during the lieu of investing in a steady system where time of an emergency. appropriate response capabilities are in

Oversees CDC’s Emergency Management Program, which is DIVISION OF EMERGENCY OPERATIONS responsible for the overall coordination of the agency’s preparedness COORDINATING CDC’S RESPONSE TO PUBLIC HEALTH EMERGENCIES for, response to, and recovery from public health emergencies, including operating CDC’s Emergency Operations Center.

RESPONSE TO PUBLIC HEALTH CDC’S EMERGENCY OPERATIONS CENTER INCIDENT MANAGEMENT THREATS (EOC) SYSTEM (IMS)

A standardized emergency response BEFORE Established in 2003 as Has supported CDC’s response to operating system used to manage CDC’s TRAINING: CDC prepares its a state-of-the-art facility response by coordinating the roles of CDC at CDC headquarters responders by improving their technical 50+ and state public health officials. skills and getting them ready to deploy in Atlanta public health threats to the site of the emergency. Can seat up to Operates 24/7/365, EMERGENCY RESPONSE EXERCISE: practice responding to 230 people providing around-the-clock ACTIVATION LEVELS different public health threats ranging at a time for health monitoring and from natural disasters to pandemic 8-hour shifts emergency response Lowest activation level, CDC experts emergencies. on the specific type of emergency Deploys scientific experts Coordinates delivery LEVEL with staff from their program area to the site of of supplies and lead the response with minimal the emergency to equipment during 3 assistance from the Division of DURING collaborate on a response an emergency Emergency Operations to address the primary needs of the response. LOGISTICS: works 24/7/365 during The command center for monitoring and coordinating CDC’s emergency response to a CDC’s emergency response to public health threats in the United States and around the world. A mid-level response, CDC experts on public health threat by purchasing and the specific type of emergency with a shipping needed supplies and equipment; large number of staff from their program shipping specimens; and making travel LEVEL area lead the response with significant arrangements for CDC personnel 2 assistance from the Division of deploying to the site of the emergency. Emergency Operations to meet the time- sensitive tasks/needs of the response COMMUNICATION: CDC’s emergency beyond CDC’s core business hours. risk communication for all-hazards preparedness and response involves The highest level of response reserved ensuring timely, consistent, targeted, CDC WATCH DESK for critical emergencies, which often and actionable information reaches LEVEL require substantial agency-wide effort the public and stakeholders during Doctors, public health agencies, and the general public report public 1 and response needs are beyond the emergencies. health threats to CDC through the EOC Watch Desk. lead CIO’s capacity because of the magnitude of the event. In 2015, the EOC Watch desk received:

AFTER AFTER ACTION REPORT: an evaluation conducted after every CDC emergency response that identifies what was done well and 25,188 1,906 calls from city, county, 2,883 calls from what can be improved. calls or state health departments clinicians/hospitals

CS256096C

46 TFAH • RWJF Key Federal Infectious Disease Program Funding

CDC—INFECTIOUS DISEASES FY 2006 FY 2007 FY 2008 FY 2009 FY 20101 FY 20111 FY 20121 FY 20131 FY 20142 FY 2015 Immunization and Respiratory Diseases $519,858,000 $585,430,000 $684,634,000 $716,048,000 $721,180,000 $748,257,000 $778,947,000 $678,935,000 $744,700,000 $798,405,000 HIV/AIDS, Viral Hepatitis, STI and TB Prevention^ $963,133,000 $1,002,513,000 $1,002,130,000 $1,006,375,000 $1,118,712,000 $1,115,995,000 $1,109,934,000 $1,048,374,000 $1,072,834,000 $1,117,609,000 Emerging and Zoonotic Infectious Diseases* $212,165,000 $221,643,000 $217,771,000 $225,404,000 $281,174,000 $304,193,000 $304,226,000 $291,073,000 $339,300,000 $404,990,000 * In 2011 CDC integrated two existing nationals centers: the National Center for Preparedness, Detection, and Control of Infectious Diseases and the National Center for Zoonotic, Vector-Borne, and Enteric Diseases to create the National Center for Emerging and Zoonotic Infectious Diseases. ^ Viral Hepatitis was added in 2007 1 FY10-FY14 numbers reflect total budget authority and include PPHF funding for Immunization and Respiratory Diseases, HIV/AIDS and Emerging and Zoonotic Infectious Diseases 2 FY2014 numbers are enacted levels. Beginning in FY14, CDC moves funds from each budget line to the Working Capital Fund for business services, resulting in different operating budgets from enacted levels. Source: http://www.cdc.gov/fmo/topic/wcf/index.html Immunization and Respiratory Diseases Source FY 2015: http://rules.house.gov/sites/republicans.rules.house.gov/files/113-1/PDF/113-HR83sa-ES-G.pdf Source FY 2014: http://docs.house.gov/billsthisweek/20140113/113-HR3547-JSOM-G-I.pdf Source FY 2012-2013: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2013_CDC_Full-Year_CR_Operating_Plan.pdf Source FY 2009-2011: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2014_CJ_CDC_FINAL.pdf, pg. 52 Source FY 2008: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2013_CDC_CJ_Final.pdf, pg. 41 Source FY 2007: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2012_CDC_CJ_Final.pdf, pg. 51 Source FY 2006: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2011_CDC_CJ_Final.pdf, pg. 53 HIV/AIDS, Viral Hepatitis, STI and TB Prevention Source FY 2015: http://rules.house.gov/sites/republicans.rules.house.gov/files/113-1/PDF/113-HR83sa-ES-G.pdf Source FY 2014: http://docs.house.gov/billsthisweek/20140113/113-HR3547-JSOM-G-I.pdf Source FY 2012-2013: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2013_CDC_Full-Year_CR_Operating_Plan.pdf Source FY 2009-2011: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2014_CJ_CDC_FINAL.pdf, pg. 74 Source FY 2008: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2013_CDC_CJ_Final.pdf, pg. 60 Source FY 2007: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2012_CDC_CJ_Final.pdf, pg. 70 Source FY 2006: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2011_CDC_CJ_Final.pdf, pg. 73 Emerging and Zoonotic Infectious Diseases Source FY 2015: http://rules.house.gov/sites/republicans.rules.house.gov/files/113-1/PDF/113-HR83sa-ES-G.pdf Source FY 2014: http://docs.house.gov/billsthisweek/20140113/113-HR3547-JSOM-G-I.pdf Source FY 2012-2013: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2013_CDC_Full-Year_CR_Operating_Plan.pdf Source FY 2009-2011: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2014_CJ_CDC_FINAL.pdf, pg. 108 Source FY 2006-2008: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2011_CDC_CJ_Final.pdf, pg. 99

CDC OFFICE OF PUBLIC HEALTH PREPAREDNESS AND RESPONSE FUNDING TOTALS AND SELECT PROGRAMS FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 FY 2014^ FY 2015^^ CDC Total* $1,747,023,000 $1,533,474,000 $1,507,211,000 $1,622,757,000 $1,631,173,000 $1,472,553,000 $1,479,455,000 $1,514,657,000 $1,522,339,000 $1,415,416,000 $1,329,479,000 $1,231,858,000 $1,323,450,000 $1,352,551,000 State and Local Preparedness $940,174,000 $1,038,858,000 $918,454,000 $919,148,000 $823,099,000 $766,660,000 $746,039,000 $746,596,000 $760,986,000 $664,294,000 $657,418,000 $623,209,000 $655,750,000 $661,042,000 and Response Capability** SNS $645,000,000 $298,050,000 $397,640,000 $466,700,000 $524,339,000 $496,348,000 $551,509,000 $570,307,000 $595,661,000 $591,001,000 $533,792,000 $477,577,000 $535,000,000 $534,343,000 * CDC Total also includes CDC Preparedness and BioSense ** May include Public Health Emergency Preparedness (PHEP) cooperative agreements, All Other State and Local Capacity, Centers for Public Health Preparedness, Advanced Practice Centers (FY2004-09), Cities Readiness Initiative, U.S. Postal Service Costs (FY 2004), and Smallpox Supplement (FY 2003). ^ FY2014 numbers are enacted levels. Beginning in FY14, CDC moves funds from each budget line to the Working Capital Fund for business services, resulting in different operating budgets from enacted levels. Source: http://www.cdc.gov/fmo/topic/wcf/index.html ^^ Totals do not include Ebola funding Source FY 2015: http://rules.house.gov/sites/republicans.rules.house.gov/files/113-1/PDF/113-HR83sa-ES-G.pdf Source: FY 2014: http://docs.house.gov/billsthisweek/20140113/113-HR3547-JSOM-G-I.pdf Source: FY 2012-13: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2013_CDC_Full-Year_CR_Operating_Plan.pdf Source: FY 2010-11: U.S. Centers for Disease Control and Prevention. “2011 Operating Plan.” http://www.hhs.gov/asfr/ob/docbudget/2011operatingplan_cdc.pdf Source: FY 2002-09: http://www.cdc.gov/phpr/publications/2010/Appendix3.pdf

TFAH • RWJF 47 Key Federal Infectious Disease Program Funding

NATIONAL INSTITUTES OF HEALTH (NIH)—INFECTIOUS DISEASE FY 2002 FY 2003* FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015^^ National Institute of Allergy and $2,367,313,000 $3,706,722,000 $4,304,562,000 $4,402,841,000 $4,414,801,000 $4,417,208,000 $4,583,344,000 $4,702,572,000 $4,818,275,000 $4,775,968,000 $4,486,473,000 $4,230,080,000 $4,392,670,000 $4,358,541,000 Infectious Diseases * In 2003 NIAID added biodefense and emerging infectious diseases (BioD) ^^ Totals do not include Ebola funding Source FY 2015: http://rules.house.gov/sites/republicans.rules.house.gov/files/113-1/PDF/113-HR83sa-ES-G.pdf Source FY 2013-2014: http://officeofbudget.od.nih.gov/pdfs/FY15/FY2015_Supplementary_Tables.pdf Source FY 2012: http://officeofbudget.od.nih.gov/pdfs/FY14/POST%20ONLINE_NIH.pdf Source FY 2002-2011: http://officeofbudget.od.nih.gov/pdfs/FY12/Approp.%20History%20by%20IC%292012.pdf

OFFICE OF ASSISTANT SECRETARY FOR PREPARDNESS AND RESPONSE FUNDING TOTALS AND SELECT PROGRAMS FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015^^ ASPR Totals ------$632,000,000 $694,280,000 $632,703,000 $788,191,000 $891,446,000 $913,418,000 $925,612,000 $897,104,000 $1,054,375,000 $1,045,580,000 HPP^ $135,000,000 $514,000,000 $515,000,000 $487,000,000 $474,000,000 $474,030,000 $423,399,000 $393,585,000 $425,928,000 $383,858,000 $379,639,000 $358,231,000 $254,555,000 $254,555,000 BARDA** ------$5,000,000 $54,000,000 $103,921,000 $101,544,000 $275,000,000 $304,948,000 $415,000,000 $415,000,000 $415,000,000 $415,000,000 $415,000,000 BioShield Special -- -- $5,600,000,000* ------$255,000,000 $255,000,000 Reserve Fund * One-time Funding Source FY 2010-11: http://www.hhs.gov/asfr/ob/docbudget/2011operatingplan_phssef.pdf ^ HPP moved from HRSA to ASPR in 2007 Source FY 2008-09: http://www.hhs.gov/asfr/ob/docbudget/2010phssef.pdf, p. 8 ** BARDA was funded via transfer from Project BioShield Special Reserve Fund balances for FY2005-FY2013 Source FY 2007: http://www.hhs.gov/budget/09budget/budgetfy09cj.pdf, p. 288 ^^ Totals do not include Ebola funding Source FY 2006: http://www.hhs.gov/asfr/ob/docbudget/2008budgetinbrief.pdf, p. 109 Source FY 2015: http://rules.house.gov/sites/republicans.rules.house.gov/files/113-1/PDF/113-HR- Source BARDA FY 2005-06: http://www.hhs.gov/asrt/ob/docbudget/2010phssef.pdf, p. 45. 83sa-ES-G.pdf Source HPP FY 2005: http://archive.hhs.gov/budget/07budget/2007BudgetInBrief.pdf, p. 20 Source FY 2014: http://www.hhs.gov/budget/fy2015/fy2015-public-health-social-services-emergency-bud- Source HPP FY 2004:http://archive.hhs.gov/budget/06budget/FY2006BudgetinBrief.pdf, p. 16 get-justification.pdf Source HPP FY 2003: http://archive.hhs.gov/budget/05budget/fy2005bibfinal.pdf, p. 16 Source FY 2013: http://www.hhs.gov/budget/fy2015/fy2015-public-health-social-services-emergency-budget-justification.pdf Source HPP FY 2002: http://archive.hhs.gov/budget/04budget/fy2004bib.pdf, p. 14 Source FY 2012: http://www.hhs.gov/budget/safety-emergency-budget-justification-fy2013.pdf

48 TFAH • RWJF KEY INFECTIOUS DISEASE AND EMERGENCY RESPONSE RESPONSIBILITIES Requirements for an effective 24/7 and 3) any actions they or their families approach to combat infectious disease should take to protect themselves; threats include: l A focused and effective response strat- l Strong surveillance to identify and mon- egy, including targeted communications, itor ongoing and emerging infectious to address the concerns of at-risk pop- disease outbreaks; ulations, such as children, the elderly, pregnant women and groups or areas l Intensive investigative capabilities that are particularly susceptible to a par- — including an expert scientific and ticular threat; medical workforce and comprehensive laboratory capabilities — to quickly l Coordination and partnership with the diagnose outbreaks; healthcare sector to ensure people in need have access to and receive the l Containment strategies, including best available treatment at any stage of medicines and vaccines to prevent an outbreak — including surge capacity and stop the spread of a disease, for mass outbreaks when necessary; well-trained public health disease intervention specialists in all states l An informed and engaged public that ready to deploy to conduct contract can provide material and moral support tracing (identifying how the disease to professional responders, and can has spread) and under special render aid when necessary to friends, circumstances collect specimens, family, neighbors and associates; and isolation and quarantine when l Improving research and development of necessary; strategies to support non-pharmaceuti- l Streamlined and effective communica- cal disease containment for emerging tion channels so health workers can outbreaks when no or before vaccines or swiftly and accurately communicate with medicines are available; and each other, other front-line workers and l A strong research capacity that is able the public about 1) the nature of the dis- to rapidly develop new vaccines or medi- ease threat; 2) the risk of exposure and cal treatments to counter new threats. how to seek treatment when needed;

There have been a number of efforts and accountability to be achieved — but by the IOM, the Transforming Public the current system is not achieving the Health Project funded by the RWJF, CDC needed results. For instance, modern- and other leading public health groups izing business practices and finding that have called for establishing and efficiencies may require exploring inno- assuring that baseline capabilities are vative approaches such as regionaliza- in place nationally and are consistently tion, increased healthcare and public met across the country.184,185 This health integration, public-private part- may be achieved through new funding nerships, resource-sharing and working mechanisms or by giving states and with Accountable Care Organizations localities more flexibility in exchange for (ACOs), or within new capitated care increased demonstration of capabilities structures and global health budgets.

