ISSUE REPORT Ready or Not: PROTECTING THE PUBLIC’S HEALTH FROM , DISASTERS, AND 2020

Inside

• Preparedness Incidents, Events and Actions: 2019 in Review

• The Response to

FEBRUARY 2020 the Vaping Crisis

• Ensuring Appropriate Disaster Response for People with Disabilities

•  Preparedness Assessments

• Policy Recommendations Acknowledgements Trust for America’s Health (TFAH) is a nonprofit, nonpartisan The Ready or Not report series is supported by generous grants public health policy, research, and advocacy organization that from the Robert Wood Johnson Foundation. Opinions in this promotes optimal health for every person and community and report are TFAH’s and do not necessarily reflect the views of makes the prevention of illness and injury a national priority. the foundation.

TFAH BOARD OF DIRECTORS Gail Christopher, D.N. David Lakey, M.D. John Rich, M.D., MPH Chair of the TFAH Board Chief Medical Officer and Vice Chancellor for Co-Director Executive Director Health Affairs Center for Nonviolence and Social Justice National Collaborative for Health Equity The University of Texas System Drexel University Former Senior Advisor and Vice President Octavio Martinez Jr., M.D., DPH, MBA, FAPA Eduardo Sanchez, M.D., MPH W.K. Kellogg Foundation Executive Director Chief Medical Officer for Prevention and Chief of David Fleming, M.D. Hogg Foundation for Mental Health the Center for Health Metrics and Evaluation Vice Chair of the TFAH Board The University of Texas at Austin American Heart Association Vice President of Programs Stephanie Mayfield Gibson, M.D. Umair A. Shah, M.D., MPH PATH Senior Physician Advisor and Population Health Executive Director Robert T. Harris, M.D. Consultant Harris County (Texas) Public Health Treasurer of the TFAH Board Former Senior Vice President, Population Health, Vince Ventimiglia, J.D. Senior Medical Director and Chief Medical Officer Chairman, Board of Managers General Dynamics Information Technology KentuckyOne Health Leavitt Partners Theodore Spencer Karen Remley, M.D., MBA, MPH, FAAP Secretary of the TFAH Board Senior Fellow TRUST FOR AMERICA’S HEALTH Founding Board Member de Beaumont Foundation LEADERSHIP STAFF Former CEO and Executive Vice President John Auerbach, MBA Cynthia M. Harris, Ph.D., DABT American Academy of Pediatrics President and CEO Director and Professor Institute of Public Health J. Nadine Gracia, M.D., MSCE Florida A&M University Executive Vice President and Chief Operating Officer

REPORT AUTHORS Rhea K. Farberman, APR The National Health Security Preparedness Index (NHSPI) is a joint initiative of the Robert Wood Director of Strategic Communications and Policy Johnson Foundation, the University of Kentucky, and the University of Colorado. TFAH wishes to Research recognize and thank Glen Mays and Michael Childress of the NHSPI for their collaboration and expertise as well as the Robert Wood Johnson Foundation for its continued funding support. Dara Alpert Lieberman, MPP Director of Relations Ready or Not and the NHSPI, are complementary projects that work together to measure and improve the country’s health security and emergency preparedness. TFAH looks Matt McKillop, MPP forward to a continued partnership. Senior Health Policy Researcher and Analyst

CONTRIBUTORS PEER REVIEWERS Zarah Ghiasuddin This report benefited from the insights and expertise of the following external reviewers. Although TFAH Intern they have reviewed the report, neither they nor their organizations necessarily endorse its findings or conclusions. TFAH thanks these reviewers for their time and expertise: Rachel Dembo TFAH Intern Jeffrey Engel, M.D. James S. Blumenstock Executive Director Chief Program Officer for Health Security Council of State and Territorial Epidemiologists Association of State and Territorial Health Publisher’s Note: TFAH publishes Ready or Not Officials Vincent Lafronza, EdD annually with a typical release date in early President and CEO Laura Biesiadecki February. Each edition is based on the most National Network of Public Health Institutes Senior Director, Preparedness, Recovery and recently available data, typically data available Response in the year before publication. Nicole Lurie, M.D., M.S.P.H. National Association of County and City Health Coalition for Preparedness Innovations Officials 2 TFAH • tfah.org TABLE OF CONTENTS Table of Contents Ready or Not Executive Summary ...... 4 Sidebar: Impact of Health Disparities before, during, and after health emergencies . . . . 9 2020 Indicators Performance Matrix by State ...... 10