TFAH • RWJF 49 SOME KEY CDC INFECTIOUS DISEASE PROGRAMS l CDC’s Epidemic Intelligence Service recovery; emergency operations coordi- (EIS): EIS officers serve as expert nation; emergency public information and “disease detectives” who conduct in- warning; facility management; information vestigations, research and surveillance sharing; mass care; medical countermea- — around the United States and abroad. sure dispensing; medical materiel man- EIS is a two-year post-graduate training agement and distribution; medical surge; program for physicians, nurses, veteri- non-pharmaceutical interventions; public narians and PhD-trained scientists. health laboratory testing; public health surveillance and epidemiological investi- l CDC’s Division of Global Health Pro- gations; responder safety and health; and tection: The Division works in over 60 volunteer management.189 countries to build global public health capacity to rapidly detect, fight and con- l Strategic National Stockpile: The SNS is trol disease outbreaks. This includes the a national repository of antibiotics, chem- Global Disease Detection (GDD) Program, ical antidotes and other medicines and the Field Epidemiology Training Program medical supplies for use during a major (FETP), National Public Health Institutes disease outbreak, bioterror or chemical Program, Global Health Security, and attack or other public health emergency.190 Emergency Response and Recovery.186 Push Packages of supplies are kept in se- The GDD program works to strengthen cure locations around the country and are global health security — especially sup- immediately deployed during emergencies porting countries with limited capabilities — and/or the federal government also can — in order to rapidly detect, accurately employ systems to work with some private identify, and promptly contain emerging pharmaceutical distribution companies and infectious disease and intentional bio- pharmacies to be able to distribute vac- terrorist threats that occur.187 FETP has cines or medicines during an outbreak. trained more than 3,000 field epidemi- l WHO Collaborating Center: CDC’s In- ologists globally to become “disease fluenza Division has served as a WHO detectives” in their home countries and Collaborating Center for Surveillance, quickly identify causes of communicable Epidemiology, and Control of Influenza in and non-communicable outbreaks. CDC Atlanta, Georgia since 1956 and is the has begun providing technical support to largest global resource and reference 30 countries through the Global Health center supporting public health interven- Security program to better prevent, detect tions to control and prevent pandemic and respond quickly and effectively to and seasonal influenza. As a WHO public health threats in accordance with Collaborating Center, CDC’s Influenza the Global Health Security Agenda. Division plays a major role in year-round l Public Health Emergency Preparedness surveillance for early detection and iden- Cooperative Agreement Program: PHEP tification of antigenically drifted seasonal provides formula-based cooperative influenza viruses as well as novel influ- agreement funds to states, territories and enza A viruses that may have pandemic urban areas to build and sustain the abil- potential. The Influenza Division collects ity to prepare for and respond to all types and analyzes influenza viruses from of major health emergencies.188 PHEP fo- around the world for epidemiological, an- cuses on 15 key capability areas, includ- tigenic (immune response), antiviral sus- ing community preparedness; community ceptibility and genetic characterizations. 50 TFAH • RWJF TFAH • RWJF 51 RECOMMENDATIONS: Public Health — Leadership, Foundational Capabilities and Funding

To achieve a more effective, efficient and nization and integration in response to l Defining, prioritizing and fully funding modern approach to combating infectious outbreaks and other public health emer- a set of foundational capabilities for disease threats, TFAH recommends that gencies ranging from the West Virginia public health departments at all levels health departments at the federal, state chemical spill to the Ebola outbreak. of government: Public health depart- and local levels establish foundational There must also be improved coordina- ments need the tools and skills that capabilities to ensure consistent, basic tion across the levels of governments and are necessary to provide basic public levels of protection across the country agencies within government as well as protections while adapting to and ef- — and public health departments at all across regions, states and jurisdictions. fectively addressing changing health levels must receive adequate funding to threats. The IOM and RWJF’s Trans- l Increasing support for global infectious achieve these capabilities, including: forming Public Health project have iden- disease prevention and control pro- tified key foundational capabilities.191, l Infectious disease policy — including grams: Infectious disease control strat- 192 In 2015, Washington state issued for emerging threats — should be egies rely on the ability to detect and Foundational Public Health Services: A driven by the best available science contain diseases as quickly as possible New Vision for Washington State, their and be consistent across the country, — which means working with other assessment of defined, basic set of especially in the midst of a dynamic countries and across borders to contain capabilities and programs that must outbreak: Public health should be threats globally. Additional support and be present in every community in order based on the best available evidence priority must be placed on strengthen- to efficiently and effectively protect all to weigh the potential benefits and ing global public health infrastructure people in Washington.193 harms of policies such as social dis- and the Global Health Security Agenda tancing, direct monitoring of travelers — including the need to improve sur- l Maintaining the Prevention and Pub- and quarantine. veillance, laboratory systems, public lic Health Fund (PPHF): The PPHF health workforce, communications and invests in systems that are essential l Appointing a permanent Special As- other basic capabilities; and global to infectious disease prevention, such sistant to the President for Health health programs at CDC, the State as epidemiology and laboratory ca- Security: There should be a White Department, Department of Defense, pacity grants, the 317 Immunization House public health leadership position National Institutes of Health and other Program, and healthcare associated to manage infectious and other public U.S.-based programs; and partnering infection prevention efforts. health threats — and be responsible with WHO and other countries. for coordinating a government-wide l Exploring new funding and business approach to preparedness, response l Increasing funding for public health models to assure sufficient levels of and recovery efforts. While the appoint- at the federal, state and local levels: funding to support foundational capa- ment of an emergency Ebola response Federal, state and local health depart- bilities — including better integration of coordinator was important, there is an ments must receive a sufficient level of public health with the larger healthcare ongoing gap in the permanent structure funding, and some existing funding lines system. The federal government and of the White House to respond effec- may need to be realigned to be able to states should develop a new financing tively to emerging and ongoing public ensure all states are able to meet and system for public health that gives health threats. maintain a core set of foundational capa- priority to foundational capabilities and bilities so they can adequately respond assures that every American is served l Improving federal, state, local and inter- to emerging and ongoing threats. The by a health department that has these state coordination during a multi-agency use of all federal public health funds and capabilities. This can be achieved emergency response: At the federal the outcomes achieved from the use of through new funding mechanisms or by level, in addition to increased White funds must be transparent and clearly giving states more flexibility with exist- House leadership and engagement, there communicated with the public. ing funding streams. Modernizing busi- must be improved interagency synchro-

52 TFAH • RWJF ness practices and finding efficiencies to control outbreaks by restricting indi- ing messages from different sources may require innovative approaches viduals exposed to infectious diseases and unnecessary actions taken based such as regionalization of some ca- and contact with others. Despite years on perception rather than science pabilities, public-private partnerships, of experience and planning for quaran- compounded the confusion and contrib- resource sharing and participating tine scenarios, the federal government uted to rising levels of fear. Improved in Accountable Care Organizations and state governments struggled to communications strategies could help or Accountable Health Communities respond to the domestic Ebola threat better educate and inform the public and (AHCs).194 This should include contin- with a cogent and consistent approach communities about their relative risk and ued and expanded emphasis for ongo- to administer and execute quarantine what measures, if any, are being taken or ing training and drilling between local and isolation, raising the question of are needed to help protect themselves health departments, healthcare sys- transparency and reliance on uniform and their families. In communicating tems and emergency response teams scientific and medical rationale. Federal, with the public and healthcare workers, in preparedness for possible outbreaks state and local public health and policy public health should take into account of highly infectious diseases. leaders should come together and agree uncertainty of an evolving situation and on a common decision-making frame- partner with trusted community sources l Establishing an emergency reserve work ahead of the next outbreak to help in outreach to at-risk communities. Pub- fund: When a major new outbreak states make movement and monitoring lic health should establish relationships threat occurs, the current appropri- decisions that 1) are based upon the with media ahead of crises and leverage ations process, even for emergency best available scientific and medical social media to ensure accurate informa- supplemental funding, lags behind evidence; 2) preserve social and eco- tion reaches the public. Communications the spread of the disease, and this nomic continuity to the greatest extent strategies must prepare the public — as lack of available resources hampers possible; and 3) are in the best interest well as policy makers — that policies the response and requires diverting of the public’s health.195 may shift as understanding of the threat resources from other ongoing public evolves. CDC communication should co- health priorities. There should be a l Improving and coordinating risk com- ordinate with international counterparts contingency fund for rapid use during munications: The Ebola outbreak raised — such as WHO — and should also an emergency, which would allow an concerns about risk communications build bidirectional communication path- immediate response to a crisis. and media relations capabilities — there ways with state and local public health was a significantly disproportionate l Advancing a shared framework for iso- departments on a regular basis, not just sense of concern in relation to the very lation, quarantine, movement and moni- during the outbreak. low risk that Americans faced. Conflict- toring decisions: Guidance can be used

A NATIONAL BLUEPRINT FOR BIODEFENSE: Leadership and Major Reform Needed to Optimize Efforts196

In October 2015, the bipartisan Blue Lieberman (co-chair), Governor Thomas modernizing and updating biosurveillance Ribbon Study Panel on Biodefense is- Ridge (co-chair); former U.S. Secretary and information systems, improving and sued a Blueprint identifying the need of HHS Donna Shalala, Senator Thomas incentivizing the medical countermea- for increased leadership to elevate co- Daschle, Representative James Green- sures enterprise, providing support to ordination and collaboration and drive wood and Kenneth Wainstein. The Blue- build and maintain coordinated and func- innovation to improve the nation’s pre- print for Biodefense recommendations tional hospital preparedness and main- paredness for biological threats. Panel included: having a strong comprehensive taining sufficient and ongoing support for members include: former Senator Joseph national biodefense strategy and plan, state and local preparedness capacity.

TFAH • RWJF 53 B. MODERNIZE DISEASE SURVEILLANCE: For Detecting, Tracking and Containing Disease Threats One of the most fundamental components of infectious disease prevention and control is the ability to identify new and track ongoing outbreaks.

Currently, the United States lacks Current systems do not capitalize on an integrated, national approach to the advances that have been made in biosurveillance — which limits the rapid information technology to be able to detection and tracking of diseases. As of track disease threats and trends — 2011, there were more than 300 different compromising the ability to quickly health surveillance systems or networks detect, diagnose and contain outbreaks. supported by the federal government.197 l At a federal level, CDC runs the Most of the systems are not integrated majority of national human health or interoperable and serve an array of surveillance networks. Some of these different purposes. include the Arboviral Surveillance Surveillance allows health professionals System (ArboNET), BioSense, to quickly identify an emerging infectious Electronic Food-Borne Disease disease or foodborne illness outbreak. Outbreak Reporting System (eFORS), But systems that track ongoing concerns Emerging Infection Program (EIP), must also be modernized to provide Environmental Public Health Tracking more timely and coordinated data, so Network, Global Disease Detection health professionals can better detect and the National Outbreak Reporting and contain threats. For instance, there System (NORS). is often a lag in the reported data for l Within each state there are also often diseases like HIV/AIDS, which limits more than a dozen health surveillance the ability to target effective prevention systems that work independently strategies and interventions when they and voluntarily feed data to the are needed. The recent rapid growth of corresponding national network at CDC. hepatitis C outbreaks — corresponding to the rise in injection drug use in some l In addition, other federal agencies communities — shows the importance and departments have their own of being able to identify long-standing biosurveillance systems, including the disease concerns in real-time and to Environmental Protection Agency, assess how effective prevention and Department of Homeland Security control strategies may be or when (DHS), USDA, Food and Drug adjustments or further action is needed. Administration (FDA), Department For instance, the lack of appropriate of Veterans Affairs (VA), Department subtyping tools has been a challenge of Defense (DoD) and the Office of for identifying the source of recent the Director of National Intelligence outbreaks of cyclosporiasis, a foodborne (ODNI). parasitic infection, in the United States.

54 TFAH • RWJF In 2014, CDC released a Surveillance surveillance systems through shared l In 2016, the NSSP will provide Strategy to facilitate consolidating IT services. This work will provide new enhanced systems and tools through systems, eliminate unnecessary opportunities for data integration; data the BioSense Platform to support timely redundancies and reduce reporting analysis and visualization; and advancing exchange of syndromic surveillance burdens by supporting a system that work with electronic health records and data among local, state, and federal would achieve four cross-cutting priority other emerging health information agencies for nationwide situational initiatives: standardizing health data and technology. These efforts can be awareness and response to hazardous exchange systems through the Notifiable accelerated through additional resource events and disease outbreaks. Diseases Surveillance System (NNDSS) investments. Based on progress to date, l In 2016, 70 percent of laboratory Modernization Initiative, enhancing CDC anticipates: reports to public health agencies the National Syndromic Surveillance l By 2016, 90 percent of data on (CDC and states) will be received as Program (including BioSense) to make nationally notifiable diseases will be electronic lab reports. real-time pre-diagnostic data from transmitted through NNDSS using electronic health records more accessible l In 2016, 70 percent of death reports (i.e., Health Level 7 (HL7) standards and usable, accelerating electronic lab cause of death) occurring in at least 25 thereby enhancing timeliness, reporting and enabling rapid electronic states will be transmitted electronically availability and usability by CDC mortality reporting through the to public health agencies within one day programs and state, territorial, local National Vital Statistics System (NVSS). of registration and to CDC/National and tribal (STLT) agencies. CDC is currently working to integrate Center for Health Statistics.198

TFAH • RWJF 55 RECOMMENDATIONS: Modernizing Disease Surveillance

Disease surveillance needs to be dramati- l At a state and local level, many a pathogen’s match to more efficiently cally improved to become a true real-time, health departments still lack the identify an outbreak.202 interoperable system, able to quickly iden- basic hardware, software, and staff l Leveraging Health Information Tech- tify outbreaks and threats and implement training to be able to receive and nology: The increased widespread and containment and treatment strategies. interpret data from EHRs or other consistent use of EHRs and electronic Advances in health information technol- sources and to be able to integrate laboratory reporting have the potential to ogy (HIT) and EHRs provide new opportu- or upgrade systems. Support for provide public health officials with data nities to integrate and improve systems. building and maintaining baseline ca- in real time and offer two-way commu- TFAH recommends expeditiously moving pabilities should be a high priority. nication between healthcare providers forward on the recommendations of the l CDC should review its grants that and health departments. This can allow 2014 CDC Surveillance Strategy,199 the include a disease surveillance com- health departments with better, faster 2012 National Biosurveillance Strategy200 ponent to ensure they dovetail with data to track outbreaks and let provid- and the 2013 National Biosurveillance the agency’s surveillance strategy by ers know about risks to their patients Science and Technology Roadmap201 and prioritizing interoperability and inte- in a more timely way. The Office of the addressing key concerns, including: gration of data systems, upgrading National Coordinator for Health Informa- l Modernizing and integrating sys- state and local health informatics tion Technology (ONC) must work with tems: Significant new investments are workforce and technical capacity, software developers, public health pro- needed to update the disease surveil- adapting to a standardized messag- fessionals, providers and laboratorians to lance landscape, including internal ing language, and reducing redun- ensure information exchange is feasible CDC systems and state and local in- dancy and reporting burden. and accessible while maintaining patient formatics capacity. The federal govern- privacy. Government agencies should set l Supporting new technological advances: ment should work to upgrade systems standards for data, identify what health Even the most developed systems at to the latest technologies to allow for information is most relevant for public CDC must continually be upgraded to real-time and interoperable tracking of health purposes, and ensure that public take advantage of new technological diseases — to more efficiently collect health agencies have ready access to advances. For instance, technologies to and analyze data, to better identify these data and the capacity to analyze make point-of-care (POC) diagnostics in- threats and to understand how threats information. CDC should continue to ex- creasingly available would greatly improve can be interrelated. By investing in plore the feasibility and implementation appropriate care during mass emergen- modernization now, the public health of a cloud-based platform for electronic cies. Also, prioritizing funding of CDC’s system at the federal and state levels case reporting. Such a platform would Advanced Molecular Detection (AMD) could save money in the long run by enable healthcare providers and public initiative to build molecular sequencing reducing duplicative, work-intensive health to exchange de-identified health and bioinformatics capacities would allow legacy systems. data on a common system, rather than public health workers to rapidly look for separate systems for each state.

56 TFAH • RWJF C. Incentivize and Support Medical Countermeasure Research, Development and Distribution The government is often the only real customer for most medical countermeasure products, such as anthrax and smallpox vaccines. As a result, the U.S. government has invested in the research, development and stockpiling of emergency MCMs for a pandemic, bioterror attack, emerging infectious disease outbreak, or chemical, radiological, or nuclear event.

Development of medical products for initial investment has been depleted the nation’s biodefense is a key piece of and is now dependent on substantially any public health emergency response. decreased appropriations of $255 A successful domestic MCM enterprise million annually. will prepare the nation for new threats, The Public Health Emergency expected or unexpected, by building the Medical Countermeasures Enterprise science, policy and production capacity (PHEMCE), created in 2006 by HHS, is in advance of an outbreak. made up of federal partners, including Congress enacted Project BioShield the Office of the Assistant Secretary in 2004 to spur development and of Preparedness and Response, CDC, procurement of MCMs. The Pandemic FDA, NIH, DoD, VA, DHS and USDA, and All-Hazards Preparedness Act responsible for protecting the nation (PAHPA) of 2006 established and from the health effects associated with authorized the Biomedical Advanced chemical, biological, radiological and Research and Development Authority nuclear (CBRN) threats, through the (BARDA) to speed up the development use of MCMs. In 2014, ASPR released a of MCMs by supporting advanced PHEMCE Strategy and Implementation research, development and testing; Plan, which provide the blueprint the working with manufacturers and PHEMCE will follow for the next five regulators; and helping companies years to achieve its strategic goals, which devise large-scale manufacturing include developing critical MCMs, strategies. BARDA bridges the funding establishing clear regulatory pathways, gap between early research and developing operational plans for use, production.203 The Project BioShield and addressing gaps and plans for Special Reserve Fund (SRF) was making sure new MCMs are available for originally established as a $5.6 billion all sectors of the population.204 PHEMCE fund, over 10 years, to guarantee a will require significant new investments market for newly developed vaccines to achieve the goals outlined. and medicines needed for biodefense BARDA, along with partners at NIH, that would not otherwise have a FDA, CDC, DoD, international health commercial market. After delivering agencies and private companies have 12 new medical countermeasures to been instrumental in making advances the Strategic National Stockpile, that

TFAH • RWJF 57 toward developing vaccines and treatments being piloted for Ebola. Due to Ebola supplemental funding, BARDA’s portfolio of Ebola MCMs grew from no candidates in early 2014 to 10 vaccine and therapeutic candidates in eight months to address the current and future Ebola epidemics and potential Ebola-related bioterrorism acts.205

In 2015, in addition to multiple Ebola products, HHS invested in research and development of a new anthrax vaccine and test, novel antibiotics, mass decontamination response, a treatment for mustard gas, experimental flu antivirals, more effective flu vaccines, and burn treatments.206 All told, BARDA investments have resulted Source: Bavarian Nordic in over 160 candidate products in the pipeline for CBRN threats and pandemic influenza, with eight products and availability of medical products population during emergencies, when receiving FDA approval in the past three — treatments, vaccines, diagnostic there is no adequate, approved and years and 12 products procured for the tests and PPE — to help bring an available alternative.208 In August SNS through Project BioShield.207 epidemic under control as quickly 2010, FDA launched the Medical l FDA and Biomedical Infectious as possible. Under its Emergency Countermeasures Initiative (MCMi) to Disease Research, Development and Use Authorization (EUA) authority, help define and prioritize requirements Safety: FDA plays an important role FDA can allow the use of an for MCMs in public health in the development and approval of unapproved medical product — or emergencies, coordinate research, set new drugs and devices. The agency an unapproved use of an approved deployment and use strategies, and can also expedite the development medical product — for a larger facilitate access to products.209

NEW SCREENING TESTS Reliable, rapid and simple screening tests ored, prism-shaped silver nanoparticles to (ELISA), these paper-based tests provide can speed up diagnosis and reporting and detect multiple infections by capturing virus an important tool for health professionals enhance faster access to care. proteins from a patient’s blood. The paper out in the field to track outbreaks. The time turns red for Ebola, green for dengue or and location of each test can be read by a A new paper-based test has been devel- orange for yellow fever. While not as accu- cellphone and uploaded to the Internet to oped to quickly diagnose Ebola, dengue rate as the controlled lab-based tests PCR generate a map of the outbreak.210 fever and yellow fever in the field with no and enzyme-linked immunosorbent assay electricity or running water. It uses multicol-

58 TFAH • RWJF RECOMMENDATIONS: Improving Research, Development and Distribution of Medical Countermeasures

TFAH recommends that the United States partners to determine the regulatory women in the SNS: Progress contin- place a higher priority on research, de- and scientific barriers to non-emergency ues to be made to make sure there velopment and procurement of MCMs, use of biodefense technologies. are safe options available for children. including vaccines, medicines and di- The federal government should set l Creating new incentives to encourage agnostics. Policymakers must ensure a goal to increase the development private sector partners to continue that the public health system is involved and procurement of pediatric and investing in medical countermeasures in this process, from initial investment obstetrical MCMs so that the right development: New incentives are through distribution and dispensing. The countermeasure in the right dose and needed to ensure medical countermea- nation’s MCM enterprise could be ad- formulation at the right time can be sures are developed, licensed, and vanced through the following activities: safely delivered to all children during available to protect Americans from an emergency. l Supporting the entire medical counter- all national security threats. The major measure enterprise, from initial incentive for biopharmaceutical compa- l Fostering public-private partnerships research through stockpiling and com- nies in biodefense — the “guaranteed for distributing and administering vac- munity-level distribution and dispens- market” intended by the BioShield Spe- cines and medications: Federal, state ing: The PHEMCE must receive robust cial Reserve Fund — is effectively gone and local health departments should federal funding to ensure continuation with limited funding available. One op- partner with nongovernmental entities of the pipeline, provide assurances to tion being explored is extending priority to develop the most efficient distribution industry that the government will be a review vouchers for biodefense medical and dispensing mechanisms for MCMs reliable partner in development and pro- countermeasures to encourage compa- in an emergency. In some communities, curement of new products, and ensure nies to continue development efforts. private sector, healthcare, communi- products reach the intended recipients. ty-based or faith-based organizations l Ensuring the development and avail- These funding priorities should include may have better systems in place to ability of safe vaccines and medi- no-year funding in the SRF for procure- reach target populations. cations for children and pregnant ment; annual funding for advanced development at BARDA; regulatory science in FDA’s MCMi to promote safe pathways to approval for new products; adequate resources for the SNS to maintain existing, expiring, and new product stockpiles; and support for state and local health capacity to dispense MCMs. The PHEMCE multiyear budget plan should be a guide for funding these programs for the coming years. l Exploring alternate uses for MCM innovations: Some MCM technologies, such as innovations in pandemic influenza vaccine development, may have appli- cations for non-biodefense purposes, such as a severe flu season with a mismatched vaccine. HHS should work with international and private sector Source: Alliance for Biosecurity

TFAH • RWJF 59 D. Address Climate Change Impact on Infectious Disease Outbreaks Health departments have an important role to play in helping communities prepare for the adverse effects of climate change, given their role in building healthy communities. Public health workers are trained to develop communication campaigns that both inform and educate the public about health threats and can use these skills to educate the public about climate change-related disease prevention and preparedness. Public health departments are also on the frontlines when there is an emergency, whether it is a natural disaster or an infectious disease outbreak. These types of emergency preparedness and response skills will be invaluable as extreme weather events become more common.

RECOMMENDATIONS: Preventing and Preparing for the Adverse Impact of Climate Change on Infectious Disease Outbreaks

To help prevent and prepare for the new and l Developing sustainable state and local l Expanding the National Environmental increased infectious disease threats that mosquito control programs: A review Health Tracking Network: The CDC’s climate change poses, TFAH recommends: by ASTHO found that many states and environmental public health tracking local communities are challenged to program should be expanded and fully l Ensuring every state has a compre- develop and maintain vector control funded to cover every state. Currently, hensive climate change adaptation programs, especially in tight budgetary the program only supports efforts in 23 plan that includes a public health times and when emergency situations states and New York City. CDC should assessment and response: State and have quieted, but that these programs be provided with the mandate and local health agencies should engage in are a vital public health strategy to help resources to expand the network so it public education campaigns and estab- control vector-borne diseases.211 can become a centralized, nationwide lish relationships with vulnerable pop- health tracking center, and each state ulations as part of any plan. States l A review by the Council of State and should receive the necessary funding to should update state hazard mitigation Territorial Epidemiologists of capabil- fully conduct health-tracking activities. plans to include climate change adap- ities for surveillance, prevention and A fully funded tracking network should tation, as proposed by FEMA. control of mosquito-borne virus infec- demonstrate interoperability with the tions found that the number of staff l Improving prioritization and coordi- larger HIT system to facilitate two-way working at least half time on WNV sur- nation across public health and en- communication between clinicians and veillance has dropped by 41 percent vironmental agencies: Public health state and local public health officials. and the number of states conducting agencies at all levels must work in mosquito surveillance dropped from l Building resilience to climate-related coordination with environmental and 96 to 80 percent; 58 percent of health effects at the federal, state and other agencies to undertake initiatives states have reduced mosquito trap- local level: Climate change prepared- to reduce known health threats from ping capabilities; and 68 percent of ness should be a required element of food, water and air, and educate the states reduced mosquito testing from PHEP and HPP plans and grants. Fund- public about ways to avoid potential 2004 to 2012.212 Cuts in federal sup- ing should be significantly increased risks. State and local public health de- port via the Epidemiology and Labora- to expand CDC’s Climate Ready States partments are also uniquely positioned tory Capacity cooperative agreement and Cities Initiative nationwide and to to help states understand the health program has resulted in reduced mos- build capacity at the federal, state and impacts of climate change as they quito surveillance (trapping, testing or local level to understand the impact of work to develop and implement state both) in 70 percent of states and 75 climate change and apply this to long- plans to curb carbon pollution emis- percent of local health departments. range health planning. sions under the EPA Clean Power Plan.

60 TFAH • RWJF ONE HEALTH

CDC is part of an international ef- prevent and rapidly contain the spread fort that recognizes the importance of novel, emerging and reemerging dis- of human health being connected to eases before they spread globally has the health of the environment and significant implications for national se- animals.213 Many new and emerging curity as well as health. illnesses are transmitted from animals The initiative focuses on efforts around to humans over time — such as MERS, the globe to prevent and quickly contain avian flu or vector-borne diseases trans- zoonotic disease threats. A recent re- mitted through mosquitos or ticks; and view highlighted One Health activities in scientists estimate that six in every 17 different international locations be- 10 infectious diseases in humans are tween May 2013 and April 2014.214 spread from animals. Being able to

National Center for Emerging and Zoonotic Infectious Diseases

One Health and Zoonoses Activities at 17 Select International Locations

May 2013-April 2014

Changes Contributing to the Emergence and Reemergence of Animal-Borne Infectious Diseases Cause Effect Human populations are growingCompiled and expanding by the One As aHealth result, Officemore people live in close contact into new geographicDivision areas. of High-Consequencewith Pathogens wild and domestic and Pathology animals. Close contact provides more opportunities for diseases National Center for Emerging andto Zoonotic pass between Infectious animals Diseases and people. The earth has experiencedCenters changes for Disease in climate Control Disruptions and Prevention in environmental conditions and and land use, such as deforestation and inten- habitats provide new opportunities for dis- sive farming practices. http://www.cdc.gov/onehealtheases to pass to animals. [email protected] International travel and trade have increased. As a result, diseases can spread quickly across the globe. Source: One Health, CDC

TFAH • RWJF 61 E. Build Community Resilience Ensuring communities can cope with and recover from emergencies such as infectious disease outbreaks is a significant challenge to public health preparedness.

l Developing ongoing relationships between health officials and members of the community, so they are trusted and understood when emergencies arise; and

l Engaging members of the community directly in emergency planning efforts.

Building community resilience is one of the two overarching goals identified by HHS in the release of the draft Biennial Implementation Plan for the National Health Security Strategy. It calls for fostering The most vulnerable members of the community.217, 218 Access to high- informed, empowered individuals a community, such as children, the quality health and behavioral health and communities. Numerous tools elderly, people with underlying health services and social services (including are available to help communities conditions and those with limited- those that address homelessness and develop resilience capabilities. In English proficiency, face special substance misuse) on an everyday basis 2013, HHS and DHS launched a challenges that must be considered can mitigate vulnerabilities for ongoing Community Health Resilience Initiative before disaster strikes. disease threats and during disasters.219 (CHRI), a public-private collaboration intended to provide stakeholders with The resilience of a community — Experts recommend that improving resources and guidance to promote including its ability to recover from resilience, particularly among resilience in their communities.220 disasters — is inextricably linked to vulnerable populations, requires: CDC has also funded the development that community’s capacity to promote of a Community Resilience Index: l Improving the overall health status health, wellbeing and engagement.215 of communities so they are in better Composite of Post-Event Wellbeing Resilience is strongly tied to ongoing condition to weather and respond to (CoPE-WELL), to develop a predictor strong relationships between public emergencies. Initiatives and programs of the ability of a community to health officials and the communities supported by the Prevention and Public prepare for, survive and rebuild from a 221 they serve. The benefits of cross- Health Fund can assist in these efforts; disaster scenario. In 2015, HHS also sector collaborations were on display launched the EmPOWER Map, which l Providing clear, accurate, in response to the Boston Marathon helps communities reach Medicare straightforward guidance to the public bombing, for example, as the city beneficiaries with electricity-dependent in multiple languages via trusted depended on partnerships with equipment who could be at risk during sources respecting different cultural 222 nonprofit and faith-based partners to a power outage. RAND also has perspectives — and delivered via help the city heal.216 Resilience is also online toolkits and trainings available multiple media, beyond the Internet, dependent on public efforts to improve to help communities leverage existing such as radio, racial and ethnic 223 the overall health and wellbeing of resources to build resilience. publications and television;

62 TFAH • RWJF Are you

Nearly half of U.S. adults do NOT have the resources and plans in place in the event of an emergency. Are you prepared? Nearly half of U.S. adults do NOT have the resources and plans in place in the event of an emergency. Store a 3-day supply of water: one gallon per Store a 3-day supply of water: one gallon perperson, per day. person, per day.

Store at least a 3-day supplyStore at least a 3-day supply of non perishable of non perishable,easy to prepare food. easy to prepare food. 48% of Americans do not have emergency supplies.

44% of Americans do not have first aid kits. 20% of Americans get emergency info from mobile apps. Keep a charger handy in an emergency. 44% of Americans 20% of Americans use social media for alertsdo NOT have 48%and warnings. Make sure to keep a chargerfirst aid kits. of Americanshandy in an emergency. do NOT have emergency supplies.52% of Americans do not have copies of crucial personal documents.

Don’t forget your pets! You need a 3-day supply of food and water per pet.

of20% Americans get emergency Prepare supplies for home work infoand from vehicles. mobile apps. Keep Emergencies can happen anywhere.a charger handy in an emergency. 20%For more information visit: emergency.cdc.gov of Americans use social media for alerts and warnings. Make sure to keep a charger handy in an emergency.

Don’t forget your pets! You need a 3-day supply of 52%of Americans do NOT have food and water copies of crucial personal per pet. documents.

Prepare supplies for home, work, and vehicles. Emergencies can happen anywhere.

For more information visit: emergency.cdc.gov

TFAH • RWJF 63 RECOMMENDATIONS: Improving Community Resilience

Helping build healthier and stronger com- the needs and concerns of the public l Prioritize plans for protecting children: munities ensures they can cope with and are heard and addressed. Federal Special efforts must be made to work recover from major outbreaks, health partners must provide strong technical with childcare centers and schools to emergencies and other disasters more assistance to allow for the creation of coordinate and plan for emergencies. All easily. TFAH recommends that improving models that can be adapted to meet childcare facilities should have appropri- community resilience should be a top the needs of specific communities. ate disaster plans in place, and public priority for federal, state and local gov- health officials should work with parents, l Build community partnerships and ernments, and they should: educators, schools and school systems integrate preparedness activities into to ensure every school has a plan in l Support prevention and public health the ongoing work of public health de- place and that the plans are tested. programs: Prevention programs that partments and other social services Children should be taught how to be pre- help improve the health of communities, and community organizations: Build- pared, for example by creating plans to such as diabetes and obesity prevention ing partnerships and preparedness en- reunify with teachers or parents. efforts and infection control programs, gagement between health departments can decrease the vulnerability for infec- and other services, agencies and com- l Ensure rebuilding efforts incorporate tious diseases by improving American’s munity groups, such as housing and best practices for making the commu- underlying health and contribute to strat- faith-based organizations, creates im- nity even stronger: As communities egies to contain the spread of infections portant channels for reaching and pro- recover from a disaster, they should be and reduce the need for chronic disease viding assistance to at-risk individuals rebuilt to maximize community resil- services during an emergency. and neighborhoods in times of crisis ience, health outcomes and social ser- — and should be a core foundational vices. The IOM’s 2015 report, Healthy, l Include community resilience in emer- capability for health departments.224 Resilient, and Sustainable Communities gency preparedness plans: It is im- After Disasters: Strategies, Opportunities, portant for health officials to know and l Incorporate community resilience and Planning for Recovery, laid out strat- understand special needs and concerns into hospital activities: Under recent egies for communities to improve upon in different areas of the community, par- changes to nonprofit hospitals’ Form the pre-disaster status quo, including ticularly where there are many vulner- 990 reporting, the Internal Revenue integrating health considerations into able populations. Health officials and Service (IRS) will allow a hospital’s ef- recovery decision-making through emergency management officials must forts on community resilience to count National Disaster Recovery Framework, have plans and mechanisms in place to as a community benefit activity.225 engaging the community through acces- provide assistance to these neighbor- Hospitals should incorporate communi- sible information and training, and coor- hoods in times of crisis, and members ty-wide disaster preparedness planning dinating recovery resources.226 of these communities should be part of into their community benefit efforts. any emergency planning effort to ensure

64 TFAH • RWJF GUARANTEED PAID SICK LEAVE

Nearly 40 percent of private-sector em- and occupations that require frequent one or two days off could reduce workplace ployees cannot earn paid sick days for contact with the public are some of the infections by up to 40 percent228 while an- their own illness or injury or to care for least like to provide paid sick days. This other estimates that seasonal flu results an ill family member. And low-wage work- increases the chance of infectious dis- in $18.9 billion per year in indirect costs ers are much less likely to be offered eases spreading through contact with attributable to lost productivity.229 paid sick leave than highly paid workers. food, co-workers and the general public Paid sick days also improve access to — and it could threaten the productivity Paid sick days help reduce the spread preventive care by giving employees the and safety of America’s businesses. of contagious illnesses and diseases ability to take time to go to a clinician and and increase access to preventive care Paid sick days help to ensure workers to ensure their children get routine check- among workers and their families. When can comply with science-based guidance ups and immunizations. A 2012 CDC workers without paid sick leave get sick, on controlling the spread of an outbreak. report found that workers without paid they face the impossible choice of going According to a 2010 report, almost 26 sick time are less likely to get screened to work and potentially infecting others or million employed Americans age 18 and for cancer.230 There are clear signs that staying home and risking losing their jobs. older may have been infected with the delaying or skipping necessary preventive H1N1 influenza in 2009, and nearly eight care can result in poor health outcomes Employees who are sick and possibly million people took no time off work while and more costly care for the more than 43 contagious in the workplace enable the infected.227 Another recent study found that million American workers who lack paid spread of illness among co-workers and providing employees who have the flu with sick days and their families. customers alike, and the very industries

TFAH • RWJF 65 F. Health System Preparedness and Enhancing Surge Capacity and Infection Control In public health emergencies, such as a new or major disease outbreak, a bioterror attack or catastrophic natural disaster, U.S. hospitals and healthcare facilities are on the front lines providing triage and medical treatment to individuals. The ability of our healthcare system to quickly provide safe care for an influx of patients during an emergency is critical, but it is often identified as one of the most difficult components of a preparedness response.