SECTION 1: Year in Review—Health Threats and Preparedness Actions 2019 ...... 12 Outbreaks ...... 12 Severe Weather and Natural Disasters ...... 21 All-Hazards and Events Policy Actions ...... 26

SECTION 2: Assessing State Preparedness ...... 32 Indicator 1: Nurse Licensure Compact ...... 33 Indicator 2: Hospital Participation in Healthcare Coalitions ...... 34 Indicators 3 and 4: Accreditation ...... 36 Indicator 5: Public Health Funding ...... 38 Indicator 6: Water System Safety ...... 40 Indicator 7: Access to Paid Time Off ...... 42 Indicator 8: Flu Rate ...... 44 Indicator 9: Patient Safety in Hospitals ...... 46 Indicator 10: Public Health Laboratory Surge Capacity ...... 47

SECTION 3: Recommendations for Policy Actions ...... 48 Priority Area 1: Provide Stable, Sufficient Funding for Domestic and Global Public Health Security ...... 48 Priority Area 2: Prevent Outbreaks and ...... 50 Priority Area 3: Build Resilient Communities and Promote Health Equity in Preparedness . 52 Priority Area 4: Ensure Effective Leadership, Coordination, and Workforce ...... 54 Priority Area 5: Accelerate Development and Distribution of Medical Countermeasures . . .55 Priority Area 6: Ready the Healthcare System to Respond and Recover ...... 57 Priority Area 7: Prepare for Environmental Threats and Extreme Weather ...... 59

APPENDIX: Methodology ...... 60

Endnotes ...... 64

View this report online at www.tfah.org/report-details/readyornot2020. FEBRUARY 2020

Cover photos from left to right: sgtphoto; ~User7565abab_575; Kevin Lendio EXECUTIVE SUMMARY Ready or Not Executive Summary

2020 The public health emergencies of the past year—outbreaks of measles, hepatitis A, and other vaccine preventable diseases1, record heat, foodborne illness, devastating hurricanes, a mysterious lung illness associated with vaping, wildfires, and months of cascading flooding2 along the Missouri, Mississippi, and Arkansas Rivers affecting 16 states and nearly 14 million people—all reinforce the need for every jurisdiction to be vigilant about preparing for emergencies in order to safeguard the public’s health.