Not only must healthcare facilities be This requires a solid foundation built able to quickly ramp up staffing to meet on basic infection control principles, increasing demand, but they must be sufficient personal protective equipment able to do so with clear and effective and training in the proper use, removal safety protocols in place, including and disposal of protective gear. There adequate personal protective equipment must also be regular drilling to simulate and staff that are highly trained to potential outbreaks and identify gaps in protect not only patients, but themselves. preparedness.

l Basic Infection Control and Safety: l Surge Capacity: During a severe health It is critical that all medical care emergency — such as a pandemic be provided under conditions flu outbreak or mass bioterror attack that minimize or eliminate risks of — the healthcare system would be healthcare-associated infections and stretched beyond normal limits. adverse events. Outbreaks and large- Patients would quickly fill emergency scale patient infections continue rooms and doctors’ offices, exceed the to be associated with breakdowns existing number of available hospital in standard precautions and lack beds, and cause a surge in demand for of adherence to recommended critical medicines, healthcare providers prevention practices. A strong and equipment. The challenge of how foundation in infection control and to equip hospitals and train healthcare prevention is needed across the staff to evaluate and care for the large healthcare continuum. This will influx of critically injured or ill patients require clear standards, training, and who require treatment after or during dedicated resources. a public health emergency remains a challenging issue for public health l Emerging Threats: Healthcare facilities and medical preparedness. Emergency must have standard procedures in rooms and intensive care units (ICUs) place when new serious outbreaks often have limited numbers of beds, occur to be able to safely diagnose and staff and equipment during normal treat patients, and to ensure that other conditions and would be tested if there patients and the healthcare workers were a major influx of patients. themselves are protected from exposure.

66 TFAH • RWJF The Hospital Preparedness Program, information and coordinate planning administered by ASPR, provides and response efforts.232, 233 Through leadership and funding through grants the planning process and cooperation and cooperative agreements to states, within healthcare coalitions, facilities territories and eligible cities to improve are learning to leverage resources, surge capacity and enhance coordinated such as developing interoperable community and hospital preparedness communications systems, tracking for public health emergencies.231 HPP available hospital beds, and sharing assets was created to build capabilities in the such as mobile medical units. HPP was areas of health system preparedness, reauthorized in the Pandemic and All- health system recovery, medical surge, Hazards Preparedness Reauthorization emergency operations coordination, Act (PAHPRA, P.L. 113-5), but funding fatality management, information for the program has been cut from a sharing, responder safety and health and high point of $515 million in 2004 and volunteer management. HPP supports is now funded at about $255 million regional coalitions of healthcare facilities annually to support the entire nation’s and public and private partners to better health system preparedness. use assets across systems, disseminate

TFAH • RWJF 67 RECOMMENDATIONS: Enhancing Health System Preparedness for Infectious Diseases and Surge Capacity

Health system preparedness capacity quality initiatives, such as CMS mea- and capabilities have been one of the sures, Joint Commission standards and most persistent problems in public health National Quality Forum (NQF) measures. preparedness and require increased The payment system should also pro- agreement and implementation on crisis mote preparedness and community standards of care and improved inte- health resilience by incorporating key gration of preparedness concerns into indicators of preparedness into clinical overarching healthcare systems and quality measures, such as Medicare’s coordination across public health and shared savings program and Merit-Based healthcare providers. To help improve Incentive Payment System.234; and

health system preparedness concerns, l Publicly reporting outcomes data from while also ensuring safety protocols are HPP measures so policymakers can in place, TFAH recommends: track progress and gaps in the program.

l Continuing to rebuild and modernize l Improving hospital preparedness — as the Hospital Preparedness Program, a partnership across hospitals, HPP including focusing on: and public health — for emerging and l Rebuilding the program by restoring ongoing infectious disease threats:

funding to enable adequate develop- l Every hospital should have baseline ment of healthcare coalitions and train- capabilities for screening and basic iso- ing and exercising of hospital staff; lation capabilities to ensure healthcare l Continuing to prioritize coordination workers and patients are safe from a between the inpatient and outpatient potential threat — including training in health systems, including long-term infection control and use of protective care facilities and clinical laboratories, gear and safe removal and disposal of and ensure that healthcare coalitions protective gear and waste. To maximize are reaching out to these partners; efficient and effective use of expertise

l Strengthening coordination between and resources, HHS, state public health the HPP and CDC programs, including departments and hospitals should main- PHEP and other infectious disease tain the “tiered” system created with control efforts; Ebola response funds — where patients are safely transported to a set of hospi- l Defining a minimum set of standards tals with increased capabilities and facil- and population size that a healthcare ities to treat different potential scenarios coalition must meet to be considered for a range of types of emerging threats effective. While HPP has avoided — to ensure a nationwide capability to being overly-prescriptive with grant- screen, triage and treat a mass influx ees, limited budgets demand that of patients during a severe pandemic healthcare coalitions should meet a flu outbreak. This should include sup- federally-defined standard for their porting and assuring Emergency Man- ability to respond to a disaster; agement System (EMS) capacity and l Refining HPP measures and aligning capabilities as first responders as well measures with other health system as in handling inter-facility transport;

68 TFAH • RWJF l Hospitals, public health agencies and release of emergency preparedness emergency response units should requirements for Medicare and Med- invest in individual and joint training, icaid participating providers, which drills and preparing frontline health- were proposed in 2013.236 Once care workers for unfamiliar infections finalized, CMS and ASPR should work and disasters; together to align those requirements

l Every hospital and outpatient health- with HPP, provide technical assis- care system should be able to screen tance to eligible entities, ensure for emerging threats, isolate patients coordination between CMS suppliers when necessary, protect healthcare and local healthcare coalitions and workers and other patients, and pre- track progress;

pare patients for transport if unable l Expand telemedicine and telephone to treat; triage, such as the Flu On Call l Health systems and HIT vendors model,237 to increase surge capacity should incorporate health alerts from and concentrate resources where CDC into electronic medical records so needed; and that the triage process includes rele- l The HPP program and CDC’s PHEP vant screening questions and decision program should ensure that com- support. Health providers should rou- munities and health systems are tinely take travel histories upon intake regularly exercising and evaluating and be prepared to promptly isolate emergency response plans. potential cases needing evaluation; l l The inpatient and outpatient Establishing and implementing ef- healthcare system, HPP and fective crisis standards of care and healthcare coalitions, Joint resource allocation planning: Commission and CMS should l Public health must take a leadership ensure health facilities incorporate and quality assurance role to ensure pediatric considerations, such as health facilities and systems are en- those proposed by the Emergency gaging in meaningful crisis and con- Medical Services for Children tingency standards of planning and National Resource Center, into using resources created by the IOM disaster preparedness plans and and ASPR’s Communities of Interest capabilities;235 and website. If necessary, the federal

l Clinical laboratories should have ongo- government should require crisis ing staff training to ensure familiarity standards planning of PHEP and HPP and adherence with protocols for han- grantees. Meanwhile, given recent dling, packaging and preparing danger- shortages of everyday medical prod- ous pathogens and waste for transport. ucts, the roles and potential actions of federal agencies, including ASPR, l Incorporating preparedness into the CMS and FDA, should be clarified be- healthcare delivery system: fore the next outbreak, disaster drug l CMS should finalize and expedite the or medical supply shortage.

TFAH • RWJF 69 RECOMMENDATIONS: Reducing Healthcare-Associated Infections Across the Healthcare Spectrum

HAIs continue to be an ongoing, serious assistance and to monitor national preventable problem, where millions progress in infection control; of Americans are infected each year l Support the identification of single while receiving routine medical care in infections and clusters of infections, hospitals and through outpatient and and rapidly implement control long-term care facilities. HAI tracking measures; and and oversight is currently limited in non- hospital settings. l Implement and facilitate new infection control licensure requirements for Recent efforts to improve infection healthcare workers and collaborate control practices have started showing with state hospital associations and promising results in reducing HAIs. medical societies to survey infection TFAH recommends that public health control training needs and provide and healthcare officials should make CDC supported trainings. limiting HAIs a top priority in hospitals and across the U.S. healthcare system, l Fully and Swiftly Implementing the which includes: National Action Plan to Prevent Healthcare-Associated Infections: A l Aligning incentives to promote Roadmap to Elimination:239 Some key prevention: Initiatives like the strategies in the Action Plan include: Medicare “no pay” rules and prevention-oriented healthcare l Reducing inappropriate and payment strategies outlined in a call unnecessary use of devices, like to action in the American Journal catheters and ventilators; of Infection Control can provide l Expanding HAI prevention efforts incentives for healthcare providers to beyond the hospital setting, to improve practices to reduce infections include ambulatory surgery centers, and infection-related costs.238 dialysis clinics, and long-term care l Supporting State HAI and Infection (LTC) facilities, including finalizing Control Programs: Key areas where the CMS proposed rule to improve states can play a critical role in antibiotic stewardship, vaccination supporting infection control and HAI and other infection control prevention: practices in LTC;240

l Coordinate and assess infection l Adhering to the best hygiene practices; control capacity across healthcare l Prescribing antibiotics only when facilities in each jurisdiction; absolutely necessary; l Ongoing tracking of local facilities l Improving education, communication performance through National and best-practice protocols as the Healthcare Safety Network to regular standard-of-care throughout identify facilities in need of entire healthcare facilities; and

70 TFAH • RWJF l Improving reporting and regulatory of HAIs so that gaps in infection oversight of HAIs and financial prevention in the targeted locations incentives for reducing the number can be addressed. TAP reports are of infections. available within the NHSN application for use by hospitals and NHSN l All healthcare facilities should make Groups with access to hospital following infection control best data for catheter-associated urinary practices a top priority: tract infections (CAUTI), central line- l Efforts to define and enforce basic associated bloodstream infections standards of infection control in and laboratory-identified (LabID) event inpatient and outpatient settings (e.g., Clostridium difficile infections (CDI).242 CDC’s Guide to Infection Prevention for l Ensuring the country maintains Outpatient Settings)241 and effective sufficient personal protective oversight activities (e.g., audits and equipment and infection control inspections), though increasing, require training to be able to provide strengthening at both the state and adequate protection for healthcare federal levels. workers, patients and others during an l In order to have a robust infection outbreak: Limits in the availability and prevention program that is able to training on the appropriate use of PPE prevent infections day to day and scale were a cause for concern for healthcare up operations during a public health workers and others during the Ebola emergency, healthcare facilities must outbreak and pandemic H1N1. have appropriate infection prevention Different outbreaks require different personnel staffing, ample training PPE responses, and it is important to and observation to ensure that have strategies, training and support in guidelines are followed precisely, and place for different scenarios. Issues technology and equipment to maximize of sufficiently available appropriate PPE efficiencies and provide real-time data could become exponentially amplified to help infection prevention specialists during a widespread outbreak. detect and prevent infection. Healthcare and public health systems and accrediting bodies should ensure l Healthcare facilities must work systems and supplies are in place to target HAI prevention efforts. to provide the appropriate staff — CDC has developed the Targeted healthcare workers, first responders, Assessment for Prevention (TAP) and ancillary staff such as cleaning strategy, which uses National professionals — with adequate training Healthcare Safety Network data for on the PPE and infection control action to target healthcare facilities procedures relevant to their roles. and specific units within facilities with a disproportionate burden

TFAH • RWJF 71 G. Improve Vaccination Rates — for Children and Adults Vaccines are the safest and most effective way to manage many infectious diseases in the United States. Some of the greatest public health successes of the past century — including the worldwide eradication of smallpox and the elimination of polio, measles and rubella in the United States — are the result of successful vaccination programs.243 A recent model estimated that from 1994 to 2013 the Vaccines for Children program in the U.S. will have prevented as many as 322 million illnesses and 732,000 deaths at a net savings of $1.38 trillion in societal costs.244

However, despite the recommendations of the vaccines they need unless they are medical experts that vaccines are effective part of institutions that have vaccine and that research has shown vaccines to requirements, such as being enrolled be safe, on average, an estimated 45,000 in colleges or universities, serving in adults and 1,000 children die annually the military or working in a healthcare from vaccine-preventable diseases in the setting. Significant numbers of adults do United States.245 not have regular well care exams, switch doctors or health plans often or only Millions of Americans are not receiving the seek care from specialists who do not recommended vaccinations. For instance, traditionally screen for immunization more than 2 million preschoolers do not histories or offer vaccines. This makes receive recommended vaccinations; there it extremely difficult to establish ways have been outbreaks of measles, mumps for people to know what vaccinations and whooping cough around the country; they need and for clinicians to track and vaccination gaps put teens and young recommend vaccines to patients. adults at risk for HPV and bacterial meningitis; and more than 35 percent of seniors The Community Preventive Services have not received the recommended pneu- Task Force, which evaluates the available mococcal vaccination.246, 247, 248 evidence base for public health programs and strategies, has found that when While many efforts focus on vaccines education and registry systems are in for children, it is also important to place and used, combined with other address the fact that currently, there is intervention components, they are no real system or structure in place to effective in improving vaccination rates.249 ensure adults have access to or receive

72 TFAH • RWJF HPV VACCINATION IS THE BEST WAY TO PREVENT MANY TYPES OF CANCER MANY ADOLESCENTS HAVEN’T STARTED THE HPV VACCINE SERIES

* NATIONWIDE Percentage of adolescent girls who have received one or more doses of HPV vaccine OUT 4 OF10 GIRLS ARE UNVACCINATED

National coverage is 60% Coverage by state: 49% or less 50-59% 60-69% 70% or greater

* NATIONWIDE Percentage of adolescent boys who have received one or more doses of HPV vaccine OUT 6 OF10 BOYS ARE UNVACCINATED

National coverage is 42% Coverage by state: 29% or less 30-39% 40-49% 50% or greater

IMPROVING HPV VACCINATION RATES WILL HELP SAVE LIVES. *Estimated coverage with ≥1 dose of Human Papillomavirus (HPV) vaccine, A high national Tdap vaccination rate of 88% shows that it either quadrivalent or bivalent, among adolescents aged 13-17 years, National Immunization Survey–Teen (NIS–Teen), United States, 2014 is possible to achieve high HPV vaccination coverage. Source: MMWR July 31, 2015

U.S. Department of Health and Human Services Centers for Disease www.cdc.gov/hpv Control and Prevention CRDi ly

TFAH • RWJF 73 RECOMMENDATIONS: Increasing Vaccination Rates

Improving the nation’s vaccination rates of tools for providers to communicate vaccination histories for all patients would help prevent disease, mitigate with parents.253 Training is also needed — including adults — and offer vaccina- suffering, and reduce healthcare costs. for providers to ensure they are able to tions to adults during other doctor and TFAH recommends a number of actions effectively educate patients and make hospital visits. that can be taken to increase vaccina- a strong recommendation for vaccines l Bolstering immunization registries tion rates for children, teens and adults across the life cycle. and tracking: Federal and state policy- around the country, including: l Making adult vaccinations routine — makers should take steps to facilitate l Minimize vaccine exemptions: States including regular recommendations interoperability and data use between should enact and enable universal and referrals: Private providers and immunization registries and EHRs as childhood vaccinations except where im- health systems should have standing well as between state immunization munization is medically contraindicated. orders for vaccinations so every pro- registries. This will help track when Non-medical vaccine exemptions, includ- vider of care for adults can assess patients receive vaccines, improve infor- ing personal belief exemptions (PBE), en- the need and recommend, and either mation sharing and data security across able higher rates of exemptions in those provide directly or refer to another pro- providers, remind providers to routinely states that allow them. School exemp- vider for vaccination. Vaccine locator provide recommended vaccinations, tion rates should also be made publicly systems should be expanded to build remind patients of vaccinations and available so parents and educators un- an effective vaccine referral system so address gaps. State health information derstand the risks. The National Vaccine providers can ensure the vaccine is ad- exchanges or hub models may make Advisory Committee (NVAC) recommends ministered, just as for mammograms or this process simpler by encouraging in- states with existing PBE policies should other preventive services. EHRs should tegration of registry data into EHRs and strengthen policies so that exemptions provide reminder recalls to patients enabling immunization registries (immu- are only available after appropriate par- and providers through text messages or nization information system (IIS)) data ent education and acknowledgement of other communications. A routine adult exchange between states. Measures risks to their child and the community.250 vaccination schedule should be estab- must be taken to encourage greater lished, where healthcare providers are participation by healthcare providers and l Boosting demand for vaccines: Fed- expected to purchase, educate, advise pharmacists, particularly private provid- eral, state and local health officials, in about and administer immunizations to ers, in registries. Lifespan registries partnership with medical providers and patients. would also help better track patients’ community organizations, should con- medical history to ensure they have re- tinue to expand assertive campaigns l Expand alternate delivery sites: NVAC ceived all needed vaccinations through- about the importance of vaccines, has recommended including expansion of out their lives — to help improve and particularly stressing and demonstrat- vaccination services offered by pharma- track vaccination rates for both children ing the safety and efficacy of immuni- cists and other community immunization and adults. zations. Targeted outreach should be providers, vaccination at the workplace, made to high-risk groups and to racial and increased vaccination by providers l Supporting expanded research and use and ethnic minority populations where who care for pregnant women.254 of alternatives to syringe administration the misperceptions about vaccines of vaccination: Experiences with alterna- l Increasing provider education: Profes- are particularly high.251, 252 To increase tive delivery methods, such as using the sional medical societies and medical confidence and demand for vaccines, nasal mist administration of live-attenu- and nursing schools should support on- an NVAC committee has also recom- ated influenza vaccine (LAIV), have been going education and expanded curricula mended an index to measure and track well-received by the public and have con- on vaccines and vaccine-preventable vaccine confidence, consistent commu- tributed to increased uptake in pediatric diseases, and expand standard prac- nications assessment and feedback for and adult vaccinations.255, 256 tice for providers to discuss and track vaccine confidence, and a repository

74 TFAH • RWJF l Ensuring first dollar coverage and patient must get immunized by an in-net- ican (SHEA) and the Pediatric Infectious access to all recommended vaccines work pharmacist or find a healthcare Diseases Society (PIDS) support univer- under Medicaid, Medicare and private provider who accepts Part D and carries sal immunization of healthcare person- insurance: State Medicaid programs the needed vaccine, and not all benefi- nel (HCP) by healthcare employers (HCE) are not currently required to offer all ciaries have Part D coverage. All public as recommended by ACIP. According to a recommended adult vaccinations without and private payers should ensure that all joint policy statement by the three Soci- co-payments. While some states offer ACIP-recommended vaccines are covered eties, mandatory immunization programs coverage of all recommended vaccines, without cost sharing requirements. are the most effective way to increase others do not, and many have co-pay- HCP vaccination rates.257 The Societies l Requiring on-time immunizations — ments, which present a significant cost also support requiring comprehensive based on the medically-recommended barrier to getting immunized. The ACA educational efforts to inform HCP about vaccines for a person’s age and health also incentivizes state Medicaid pro- the benefits of immunization and risks of status — as a quality measure for all grams to cover preventive services for not maintaining immunization. health plans. adults, such as recommended vaccines, l Support development of maternal by offering a 1 percent Federal Medical l Continuing support for vaccine programs: immunizations: Consistent with the Assistance Percentage (FMAP) increase The Vaccines for Children (VFC) and Sec- recommendation of two federal advisory to states that cover services without cost tion 317 immunization programs provide committees, the Secretary of HHS should sharing, but as of 2015, only 11 states a safety net for individuals who are unin- ensure inclusion of maternal immuniza- covered all recommended services, in- sured or remain outside of the traditional tions in the vaccine injury compensation cluding: California, Colorado, Delaware, healthcare system, such as children who program (VICP) in order to allow claims to Hawaii, Kentucky, New Hampshire, New are eligible but not enrolled in Medicaid/ be pursued in the VICP to address a bar- Jersey, New York, Nevada, Ohio and State Children’s Health Insurance Program rier to developing and delivering vaccines Wisconsin. Medicare also does not (CHIP). Section 317 grants to states have for pregnant women to protect the new- consistently provide first dollar coverage also been key to building the immuniza- borns.258, 259 These vaccines are a critical for vaccines, and the different policies tion infrastructure, including enhancing tool to protect the health of newborn ba- dictate what is covered under Part B and registries, monitoring the safety and bies, who remain vulnerable to dangerous Part D, leaving many seniors with gaps in effectiveness of vaccines, responding to vaccine preventable diseases until they coverage. Beneficiaries can get flu, pneu- outbreaks, and conducting surveillance, can receive the full series of vaccinations mococcal and HBV (for at-risk individuals) outreach and service delivery. themselves. Recognizing obstetricians vaccine coverage under Medicare Part l Requiring universal immunization of and gynecologist as primary care provid- B, but an out-of-pocket payment may be healthcare personnel for all ACIP rec- ers would help promote immunizations required, depending on the shot and pro- ommended vaccinations: The Infectious among all women by ensuring these vider. The rest of the recommended vac- Diseases Society of American, the Soci- doctors can receive reimbursements for cines are covered under Medicare Part ety for Healthcare Epidemiology of Amer- vaccinating women. D, the prescription drug benefit, but the

VACCINE PREVENTABLE DISEASES

Anthrax, Cervical Cancer, Diphtheria, Japanese Encephalitis, Measles, Rotavirus, Rubella, Smallpox, Tetanus, Haemophilus influenza type b (Hib), Meningococcal disease, Mumps, Typhoid Fever, Varicella (Chickenpox), Hepatitis A, Hepatitis B, Human Pertussis (Whooping cough), Yellow Fever and Zoster (Shingles). Papillomavirus, Influenza (flu), Pneumococcal disease, Polio, Rabies,

TFAH • RWJF 75 H. Curbing Antimicrobial Resistance and Superbugs Antimicrobial resistance presents one of the greatest threats to human health around the world. While antibiotics have been used to treat numerous bacterial infections since the 1940s, over time, some bacteria have adapted so that antibiotics can no longer effectively treat them. In these cases, once easily cured infections like those due to Staphylococcus or Streptococcus can be lethal.

While antibiotic treatment is often companies have abandoned antibiotic appropriate and can even be lifesaving research and development because they for many types of infections, antibiotics are less profitable than drugs to treat are significantly overused. Studies other conditions. have found that up to half of human In 2014, the White House released antibiotics prescribing is unnecessary — The National Strategy for Combating and they are often used longer than is Antibiotic Resistant Bacteria and a recommended.260, 261 related executive order establishing Each year more than 2 million a DoD, USDA and HHS Task Americans develop antibiotic-resistant Force for Combating Antibiotic infections — and at least 23,000 of these Resistance. The strategies focus on: people die as a result.262 These are slowing the development of resistant considered to be conservative estimates, bacteria; strengthening surveillance; since surveillance is often incomplete, advancing development of diagnostic so national estimates are based on tests; accelerating research of new limited samples from select cities and antibiotics and vaccines; and improving surveillance systems. international collaboration. The President’s Council of Advisors on Antibiotic resistance leads to more Science and Technology (PCAST) also than eight million additional days released a report in 2014, outlining Americans spend in the hospital a year, recommendations around new costs the country an estimated extra $20 antibiotics and diagnostics, surveillance billion in direct healthcare costs and and stewardship with federal and private at least $35 billion in lost productivity partner goals to be reached by 2020.266 annually.263, 264 The White House followed with a more As resistance rates continue to detailed National Action Plan in 2015, increase, exponentially more people laying out specific actions and milestones are expected to get sickened and die across federal agencies to achieve the due to resistant infections, and there goals of the strategy, and is developing are few new antibiotics in the pipeline a companion National Action Plan for for approval.265 Many pharmaceutical Combatting MDR TB.267, 268

76 TFAH • RWJF Source: CDC

Source: CDC TFAH • RWJF 77 ANTIBIOTIC RESISTANT THREATS IN THE UNITED STATES, 2013 — CDC’S REPORT AND PRIORITIZATION OF THREATS269 CDC issued an Antibiotic Resistance U.S.OXA-48-like isolates were retrospec- l Clostridium difficile (C.diff) is often Threats in the U.S. 2013 report in which it tively identified from 2009. Testing for the healthcare-associated and causes life prioritized a list of 18 organisms that are bacteria has not been made a standard threatening diarrhea or colon inflamma- an urgent, serious or concerning threat practice. Forty-three known cases have tion. There were 500,000 infections, to patient safety in the United States as been reported in the past five years.276, 277 15,000 deaths in 2011.278 they are resistant or increasingly resistant to antibiotics or have become more CS253604 common because of widespread use of DEADLY DIARRHEA: 270 antibiotics. Most of the infections are C. DIFFICILE CAUSES IMMENSE SUFFERING, DEATH healthcare-associated, sexually transmitted, or food/water/agricultural-associated. IMPACT Threats from the reduced ability to treat in- Caused fections range from carbapenem-resistant 15,000 deaths in Enterobacteriaceae to methicillin-resistant one year Staphylococcus aureus and Streptococcus 500,000 Comes back at least once in about 1 in 5 patients who 1 in 11 people 65 and older died within a month of (common “strep throat”.) According to Caused close to half a million illnesses in one year. get C. difficile. C. difficile infection diagnosis. CDC, urgent threats identified include: RISK l Drug-Resistant Gonorrhea: More than 820,000 Americans are infected with gonorrhea each year.271, 272 One-third of cases are drug-resistant and there is only one drug regime that is still rec- People on antibiotics are 7-10 times more likely to get C. difficile while on the drugs and during the Being in healthcare settings, especially hospitals or More than 80% of C. difficile deaths occurred in ommended for treating the infection. month after. nursing homes. people 65 and older. Despite revised guidance and good SPREAD adherence to treatment, reported gonorrhea cases are increasing and CDC continues to warn that the potential for gonorrhea to become untreatable in the near future remains real.273, 274 Touching unclean surfaces, especially those in healthcare settings, contaminated with feces from an Failing to notify other healthcare facilities when patients l Carbapenem-resistant Enterobacteri- infected person. Dirty hands. with C. difficile transfer from one facility to another. aceae (CRE): A healthcare-associated PREVENT bloodstream infection with as high as a 50 percent death rate. There were 9,000 infections and 600 deaths.275 The CDC Wear gloves and gowns when Clean room surfaces with EPA- has identified a new strain of CRE that treating patient with C. difficile. approved, spore-killing disinfectant produces OXA-48-like carbapenemases — Improve prescribing of Use best tests for accurate results Rapidly identify and isolate patients Remember that hand sanitizer (such as bleach), where C. difficile antibiotics. to prevent spread. with C. difficile. doesn’t kill C. difficile. patients are treated. the “phantom menace” — which is able to transfer their invulnerability to other http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html normal bacteria found in the human body. www.cdc.gov/media

78 TFAH • RWJF RECOMMENDATIONS: Reducing Antibiotic and Antimicrobial Resistance

TFAH recommends policies that help through HIT. CMS should make an curb antibiotic overuse and encourage effective, facility-appropriate antibiotic new antibiotic development become stewardship program a Condition high national priorities, including: of Participation for all CMS-enrolled facilities, including the recently l Funding and rapidly implementing the proposed rules for long-term care.282 2014 Executive Order and National Healthcare facilities should participate Strategy for Combating Antibiotic- in CDC’s National Healthcare Safety Resistant Bacteria (CARB), and Network Antimicrobial Use and National Action Plan for Combating Resistance (AUR) Module, which Antibiotic-Resistant:279, 280, 281 In allows them to report and analyze its FY 2016 budget request, the antimicrobial usage at their facility Administration requested over $1 as part of antimicrobial stewardship billion in new funds for HHS and efforts and submit data through other agencies to combat antibiotic NHSN. AUR module data will also help resistance. The national CARB CDC to track regional and national strategy should receive significant trends in drug resistant disease and new funds, including the Antibiotic plan more targeted and effective Resistance Solutions Initiative at CDC, interventions. Finally, antibiotics which would carry out a multi-pronged usage and stewardship should be approach to reducing inappropriate added as National Quality Forum prescribing, improving detection of quality measures. resistant bacteria, investing in new and evidence-based interventions, and l To address overuse in healthcare supporting global partnerships. facilities, California, which has required hospital antibiotic l Reducing overprescribing: Effective stewardship programs since 2014, antibiotic stewardship must be passed a law in 2015 that requires embraced across the healthcare all skilled nursing facilities and system, especially in outpatient veterinary practitioners to adopt and and long-term care facilities. CMS, implement stewardship programs CDC, accrediting organizations, consistent with CDC and CMS healthcare facilities and medical guidelines.283, 284 organizations must work together to reduce overprescribing and misuse l Increased development and use of of antibiotics by tracking and publicly rapid point-of-need diagnostics are reporting prescribing data, educating also important to inform treatment providers and patients about the choices and quickly identify — or harm of inappropriate prescribing, and rule out — when antibiotic use may providing clinical decision support be appropriate or necessary.285

TFAH • RWJF 79 RECOMMENDATIONS: Reducing Antibiotic and Antimicrobial Resistance

l Reducing overuse in agriculture: The population of patients with serious or l State and local health departments, FDA should fully implement guidance to life-threatening infections and for drugs meanwhile, should be properly industry regarding the nontherapeutic that fill an unmet need based upon resourced to dedicate staff to use of antibiotics in food animals, such more limited data. This mechanism coordinate with facilities in the as by eradicating inappropriate use would speed access to new antibacterial area, work with CDC to better track for disease prevention, requiring real drugs to the patients who most and prevent infections and improve veterinary oversight on the farm and need them. In addition, the limited antibiotic use, and know the antibiotic a system to monitor how antibiotics indication would help protect those new resistance threats in the area.288 are being used on the farm, and antibacterial drugs from losing their l Vaccinations should be incorporated tracking the impact of these policies on effectiveness through overuse. into the national AR strategies: antibiotic usage and resistance. FDA l Improving surveillance: The country The National Vaccine Advisory should also finalize a rule to collect needs better data to monitor resistance Committee has recommended greater and make available species-specific patterns to inform local action to consideration for the role of vaccines in data around the use of antibiotics interrupt transmission, determine National Strategies to Combat Antibiotic in animals, which will help establish which interventions are working and Resistant Bacteria,289 including: baseline data to see if FDA actions are where they can be expanded. National national milestones related to the affecting usage.286 To address overuse programs with sufficient state/local uptake of vaccines that can help reduce in agriculture, California passed a law in public health resources to identify the transmission of resistant bacteria 2015 that requires livestock producers emerging patterns of both resistance and inappropriate antibiotic prescribing, to get veterinary prescriptions for and antibiotic use will quantify the such as Hib, pneumococcal, and medically important antibiotics for magnitude of antibiotic use in the U.S. influenza vaccines; surveillance efforts use in food animals, bans growth and inform new interventions. should determine the effects vaccine promotion and routine prevention uses uptake has on resistant pathogens of antibiotics, and creates a monitoring l Reducing transmission by increasing and help target vaccination efforts; an and tracking system.287 coordination between healthcare economic incentives analysis to identify facilities and health departments to l Incentivizing development of new strategies to encourage development of track and contain superbugs: CDC antibacterial drugs and diagnostics vaccines against resistant pathogens has recommended steps for healthcare through BARDA and other mechanisms: such as MRSA and C. difficile, to ensure facilities — which include improved Additional funds are needed to support a pipeline of vaccines for a potentially coordination and regionalization of the development of products to combat less profitable market; and better HAI prevention activities, developing superbugs, while ensuring investments coordination between NVAC and the systems to alert facilities when patients continue in other critical areas. President’s Advisory Council on CARB, with drug-resistant germs are being including an NVAC representative on the l Creating a limited population antibiotic transported and ensuring data are President’s Advisory Council on CARB. drug approval pathway: FDA should effectively shared across healthcare be able to approve drugs for a limited systems and public health departments.