From disease outbreaks to natural emergency wanes. What’s more, states are disasters, including those fueled by uneven in their levels of preparedness. climate change, the stakes are high: Some—often those that most frequently Americans face serious health risks and face emergencies—have the personnel, even death with increasing regularity. systems, and resources needed to protect Therefore, as a nation, it’s critical to ask, the public. Others are less prepared, less “Are we prepared?” experienced and have fewer resources, elevating the likelihood of preventable The Ready or Not: Protecting the Public’s harms. Additionally, some states are Health from Diseases, Disasters, and prepared for certain types of emergencies Bioterrorism series from Trust for but not others. This unstable funding America’s Health (TFAH) has tracked and uneven preparation undermine public health emergency preparedness in America’s health security. The thousands the since 2003. The series of Americans who lost their lives during has documented significant progress in Hurricanes Maria and Irma—particularly the nation’s level of preparedness as well as a result of extended power outages3— as areas still in need of improvement. are a grim warning of potential outcomes A fundamental role of the public health of increasingly severe weather. Yet, system is to protect communities from through strategic investments and disasters and disease outbreaks. To proactive policies to promote resilience this end, the nation’s health security and response capabilities, the nation could infrastructure has made tremendous mitigate or prevent some of these impacts. strides since 2001 by building modern The implications of failing to prepare laboratories, maintaining a pipeline could be devastating. The National of and the ability to use medical Academies of Science, Engineering, and countermeasures, and recruiting Medicine estimate pandemics could cost FEBRUARY 2020 and retaining a workforce trained in the global economy over $6 trillion in the emergency operations. Yet, unstable and 21st century.4 The Centers for Disease insufficient funding puts this progress Control and Prevention (CDC) also at risk, and a familiar pattern takes estimate that a global disease outbreak shape: underfunding, followed by a could cost the United States billions disaster or outbreak, then an infusion in lost trade revenue and tourism, of onetime supplemental funds, and costing hundreds of thousands—if not finally a retrenchment of money once the millions—of U.S. jobs.5 Ready or Not examines the country’s level breadth of a jurisdiction’s preparedness in key areas, including public health of public health emergency preparedness capacities. It is also important to note that funding and seasonal flu vaccination. on a state-by-state basis using 10 priority improvement in these priority areas often However, performance in other areas— indicators. (See Table 1.) Taken requires action from officials outside such as water security and paid time off together, the indicators are a checklist of the public health sector, including other for workers—has stalled or lost ground. priority aspects for state prevention and administrators and agencies, legislators, In this 2020 report, TFAH found that emergency readiness programs. However, citizens or the private sector. 10 states and the District of Columbia these indicators do not necessarily reflect improved their standing compared with This edition of the Ready or Not series the effectiveness of states’ public health last year. Four states improved by two finds that states have made progress departments or in some cases the full tiers, and six states improved by one tier.

TABLE 1: Top-Priority Indicators of State Public Health Preparedness INDICATORS

1 Incident Management: Adoption of the Nurse Licensure Compact. 6 Water Security: Percentage of the population who used a community water system that failed to meet all applicable health-based standards.

2 Cross-Sector Community Collaboration: Percentage of hospitals 7 Workforce Resiliency and Infection Control: Percentage of employed participating in healthcare coalitions. population with paid time off.

3 Institutional Quality: Accreditation by the Public Health 8 Countermeasure Utilization: Percentage of people ages 6 months or Accreditation Board. older who received a seasonal flu vaccination.

4 Institutional Quality: Accreditation by the Emergency Management 9 Patient Safety: Percentage of hospitals with a top-quality ranking (“A” Accreditation Program. grade) on the Leapfrog Hospital Safety Grade.

5 Institutional Quality: Amount of state public health funding, 10 Health Security Surveillance: The public health laboratory has a plan compared with the past year. for a six- to eight-week surge in testing capacity. Notes: The National Council of State Boards of Nursing organizes the Nurse Licensure Compact. The federal Hospital Preparedness Program of the U.S. Office of the Assistant Secretary for Preparedness and Response supports healthcare coalitions. The U.S. Environmental Protection Agency assesses commu- nity water systems. Paid time off includes sick leave, vacation time, or holidays, among other types of leave. The Leapfrog Group is an independent nonprofit organization. Every indicator, and some categorical descriptions, were drawn from the National Health Security Preparedness Index, with one exception: pub- lic health funding. See “Appendix A: Methodology” for a description of TFAH’s funding data-collection process, including its definition. Source: National Health Security Preparedness Index6