80 TFAH • RWJF I. Reduce Sexually Transmitted Infections and TB Each year, there are 20 million new sexually transmitted infections in the United States — with half of those among 15- to 24-year-olds. Overall, around 110 million Americans have some form of STI.

STIs can have serious health consequences inject drugs. For instance, of Americans among states reporting syphilis cases with — including reproductive health problems living with HIV, 25 percent are also co- known HIV status in 2014, 51 percent of and some forms of cancer. STIs cost infected with HCV and 10 percent are co- cases in MSM were among men who were the country around $16 billion in direct infected with HBV, and HIV is one of the HIV-positive, 11 percent of cases among healthcare spending annually.290 biggest risk factors for progression of TB, men who have sex with women, and 6 while TB accelerates HIV progression.299 percent of cases among women.300 Prevention through safe sex and condom HIV coinfection with syphilis is high— use, syringe exchange programs, HPV and hepatitis B vaccines and routine screening can help identify those in need of treatment and help prevent the additional spread of the diseases and Gay and Bisexual Men Face Highest – and Rising – ensure those who need treatment receive Number of Syphilis Infections appropriate care and services.291, 292 In 14,000 addition, providing treatment to those who have HIV is one of the most effective 12,000 ways to limit the continued spread of the 10,000 disease to others. 8,000 Infectious disease prevention strategies MSM† 6,000 should be coordinated and considered MSW†† 293, 294, 295, 296, 297, 298 collectively. For example, 4,000 Women STIs can make a person more likely to transmit or be infected by HIV. In 2,000 addition, syphilis, gonorrhea, HIV/AIDS, 0 viral hepatitis and TB can have some 2007 2008 2009 2010 2011 2012 20132014 overlap in at-risk populations, including † Men who have Sex with Men † † Men who have Sex with Women racial and ethnic minorities as well as men Note: Based on available data from states reporting sex of sex partners who have sex with men and people who Source: CDC

Most Reported Chlamydia and Gonorrhea Infections Occur among 15–24-Year-Olds

Gonorrhea 350,062 Cases 20% 33% 20%17% 10% Reported 1% Chlamydia 1,441,789 Cases 26% 39% 18% 11% 4% Reported 1% 0–14 15–19 20–24 25–29 30–39 40+ Percentages may not add to 100 because ages were unknown for a small number of cases.

Source: CDC TFAH • RWJF 81 SEXUALLY TRANSMITTED INFECTIONS Gonorrhea — Rates of Reported Cases by County, United States, 2014 The sexually transmitted infections chlamydia, syphilis and gonorrhea are still largely curable with antibiotics. Yet, they are increasing in the United States. In 2014, increases were seen in all three nationally reported STIs. The more than 1.44 million cases of chlamydia represent the highest number of annual cases of any condition ever reported to CDC. Gonorrhea increased more than 5 percent from 2013 to 2014, driven by a more than 10 percent increase among men.301

CDC reports that most of the increases are Source: CDC among young adults, who get infected soon after they first engage in sexual activity. Half of the 20 million new STIs that occur Gonorrhea — Rates of Reported Cases by Year, United States, 1941–2014 every year are among 15- to 24-year-olds.302

Primary and secondary syphilis increased more than 15 percent from 2013 to 2014; if not adequately treated, syphilis can lead to permanent visual impairment and stroke. Congenital syphilis in babies increased 27.5 percent over the same time period. Babies infected with syphilis during pregnancy may have developmental delays or other poor health outcomes. Historically, up to 40 percent of babies born to women with untreated syphilis may Source: CDC be stillborn or die from the infection.

Gonorrhea — Rates of Reported Cases Among Men Aged 15–44 Years by Age, United States, 2005–2014

Source: CDC

82 TFAH • RWJF Gonorrhea — Rates of Reported Cases Among Women Aged 15–44 Years by Age, United States, 2005–2014

Source: CDC

Chlamydia — Rates of Reported Cases by County, United States, 2014

Source: CDC

Chlamydia — Rates of Reported Cases by Region, United States, 2005–2014

Source: CDC

TFAH • RWJF 83 RECOMMENDATIONS: Strengthening STI Prevention and Control

Some key recommendations include: become increasingly important. In addition, they have an important role l Promote provider adherence to U.S. in identifying new HIV cases and in Preventive Services Task Forces connecting those with HIV who have and Bright Futures Guidelines for STI fallen out of care, back into care. screening. l l Screening for STIs in certain pop- Support investigations into the ulations remains low.303 Both the causes behind STI increases and pro- USPSTF guidelines for preventive care grams to address them. for adults and Bright Futures guid- l Understanding the causes behind ance for preventive care for teens and increasing rates, especially among youth include routine screening — certain populations, is important for and follow up treatment as necessary being able to address the problem.

— for at-risk populations. l Strengthen STI surveillance sys-

l Increase support for STI Disease tems by linking health department Intervention Specialists (DIS). surveillance systems with electronic health records. l Specialists employed by public health agencies conduct contact tracing, l Initiate pilot programs intended to connection to care, and counseling reduce STI rates among highly im- for all reported cases of syphilis, not pacted populations. just those found in public clinics. l Promote widespread adaptation of As cases of syphilis rise, increasing successful models and pilot programs. the capacity of this workforce will

HIV/AIDS Successful treatment regimens have led l Reducing new HIV infections, including to complacency and a belief that HIV/AIDS focus on the most at-risk communities; is under control. But, HIV/AIDS is still a l Increasing access to care and improving significant health concern — with more health outcomes for people living with HIV; than 1.2 million Americans living with HIV, and 50,000 new HIV infections in the l Reducing HIV-related disparities and most recent reported year (2010).304 health inequities; and

In 2015, the White House released a l Achieving a more coordinated national revised National HIV/AIDS Strategy for the response to the HIV epidemic. United States outlining ongoing policy efforts and for the next five years, including:305

84 TFAH • RWJF RECOMMENDATIONS: HIV/AIDS Prevention and Control

For decades, the country has approached the HIV/AIDS epidemic focused on individ- HIV, taking my meds makes you undetectable. ual behavioral risk, but the research shows “ that is only one part of the equation. And that makes me unstoppable. ” Aaron - St Louis, MO More effective strategies include focusing Living with HIV since 2011. on prevention and improving the overall wellbeing and health of members of the lesbian, gay, bisexual and transgender (LGBT) community. This includes developing supportive and respectful policies that help reduce stigma, discrimination and bullying.306

Some key recommendations from TFAH to better prevent and control HIV/AIDS include: l Implementing a full continuum approach to eliminating AIDS — from prevention to reducing HIV risk behaviors to ensuring access and sustained treatment (and treatment as prevention) to supporting access to pre-exposure prophylaxis.307

l Recent studies have shown that HIV-positive individuals with full viral HIV suppression are far less likely to TREATMENT transmit HIV infection, while model- WORKS ing studies have demonstrated the potential for “treatment as prevention” or “test and treat” initiatives in

combination with other approaches to This is my disease. It’s in my body and I need to know everything I can to fight it. I stay informed. I talk to my doctor. dramatically slow the HIV epidemic.308 I talk to my pharmacists. And I share my story through my own YouTube channel called My HIV Journey. Three years ago, when I met my partner Phil, I told him I was HIV-positive in our first conversation. He said, ‘That’s OK. There are These strategies can only be suc- lots of ways to protect ourselves.’ Phil takes PrEP and I take my meds every day. In this relationship, HIV ends with me. cessful if individuals know their HIV status and receive full treatment.

l The U.S. Public Health Service’s guid- Get in care. Stay in care. Live well. ance supports the use of pre-expo- cdc.gov/HIVTreatmentWorks sure prophylaxis (PrEP) — to promote regular use of anti-retroviral drugs by those who are not infected with HIV to reduce the risk of HIV infection in peo- prevent transmission from an infected ple who are high risk by more than 90 partner. PrEP has been shown to percent, when taken consistently.309

TFAH • RWJF 85 RECOMMENDATIONS: HIV/AIDS Prevention and Control

l Adopting strategies to end AIDS in l While Washington, D.C. has one of the l All federal and state healthcare poli- every city and state: A number of com- highest rates of HIV/AIDS (2.5 percent) cies should be revised and aligned to munities are rededicating themselves in the nation, the newly diagnosed rate support full access to comprehensive to the fight against HIV/AIDS — setting was reduced by 57 percent from 2007 PrEP services for those for whom it a goal of ending AIDS — by increasing to 2013.312 This includes an 87 per- is appropriate and desired, including their priority, support and investment in cent reduction in intravenous drug use with support for medication adher- the full continuum of effective policies transmission. The city has launched ence — and all insurers should fully and approaches. For instance: a “90-90-90-50” plan with the goal of cover PrEP for designated individuals.

l 90 percent of people knowing their HIV New York launched a Blueprint to End l Coordinating prevention strategies status, 90 percent who are living with the AIDS Epidemic in New York State and treatment when appropriate for HIV/AIDS in care or treatment, 90 per- — with a goal of reducing new annual HIV/AIDS, hepatitis and TB: Since cent of people living with HIV having an infections from 3,000 down to 750 by the at-risk populations often overlap undetectable level of the virus in their 2020. The main components of their for the conditions, it is important to bodies and reducing the number of new three-point plan include: 1) identifying coordinate strategies, surveillance and diagnoses by 50 percent by 2020. persons with HIV who remain undiag- treatment programs for the conditions, nosed and linking them to healthcare; l Routine screening for all sexually trans- which also helps more efficiently use 2) retaining persons diagnosed with mitted infections, as recommended available resources. HIV in healthcare to maximize virus by the U.S. Preventive Services Task l Removing all restrictions on syringe suppression so they remain healthy Force — and reassessing sexual risk exchange programs — and support and prevent further transmission; and reduction guidelines for treatment public safety campaigns and syringe 3) facilitating access to Pre-Exposure as prevention and pre-exposure pro- exchange programs to help prevent Prophylaxis for high risk persons to phylaxis: CDC should release revised 310 HIV and viral hepatitis: In addition, keep them HIV negative. guidelines to assist individuals in as- there should also be increased state, l San Francisco has set a goal to be an sessing their risk in the context of these local and private support for syringe AIDS-free city — including supporting new treatment and chemoprophylaxis exchange programs and campaigns to improved overall public health, health approaches to match the most recent inform the public about the effective- and social services; early and sus- evidence-based epidemiological data. ness of syringe exchange programs for tained treatment; and PrEP. The num- l All state Medicaid programs should limiting the spread of HIV/AIDS, HBV ber of new infections was reduced by cover routine screening of HIV, re- and HCV, including for protecting first-re- half between 2004 and 2011, down gardless of risk (consistent with CDC sponders and healthcare workers. to around 300 new cases a year.311 and USPSTF guidelines).

86 TFAH • RWJF ADDRESSING THE SOCIAL DETERMINANTS OF HEALTH GAY AND LESBIAN TEENS INEQUITIES AMONG GAY MEN AND OTHER MEN WHO HAVE SEX AT INCREASED RISK FOR WITH MEN IN THE UNITED STATES INJECTION DRUG USE

In the United States, gay men and other some MSM to reduce their sexual risks. Lesbian, Gay and Bisexual (LGB) MSM continue to be profoundly affected Moreover, for MSM who are also racial teens are at higher risk for drug use by HIV/AIDS. Among MSM, a history of minorities, social determinants of health — including injection drug use — two prior sexually transmitted disease may intersect in various, overlapping compared with heterosexual teens.314 (STD) infections have been found to be domains, including not only sexual ori- According to CDC’s Youth Risk associated with an eight-fold increased entation, but race, poverty, educational Behavior Surveillance (YRBS) data risk of HIV infection.313 Representing attainment and immigration status. from 2001 to 2009, 17.7 percent approximately 2 percent of the overall of gay and lesbian teens and 9.6 Strategies to address health inequities population, MSM comprise a majority percent of bisexual teens had tried among MSM — including, but not limited of new HIV infections (66 percent in heroin, compared to only 1.8 percent to, HIV — include interventions to 1) 2010) and represent more than half (56 of heterosexual teens.315 increase individual resiliency, 2) foster a percent) of all persons living with an HIV supportive community, 3) improve access diagnosis. HIV incidence is dispropor- to quality healthcare, and 4) transform tionately higher among Black MSM than the environmental context in which peo- any other risk group. ple live. While new biomedical interven- MSM also face a variety of other mental, tions such as pre-exposure prophylaxis physical and sexual health disparities, or treatment-as-prevention show prom- including substance abuse and depres- ise, their uptake will also be affected by sion, both of which correlate with high- social determinants. Addressing social risk behaviors for HIV infection, as well determinants at every stage of life will as suicide. MSM also have elevated require an array of linked individual, rates of syphilis, gonorrhea, and other biomedical and structural interventions STIs, which are associated with an in- throughout the life course. To account creased risk for HIV infection as well. for environmental factors, communi- Young MSM are more likely than their ty-level and structural interventions must heterosexual counterparts to report emo- include health policy and legislation, tional distress, depression, or self-harm, economic and social interventions and and are at higher risk of suicidal ideation cross-sector collaborations. Improved or attempts and becoming homeless. federal coordination is also essential.

The many health inequities experienced In the long term, however, reducing so- by MSM constitute a syndemic — i.e. cietal oppression and marginalization of multiple social determinants that each LGBT people will diminish the need for independently influence health out- individual and community-level interven- comes, and which mutually reinforce tions. The increasing recognition that for and amplify each other. Among MSM, MSM, HIV constitutes but one of many the syndemic comprising HIV, STIs, men- health challenges provides an opportunity tal health, substance abuse and vio- to refocus efforts to fight HIV by incorpo- lence has profound implications for HIV rating interventions within the context of prevention — as numerous health chal- MSM health and wellness promotion. lenges may overwhelm the capacity of

TFAH • RWJF 87 HEPATITIS B AND C FIND OUT IF YOU HAVE Around five million Americans have HBV or HCV, but between 65 percent and 75 percent do not know they have them.316 As they age, they are at risk for developing serious liver diseases or cancer unless they receive treatment. Baby Boomers are five times more likely to have HCV, and one in 12 Asian Americans has HEPATITIS C HBV.317, 318 An independent Milliman report found total medical IT COULD SAVE YOUR LIFE costs for HCV patients could more than double over the next 20 SOME PEOPLE DON’T KNOW HOW years — from $30 billion to $80 billion per year.319, 320 BORN OR WHEN THEY WERE INFECTED l In 2013, USPSTF recommended routine one-time HCV screening FROM People born 5X MORE LIKELY TO BE of individuals born between 1945 and 1965 for the first time, from 1945- 1945- 1965 are INFECTED WITH HEPATITIS C which means the test is now available to these individuals who 1965? are enrolled in new group or individual health insurance, Medi- 3 OUT OF EVERY 4 care or Medicaid Expansion programs with no cost-sharing.321 people with Hepatitis C were born between these years A 2013 study of 1,578 patients born between 1945 and 1965 found that only 2 percent (31) of these Baby Boomers were screened for HCV.322 Many l people can A number of new direct acting drugs — including Harvoni, So- Up to live with 75% HEPATITIS C valdi and Viekira Pak as well as other drugs currently under of people living with for DECADES Hepatitis C DO NOT WITH NO development or in review for approval — have advanced treat- KNOW THEY ARE SYMPTOMS INFECTED ment options and have very high cure rates for HCV. The costs of these treatments, however, can reach $100,000 for the re-

quired twelve-week cycle, and some patients need two cycles of HEP C Blood Test treatment.323 Because of the cost, some states and payers have CDC recommends anyone born instituted barriers to access for treatment, such as requiring from 1945-1965 GET TESTED abstinence from substance use or waiting until patients’ liver disease is advanced. According to a review by the Center for Health Law and Policy Innovation of Harvard Law School, many TESTED NOT TESTED of these barriers do not have a basis in clinical evidence.324 KNOWING YOU HAVE HEPATITIS C LEFT can help you make UNTREATED, important HEPATITIS C can cause decisions liver damage and about your health LIVER FAILURE

Many people HEPATITIS C can get is the LIFESAVING #1 CAUSE CARE AND OF LIVER TREATMENT TRANSPLANTS

Successful HEPATITIS C treatments can is a leading ELIMINATE cause of THE VIRUS LIVER from the body CANCER

Don’t go down the wrong path, talk to your doctor about getting tested. It could save your life.

88 TFAH • RWJF RECOMMENDATIONS: Preventing and Controlling Viral Hepatitis

TFAH recommends a comprehensive l Making hepatitis B and C screening strategy be carried out to better prevent, routine and active: HBV and HCV control and treat hepatitis, including: screenings should be regularly conducted for at-risk groups, including l Improving real-time surveillance to persons of Asian heritage or born in monitor and allow for containment countries with moderate to high rates for of hepatitis outbreaks — which hepatitis B and Baby Boomers (individ- is urgently needed due to the uals born between 1945 and 1965) for rising epidemics of heroin use and HCV, as recommended by the USPSTF. hepatitis C infections: Recent clusters of outbreaks show the l Reducing disparities: American urgent need for improved and real- Indians and Blacks have a time measurement of infections to disproportionately high rate of HCV allow for interventions to prevent the infections — and strategies should spread of the disease. be developed to improve education and support for those most at risk, l Ensuring everyone who is diagnosed including providing comprehensive receives appropriate care: Every treatment and wrap-around support.325 person diagnosed with HBV or HCV Half of HBV infections in the United should have access to and receive States are among Asian American a standardized level of care and and Pacific Islanders (AAPIs) — and receive support services. CMS and concerted efforts should be made for Medicaid programs should take the improved screening and treatment as lead in ensuring patients receive the necessary for those at highest risk.326 most effective treatments available and removing discriminatory coverage l Investing in biomedical, behavioral rules for HCV treatment. and health services research and development: The investment l Promoting universal HBV in hepatitis-related biomedical vaccination: HBV vaccinations have and behavioral research must be helped reduce rates of infection by significantly increased including support around 80 percent, but around 10 for understanding the differential percent of infants still do not get impact of treatment among certain vaccinated, and adults who came of populations, improving screening and age before the vaccine was available diagnostic tools, and for new and better in 1992 or were born abroad where vaccines. Research support should be the vaccine is not widely used should more proportionate to the public health also be vaccinated. threat associated with hepatitis.

TFAH • RWJF 89 TUBERCULOSIS (TB) 9,421 TB CASES REPORTED IN THE U.S. IN 2014 During the 1970s, rates of TB cases had TAKE ON A Typical TB Case Requires: significantly declined (from more than

84,000 cases to around 22,000).327 The PLUS 555 • X-rays $435 country experienced a resurgence of the MILLION • Lab tests TB TB Deaths 180days of disease in the mid-1980s — contributed • Follow-up & Total cost to U.S Too many people in 2013 medications testing of contacts for TB cases in 2014. to by complacency and cuts to control pro- in our country grams, the emergence of drug-resistant TB still suffer from Our progress towards elimination may be slowing - the U.S. saw the tuberculosis (TB). smallest decline in cases in over 10 years! and HIV/AIDS and changing immigration patterns with more people arriving from TB CAN HAPPEN ANYWHERE & TO ANYONE! countries with a high TB burden. After To eliminate TB, we must reach the hardest hit populations. significant and dedicated funding was TB case rates are: provided at the federal, state and local levels to support improvements in treat- 29x 8x 8x Higher for Higher for Higher for ment, case finding, laboratory capacity, Asians African Americans Hispanics/Latinos 2 out of every 3 and infrastructure, the United States was than whites. than whites. than whites. TB cases occur among foreign-born persons. able to regain control from the resurgence, DRUG-RESISTANT TB IS COMPLEX & COSTLY. and cases again declined. However, once Drug-resistance threatens our ability to treat & control TB. rates went down and stabilized, the fed- TOTAL 2014 CASES DIRECT TREATMENT COST PER CASE eral government and many states started 2 Extensively Drug-Resistant TB $482,000 cutting funds from TB prevention and con- 91 Multidrug-Resistant TB $150,000 trol programs again — limiting the ability Tuberculosis (Drug-Susceptible) $17,000 to effectively carry out these programs. 9,328

In 2014, 9,421 TB cases were reported in ELIMINATING TB REQUIRES A COMPREHENSIVE APPROACH. the United States with 66 percent of cases CDC is committed to fighting TB whenever & wherever it occurs through: occurring among foreign-born persons.328 While the number of cases of TB disease

has declined annually since 1993, up to Better Diagnostics Testing & Treatment of Education of 13 million people in the United States are Vigilant Surveillance & Treatments High-Risk Populations Health Care Providers estimated to have latent TB infection (LTBI), To learn more about TB, visit: www.cdc.gov/tb which, if not treated, develops into TB dis- september, 2015 ease in 5 percent to 10 percent of people. CS259400B Asians continue to have the highest case rate (17.8 per 100,000 persons) among Globally, an estimated 8.9 million people People who are at-risk for TB include those all racial or ethnic groups, as opposed to develop active tuberculosis each year, and who do not receive regular or high-qual- 2.96 per 100,000 persons overall.329 Many 1.5 million die from TB.330 About one-third ity healthcare, including people who are states report having limited or no resources of the human population is infected with homeless, foreign-born, incarcerated or to devote to LTBI concerns. Annually, about TB, but most cases of these are latent TB co-infected with other conditions, and 1 percent of U.S. TB cases are multi-drug infections and are not contagious. people with weakened or compromised resistant (MDR TB) and one or two are ex- immune systems. tensively-drug resistant (XDR TB). MDR TB Health Resources and Services Admin- and XDR TB require treatment for longer pe- istration (HRSA) recommend routine TB States have the option of adding diag- riods of time, with regimens that are more testing for children at high risk for TB, but nosed TB patients to Medicaid.332 The cov- expensive and have more side effects. there currently is not a recommendation ered TB-related services include prescribed Most cases of MDR TB and XDR TB occur in for routine screening for at-risk adults by drugs, physician’s services, lab and x-ray persons born outside the United States. CDC, HRSA or USPSTF.331 services, clinic and Federally Qualified

90 TFAH • RWJF Health Center services, case management services and other services such as those designed to encourage completion of outpatient regimens, including directly observed therapy (DOT) — the recommended standard of care where healthcare professionals watch to make sure a patient is taking all of their treatment medication. Nine states have elected to provide this Medicaid waiver/ expansion. There is receipt of matching federal dollars for treating these TB patients.

Many individuals — particularly lower-income and undocumented individuals and the homeless — still remain uninsured and/or do not receive or have access to routine medical care or attention, so there is a continued role for public health agencies to provide access to care and treatment. Public health agencies continue to do TB surveillance, contact tracing, outreach and education — as well as providing the direct medical care for TB patients. Even in states that elect to add TB patients to Medicaid, the majority of TB care is provided by health departments, and in many cases they are not able to recover the costs of TB care from insurers.

TB disease is treated with drug therapy, but it is imperative that people finish the medicine and take the drugs exactly as reduced the capacity of some state and local TB programs. Weak- prescribed. It usually involves a regimen of drugs taken for six ened programs have compromised the ability of many states to months to two years depending on whether the bacteria are drug conduct investigations to track down contacts TB patients may resistant, and if so, the number of drugs to which they are resis- have had, to test for and treat TB infections and to provide directly tant. Drugs used in regimens to treat MDR TB and XDR TB are observed therapy treatment. Drug shortages — for both MDR TB difficult for patients to tolerate, which can contribute to non-adher- as well as TB disease and latent TB infections — put patients and ence. If patients stop taking the drugs too soon or do not take the communities at greater risk for illness and disease transmission, drugs correctly, they can relapse, die or develop drug resistance. and can further the development of drug resistance. When drugs In recent years, shortages of medications and antigen used in are unavailable, fewer treatment options exist for patients. They skin tests for diagnosing TB — along with significant increases may be prescribed less effective drugs, which can cause more in costs of medications, budget cuts and hiring freezes — have side effects or prolong treatment.

TB AND DIABETES

There is a rising global co-epidemic of TB and diabetes. Dia- Experts say that bi-directional screening of people living with betics are two to three times more likely to contract or die from TB for diabetes and people living with diabetes for TB is essen- TB, due to a weakening of the immune system. In addition, the tial. India was the first country to create a national policy of drugs that treat each disease interfere with one another, com- addressing the diseases simultaneously after discovering high plicating disease control.333 rates of diabetes among TB populations.335 New treatment protocols are also being examined to better de-silo related in- Worldwide, there were 390 million diabetics in 2013 and cases fectious and non-communicable care.336 are projected to approach 600 million by 2035.334

TFAH • RWJF 91 RECOMMENDATIONS: Toward Eliminating TB in America

The resurgence of the disease is in correctional facilities and also l Addressing the TB drug costs and particularly troubling since TB is consider TB screening for international shortages and biologics shortages: treatable, curable and preventable — college students. At the federal The shortage of treatment medication and new antibiotic resistant strains of level, consideration should be given and biologics used to diagnose TB TB are worrisome. TB disproportionally to expanding the screening, and infection and the growing cost of TB affects Americans living in poverty, and requirement for treatment, of persons treatment is harmful to the appropriate those with HIV/AIDS who are at higher entering the United States and seeking care for individuals and control efforts risk for the disease. TFAH consulted work visas or other longer-term stays in states. Ensuring sufficient quanti- with a set of TB control experts to within the United States. Additionally, ties, adequate supplies of TB biologics identify key recommendations for curbing plans, procedures and sufficient fiscal (Tubersol and Aplisol) and payment for a future resurgence of TB in the United resources should be in place to ensure drugs are essential for effective TB States, which include: completion of therapy for persons control and monitoring of outbreaks who cross international borders with and diagnosing new infections. l Providing adequate federal, state infectious TB disease. and local support for TB prevention l Supporting research and development and control: The United States has l Ensuring quality control in TB of new treatments for TB: Resources a goal to eliminate TB. Achieving that treatment: Treating TB is an intensive and incentives should be devoted to will require increased resources and and long process. It requires patients increased research for improved and prioritization. TB control efforts require to take a full course of their medicine alternate ways to treat the disease. strong surveillance for individuals precisely as prescribed through directly l Encouraging all states to participate and clusters of the disease, infection observed therapy treatment, which in the TB Medicaid waiver/expansion: control programs in communities with may require additional services for All states have the option of being able outbreaks, and ensuring that infected patients who need food, housing, to add all TB patients to their Medicaid patients receive full and complete transportation, or substance use program and receive federal matching treatment. The latter is important for services. Infectious patients must support. As of 2013, only nine states their care and to limit the transmission be isolated until their treatment has reported participating.337 of the disease. TB control efforts rendered them noninfectious (which are the responsibility of state and can take several weeks, or months if l Supporting routine screening and di- local governments. CDC funds all the person has drug-resistant TB) to agnostics for target high-risk groups: 50 states, 10 major cities, and eight stop the spread of the disease and USPSTF should adjust their guidelines territories to assure comprehensive are not able to sustain employment. to recommend TB screening for those surveillance systems for reporting Private healthcare providers and at high risk. If supported by the TB cases, healthcare providers and insurers should enter into contracts USPSTF, screening would be a man- other personnel to assure evaluation and arrangements with TB public dated benefit offered to Americans with of contacts, completion of therapy health programs to refer patients to new group and individual plans and for persons with TB disease, and experts in TB care, since improper those covered by Medicaid expansion preventive therapy for high-risk care can exacerbate the development with no-copayments.338 persons with latent TB infection. of additional drug-resistant cases or l Requiring no-cost-sharing treatment Because TB is spread through the forms of the disease or lead to the for TB patients by public and private air, infection control programs must patient becoming ill again. Public payers: This is particularly important be in place in healthcare facilities health departments should be able to because of the higher-risk of TB among and other conjugate settings. States bill a patient’s insurance company for lower-income, undocumented and should ensure routine screenings direct service treatment costs. homeless populations.

92 TFAH • RWJF J. FIX FOOD SAFETY Nearly all foodborne illnesses could be avoided with a stronger U.S. food safety system. There are around 48 million cases of illness each year, with 1 million resulting in long-term complications, 28,000 leading to hospital visits and 3,000 resulting in death.339, 340

The estimates of the economic costs of foodborne illnesses range from $15.6 to Outbreak Investigations Help Everyone Make Food Safer $77 billion annually in medical costs and lost productivity.341, 342 Major outbreaks can also contribute to significant economic 1 Food produced at losses in the agriculture and food retail company A’s factory 2 John buys the gets contaminated food and uses industries, which contributed $789 billion and is distributed his store loyalty 3 A few days to grocery stores card when he after eating the to the U.S. gross domestic product (GDP) nationwide. checks out. food, John gets 343 diarrhea, fever and in 2013, a 4.7 percent share. stomach cramps. Salmonella infections alone are 4 John goes to his doctor, responsible for an estimated $365 who collects a stool million in direct medical costs annually sample to test for germs.

and the number of infections has not 6 The state public health lab 344 identifies the DNAfingerprint decreased in the past 15 years. For 7 CDC’s PulseNet finds people of the Salmonella germ from 5 The clinical lab finds in other states who got sick John and enters the results into the Salmonella germ example, a 2015 outbreak due to from Salmonella with the CDC’s PulseNet database. and sends a sample same DNA fingerprint. of it to the state contaminated cucumbers has led to public health lab for further testing. more than 838 cases, 165 hospitalizations and four deaths from Salmonella Poona poisoning in at least 38 states. One hundred and sixty-five people have been 345 hospitalized and four have died. 8a CDC contacts state health 8b The public health department departments and starts interviews John about what he a multistate outbreak ate before getting sick and asks According to CDC, produce is related investigation. Food regulators to use his store loyalty card to (FDA or USDA) trace suspect see what he bought. to the highest percentage of illnesses foods back to the source. (46 percent), but meat and poultry 346 9 Interview results, store cause the most deaths (29 percent). loyalty card data, source 10 After discussing with public tracing and food tests show health officials and regulators, Norovirus is the leading cause of illness that many sick people ate company A issues a recall and from contaminated food in the United a food from company A fixes the source of contamination. before getting sick. States.347,348 Foodborne norovirus outbreaks result most commonly from

handling of ready-to-eat foods by 11 Future illnesses and outbreaks are prevented when food regulators and companies that infected individuals, but can also occur produce similar products improve practices due to use of fecally-contaminated based on company A’s experience. SOURCE: CDC Vital Signs, November 2015. 3 water during production.349 Cyclospora cayetanensi, a microscopic parasite, has Source: CDC caused large outbreaks of diarrheal illness linked to fecally-contaminated imported produce items.

TFAH • RWJF 93 According to research conducted leading cause of hospitalizations and Produce Safety, which establishes by University of Florida Emerging death in the United States.351 standards for growing, harvesting, Pathogens Institute, the top 10 riskiest packing and holding of produce; In 2015, FDA finalized several major combinations of food and pathogens the Foreign Supplier Verification rules implementing portions of the include Campylobacter in poultry, Program for food importers to assure Food Safety Modernization Act (FSMA): Toxoplasma in pork, listeria in deli meats that imported food meets U.S. safety Preventive Controls for Human and dairy products, and Salmonella standards; and Accredited Third-Party Foods and Preventive Controls for in foods such as produce, eggs, and Certification to establish accreditation Animal Foods, which require covered poultry.350 These top 10 pathogen-food of auditors to certify foreign food facilities to analyze potential hazards combinations are responsible for more facilities.352 The FY 2016 President’s and implement risk-based preventive than $8 billion in annual economic loss. budget included a request for an controls in their production processes; Of all these pathogens, Salmonella is the additional $109 million for FDA.353

RECOMMENDATIONS: Improving and Aligning Food Safety Systems

To improve food safety in the United currently does not have a coordinated, of coordinated, cross-governmental States, TFAH recommends: cross-governmental approach to food approach to food safety is also needed safety. Right now, food safety activi- within each state. l Fully funding and implementing the ties are siloed across a range of agen- Food Safety Modernization Act: Suffi- l Improving surveillance of foodborne ill- cies, and many priorities and practices cient funding should be devoted at the nesses: Currently, foodborne illnesses are outdated. In 2014, FDA released a federal and state levels to be able to are radically underreported in the Food and Feed Program Action Plan as implement and enforce the law. FDA United States and the quality of report- a framework to help realign operations. should ensure public health is the top ing varies dramatically by state. New Each year the Office of Regulatory Af- priority as it implements FSMA pre- standards and requirements should fairs (ORA), the Center for Food Safety vention rules. FDA should also track be put in place to incentivize states to and Applied Nutrition (CFSAN), the Cen- implementation of these rules to en- improve reporting and penalize states ter for Veterinary Medicine (CVM) and sure that proposed exemptions do not for underreporting. Surveillance for the Office of International Programs increase risk from foodborne illness. foodborne illness outbreaks should be (OIP) will identify deliverables to be fully integrated with other HIT systems, l Improving enforcement and inspec- accomplished that year. In the longer which will help improve tracking and tion capacity: FDA should work with term, the Administration should de- identification of the scope of problems states to ensure they are ready to velop a plan with a set timeline for how as well as sources of outbreaks. FDA enforce FSMA regulations, develop an to restructure food safety functions and CDC should also have a plan for operational strategy and ensure com- across the federal government into requiring clinics to send cultures from pliance across states. a single, unified food safety agency rapid response tests showing problems to carry out a prevention-focused, l Moving toward a unified government to public health labs to allow for sub- integrated strategy. This same type food safety agency: The government type pathogen testing.354

94 TFAH • RWJF APPENDIX A Examples of Key Emerging and Examples Emergency Threats of Key Emerging and l Pandemic Flu: In addition to the Health Organization (PAHO),360 and seasonal flu, historically there have through October 6, 2015, 510 cases Emergency been three-to-four pandemic flu have been reported to ArboNET outbreaks each century. Pandemics from 39 states.361 In 2014, 2,799 Threats occur when a new influenza virus chikungunya cases were reported in emerges against which people have the United States, most of which were Appendix A little-to-no immunity and the virus in travelers returning home, and only spreads internationally with sustained 11 cases were contracted in the United human-to-human transmission. While States in Florida.362 experts predict influenza pandemics l Dengue Fever: A mosquito-borne will occur in the future, they cannot illness that causes flu-like symptoms predict when the next pandemic and severe joint, muscle and bone will occur, what strain of the virus pain, and there are no vaccines or will be involved, or how severe the treatments currently available. WHO outbreak will be.355 Once a novel estimates that 50 to 100 million influenza strain mutates and becomes infections occur yearly, including easily transmissible among humans, 500,000 cases of dengue hemorrhagic it can cause a worldwide pandemic fever and 22,000 deaths, mostly in a relatively short time.356 A severe among children. It is endemic in pandemic in 1918 resulted in 30 Puerto Rico and in many popular percent of the population becoming ill tourist destinations in Latin America, and 2.5 percent (625,000 Americans) Southeast Asia and the Pacific islands. of those who became ill died.357 The In the United States, small dengue most recent pandemic, the 2009 H1N1 outbreaks occurred in Hawaii in 2001, Influenza (A) virus, while considered Texas in 2005 and most recently in relatively mild, infected around 20 Florida in 2013.363, 364 percent of Americans (approximately 60 million individuals), and resulted in l Chagas Disease: Caused by the approximately 274,000 hospitalizations parasite Trypanosoma cruzi, it and 12,000 deaths.358 can lead to severe cardiac and gastrointestinal disease. It is l Chikungunya: A mosquito-borne transmitted to animals and people virus that, while rarely fatal, causes by insect vectors found exclusively in fever and joint pain that can be the Americas. As many as 8 million excruciating.359 There are no vaccines people in Mexico, Central America or treatments for chikungunya, but DECEMBER 2015 and South America—and more than symptoms usually subside in about 300,000 in the United States — have a week. In some people, joint pain Chagas disease, the majority of whom can persist for months. In 2013, the do not know they are infected. Many disease first appeared in the Americas U.S. healthcare professionals are not in the Caribbean Islands. As of July 3, familiar with the disease which leads to 2015, more than 1.5 million cases have under-diagnosis.365 been reported to the Pan American l West Nile Virus: A potentially serious develop serious symptoms and in some illness that is spread by infected cases permanent neurological effects. mosquitoes that contract the virus In 2014, 47 states and Washington, from feeding on infected birds for D.C. have reported WNV infections in which there is no vaccine. The humans, birds or mosquitoes. Overall, majority of infected individuals have 2,002 cases of West Nile virus disease no symptoms, but up to 20 percent have been reported to CDC.366 Older of infected individuals develop adults are at higher risk for developing symptoms, including fever, headache, WNV neuroinvasive disease. body aches, nausea, vomiting, swollen l Malaria: A mosquito-borne disease lymph glands and rashes on the trunk that can also be transmitted through of the body, that can last several weeks, blood contamination or childbirth — and a one in 150 people infected resulting in fever, headache, fatigue, coma and death.367 Antimalarial drugs can provide effective treatment, but resistance is emerging and spreading globally. Globally, in 2013, there were 198 million cases and 584,000 deaths, mostly among African children.368 Stop the spread of germs that can make you and others sick! The United States experiences 1,500 to 2,000 cases of the disease per year mostly through exposed outside the country. Proven interventions in Cover your mouth and nose with a malaria endemic countries can have a tissue when you cough or sneeze. Put your used tissue in the profound impact on malaria control waste basket. which saves lives, reduces risk of importation in the United States and advances the effort to eliminate malaria.

l Valley Fever: An infection caused by the fungus Coccidioides, which is endemic to the soils of the U.S. southwest, mainly Arizona and California that people can breathe in and the spores settle in the lungs.369 Most people never experience any If you don’t have a tissue, cough or sneeze into your upper sleeve or symptoms, but some patients develop elbow, not your hands. flu-like symptoms, 5 percent to 10 percent develop long-term lung problems and 1 percent may develop 370 You may be asked to put on meningitis or die. Blacks, Filipinos, a facemask to protect others. pregnant women and people with diabetes or weakened immune systems are most susceptible. Nearly 130,000 valley fever cases were reported to Wash hands often with soap and 371 warm water for 20 seconds. CDC during 1998 to 2012 and If soap and water are not available, use an alcohol-based around 100 Americans die from valley hand rub. 372 CS208322 fever annually.

96 TFAH • RWJF BIOTERRORISM THREATS

CDC classifies biological agents that the limitations on scientific analysis could be used for an intentional bioat- prevented the task force from finding tack into three categories: the culprit. l Category A, or “High-Priority Agents,” At least 22 victims contracted anthrax, is considered the most dangerous and and five people died from inhalation includes: Anthrax, botulism, plague, anthrax. An additional 31 people smallpox, tularemia and viral hemor- tested positive for exposure to anthrax rhagic fevers (e.g., Ebola, Marburg). spores. In all, 35 post offices and mailrooms were contaminated along l Category B, or “Second-highest Pri- with seven buildings on Capitol Hill in ority Agents,” includes food safety Washington, D.C. threats (e.g., Salmonella and E. coli), ricin toxin, Typhus fever and viral en- Anthrax is a potentially lethal infec- cephalitis, among others. tion, particularly when it manifests as inhalation anthrax. Historically, l Category C, or “Third-highest Priority numerous nations have experimented Agents” include emerging pathogens with anthrax as a biological weapon, that could be engineered for mass including the U.S. offensive biological dissemination in the future because weapons program that was disbanded of availability; ease of production and in 1969.374 The worst documented dissemination; and potential for high outbreak of inhalation anthrax in morbidity and mortality rates and humans occurred in Russia in 1979, major health impact. Hantavirus is an when anthrax spores were accidentally example of a Category C agent.373 released from a military biological Two threats that have been of high weapons facility near the town of focus in U.S. bioterrorism preparedness Sverdlovsk, killing at least 66 people. strategies include: l Smallpox: Although WHO declared l Anthrax: In September and October that smallpox was eradicated in 1980, 2001, at least five envelopes contain- this contagious and deadly infectious ing Bacillus anthracis (anthrax) were disease caused by the Variola major mailed to Senators Patrick Leahy and virus, remains high on the list of pos- Thomas Daschle and to members of sible bioterror threats. the media in New York City and Boca The last naturally occurring case of Raton, Florida. After the bioterrorist smallpox was reported in 1977. Cur- attacks were identified, the FBI and rently, there is no evidence of naturally the United States Postal Inspection occurring smallpox transmission any- Service (USPIS) formed a task force where in the world. Although a world- to investigate the crime. The inves- wide immunization program eradicated tigation lasted seven years and was smallpox disease decades ago, small undertaken by FBI field offices in quantities of smallpox virus officially still Miami, New York, Newark, New Haven, exist in research laboratories in Atlanta, Baltimore and Washington, D.C. At Georgia and in Novosibirsk, Russia. the beginning of the investigation,

TFAH • RWJF 97 APPENDIX B Federal, State Federal, State and Local Public and Local Health Responsibilities Public Health The nation’s public health system is responsible for improving Responsibilities the health of Americans. Public health laws “authorize and obligate the government to protect and advance the public’s Appendix B health,” including against threats from infectious diseases.375

Federal, state and local health depart- diseases that states are required to ments have different responsibilities report to CDC so they can be tracked and jurisdictions, and must also work and strategies can be developed to limit in partnership with healthcare provid- their spread.378 There are more than 95 ers; the insurance, pharmaceutical and notifiable infectious diseases, ranging medical device industries; other areas of from anthrax to yellow fever.379 government; and community groups to ef- The federal government also has fectively prevent and control diseases. Pol- authority to isolate or quarantine icies and programs to control infectious patients infected with certain diseases diseases are particularly complex since who are arriving into the United States many of the core responsibilities are based from a foreign country, are traveling in states, while diseases can easily spread between states, or who may come into across state lines and around the globe. contact with others who are traveling The federal government sets national between states when they pose a threat health goals and priorities for the to others or the national interest. This country. The federal government authority derives from the Commerce can track and report on information Clause of the Constitution. The U.S. about diseases, conduct biomedical and Secretary of HHS is authorized to prevention research, stockpile resources take measures to prevent the entry to supplement state and local response and spread of communicable diseases capabilities and provide technical from foreign countries into the United assistance to states and localities.376 States and between the states (section Federal policies can steer efforts across 361 of the Public Health Services Act the country by setting joint strategic (42 U.S. Code § 264)).380 CDC has priorities and establishing programs the responsibility for implementing and then providing funds, often these functions as deemed necessary to through grants, to carry out policies protect the public. Although rare, CDC in states or local communities. Since may detain, medically examine and

DECEMBER 2015 communicable diseases pose threats release persons arriving into the United to national security and travel across States, or people traveling between states, Congress authorized the tracking states who are suspected of being of infectious disease threats starting in exposed to or carrying communicable 1878.377 CDC, in consultation with state, diseases of public health concern. local and tribal health departments Federal isolation and quarantine are and the Council of State and Territorial currently authorized by Executive Order Epidemiologists, establishes and of the President for cholera, diphtheria, routinely updates a list of “notifiable” infectious TB, plague, smallpox, yellow fever, viral hemorrhagic fevers like Ebola, severe acute respiratory syndromes and influenza viruses that are causing or have the potential to cause a pandemic.381 The President can revise the list by Executive Order. The U.S. Customs and Coast Guard offers aid in the enforcement of quarantine rules and regulations.382 Breaking a federal quarantine order is punishable by fines and imprisonment.383

States bear most of the legal responsibility for protecting the health, safety and welfare of their citizens, granted by “police power” functions. States vary in how they are structured and many share different degrees of policies with many states choosing to significant evidence of public health responsibility with local governments, differ from CDC’s recommendations. risks outside their territory that may but still maintain the ultimate power For example, some states had required lead to or cause the international spread within their borders.384 This authority mandatory quarantines for 21 days for of disease. More than 190 nations have “underlie[s] communicable disease healthcare workers returning from signed onto the IHR.389 However, many laws authorizing surveillance, testing, treating Ebola patients in West Africa countries do not adequately fund public screening, isolation and quarantine.”385 even if they were at low risk for exposure health programs, have large endemic Every state has the general public health and were symptom-free.388 public health crises, do not have strong authority to act to control communicable healthcare systems and do not have U.S. infectious disease control strategies diseases, but state laws, programs and a tradition of setting standards for are complicated not just by interstate funding levels vary significantly. For adopting evidence-based disease control travel, but by international travel instance, some states have very specific practices or for adopting principles of and immigration. In many cases, or very broad quarantine laws. In most objectivity, fairness and transparency.390 people carrying diseases are often states, breaking a quarantine law is a Efforts like the WHO and CDC’s Global not identified when crossing borders criminal misdemeanor.386 Disease Detection (GDD) program because they may have an infection or help provide some additional support Public health laws can be controversial illness but are unaware of it, or they to less wealthy nations, but there in terms of finding an appropriate may not have developed severe enough is wide variance and major gaps in balance between protecting against the symptoms to warrant special notice or public health programs around the risk to the public versus the rights of an attention. And, even in cases where a world to control outbreaks like Ebola individual or group. In most states, for patient suspected of having a dangerous and ongoing threats like HIV/AIDS most conditions, “liberty principles” and infectious disease has been identified, and malaria and the ability to quickly “informed consent” allow individuals carrying out quarantine and isolation identify and contain new diseases. to decide whether to treat an illness laws in a timely manner and across they may have, but this may then lead different jurisdictions can present a According to the National Intelligence to required isolation of a person if the challenge. Therefore, disease outbreaks Council, emerging infectious diseases disease can be easily spread and pose a anywhere are of concern everywhere. “endanger U.S. citizens at home and danger to others.387 abroad, threaten U.S. armed forces WHO revised International Health deployed overseas, and exacerbate social States are able to establish their own Regulations (IHR) to set standards and political instability in key countries quarantine and isolation policies, such for and require notification to WHO and regions in which the U.S. has as during the Ebola outbreak, and there of any “public health emergency of significant interests.”391 has been significant variations in their international concern” or of any TFAH • RWJF 99 APPENDIX C State Public State Public Health Budget Health Budget Methodology Methodology TFAH conducted an analysis of state state funds (e.g. dedicated revenue, fee spending on public health for the last revenue, etc.), was used. In some cases, Appendix C budget cycle, fiscal year 2014-2015. For only general revenue funds were used in those states that only report their budgets order to separate out federal funds; these in biennium cycles, the 2015-2017 period exceptions are also noted. (or the 2014-2016 and 2015-2016 for Because each state allocates and reports its Virginia and Wyoming respectively) budget in a unique way, comparisons across was used, and the percent change was states are difficult. This methodology calculated from the last biennium, 2013- may include programs that, in some cases, 2015 (or 2014-2016 and 2014-2015 for the state may consider a public health Virginia and Wyoming respectively). function, but the methodology used was This analysis was conducted from selected to maximize the ability to be September to October of 2015 using consistent across states. As a result, there publicly available budget documents may be programs or items states may wish through state government web sites. to be considered “public health” that may Based on what was made publicly not be included in order to maintain the available, budget documents used comparative value of the data. included either executive budget Finally, to improve the comparability document that listed actual expenditures, of the budget data between FY 2013- estimated expenditures, or final 2014 and FY 2014-2015 (or between appropriations; appropriations bills biennium), TFAH adjusted the FY enacted by the state’s legislature; or 2014-2015 numbers for inflation (using documents from legislative analysis offices. a 0.992 conversion factor based on the “Public health” is defined to broadly U.S. Dept. of Labor Bureau of Labor include all health spending with the Statistics; Consumer Price Index Inflation exception of Medicaid, CHIP, or Calculator at http://www.bls.gov/cpi/). comparable health coverage programs After compiling the results from this online for low-income residents. Federal review of state budget documents, TFAH funds, mental health funds, addiction coordinated with the Association of State or substance abuse-related funds, WIC and Territorial Health Officials (ASTHO) funds, services related to developmental to confirm the findings with each state disabilities or severely disabled persons, health official. ASTHO sent out emails on and state-sponsored pharmaceutical October 30, 2015 and state health officials programs also were not included in order were asked to confirm or correct the data to make the state-by-state comparison DECEMBER 2015 with TFAH staff by November 12, 2015. more accurate since many states receive ASTHO followed up via email with those federal money for these particular state health officials who did not respond programs. In a few cases, state budget by the November 12, 2015 deadline. In documents did not allow these programs, the end, six states did not respond by or other similar human services, to be December 4, 2015 when the report went to disaggregated; these exceptions are print. These states were assumed to be in noted. For most states, all state funding, accordance with the findings. regardless of general revenue or other Endnotes

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