The Ready or Not report groups states and community water system that was in and became one of just three states in the District of Columbia into one of three violation of health-based standards, and which a majority of general acute-care tiers based on their performances across Delaware saw a dramatic increase in the hospitals received an “A” grade on the the 10 indicators. This year, 25 states and percentage of its hospitals with a top- Leapfrog Hospital Safety Grade. the District of Columbia scored in the quality safety ranking. Pennsylvania’s Six states and the District of Columbia high-performance tier, 12 placed in the improved score stemmed from its newly moved up from the middle tier to the middle-performance tier, and 13 were in acquired accreditation from the Public high tier: Illinois, Iowa, Maine, New the low-performance tier. (See Table 2.) Health Accreditation Board and from Mexico, Oklahoma, Vermont, and the (See Appendix A: Methodology for more strengthened drinking-water security District of Columbia. information on the scoring process.) and hospital patient safety. Tennessee increased its public health funding level No state fell from the high tier to the Four states (Delaware, Pennsylvania, in fiscal year 2019, achieved a substantial low tier. Tennessee, and Utah) showed particularly increase in its seasonal flu vaccination notable improvement, moving up from Six states moved from the middle tier to rate, and improved hospital patient the low tier to the high tier. Delaware the low tier: Hawaii, Montana, Nevada, safety. Utah significantly increased its improved its standing by increasing its New Hampshire, South Carolina, and community drinking-water security, funding for public health and reducing West Virginia. elevated its seasonal flu vaccination rate, the share of its residents that used a TFAH • tfah.org 5 TFAH’s analysis found: l Most residents who got their household Seasonal flu vaccination rates l A majority of states have made water through a community water rose during the 2018 – 2019 preparations to expand capabilities system had access to safe water. On in an emergency, often through average, just 7 percent of state residents flu season but were still below collaboration. Thirty-two states used a community water system in 2018 target. participated in the Nurse Licensure (latest available data) that did not meet Compact, up from 26 in 2017 and 31 in all applicable health-based standards, 2018,7 with Alabama as the most recent up slightly from 6 percent in 2017. member, effective January 1, 2020.8 The Water systems with such violations compact allows registered nurses and increase the chances of water-based licensed practical or vocational nurses emergencies in which contaminated to practice in multiple jurisdictions water supplies place the public at risk.

with a single license. In an emergency, l Most states are accredited in the this enables health officials to quickly areas of public health, emergency increase their staffing levels. For management, or both. As of November example, nurses may cross state lines to 2019, the Public Health Accreditation lend their support at evacuation sites or Board or the Emergency Management other healthcare facilities. In addition, Accreditation Program accredited 41 hospitals in most states have a high states and the District of Columbia; degree of participation in healthcare 28 states and the District of Columbia coalitions. On average, 89 percent of were accredited by both groups, an hospitals were in a coalition and 17 increase of three (Iowa, Louisiana and states and the District of Columbia had Pennsylvania) since October 2018. Nine universal participation, meaning every states (Alaska, Hawaii, Indiana, Nevada, hospital in the jurisdiction was part New Hampshire, South Dakota, Texas, of a coalition. Such coalitions bring West Virginia, and Wyoming) were hospitals and other healthcare facilities not accredited by either group. Both together with emergency management programs help ensure that necessary and public health officials to plan for, emergency prevention and response and respond to, incidents or events systems are in place and staffed by requiring extraordinary action. This qualified personnel. increases the likelihood that providers serve patients in a coordinated and l Seasonal flu vaccination rates, while efficient manner during an emergency. still too low, rose. The seasonal flu What’s more, most states had public vaccination rate among Americans health laboratories that had planned ages 6 months and older rose from 42 for a large influx of testing needs: 48 percent during the 2017–2018 season states and the District of Columbia to 49 percent during the 2018–2019 9 had a plan to surge public health season. (See Section 2, page 45 for laboratory capacity for six to eight additional discussion of what may weeks as necessary during overlapping have helped generate the vaccine emergencies or large outbreaks, a net rate increase.) Healthy People 2020, a increase of four states since 2017. set of federal 10-year objectives and benchmarks for improving the health

6 TFAH • tfah.org of all Americans by 2020, set a seasonal l Only 30 percent of hospitals, on influenza vaccination-rate target of 70 average, earned a top-quality patient percent annually.10 safety grade, up slightly from 28 percent in 2018. Hospital safety l In 2019, only 55 percent of employed scores measure performance on state residents, on average, had access such issues as healthcare-associated to paid time off, the same percentage infection rates, intensive-care as in 2018. Those without such leave capacity, and an overall culture of are more likely to work when they are error prevention. In the absence of sick and risk spreading infection. In diligent actions to protect patient the past, the absence of paid sick leave safety, deadly infectious diseases can has been linked to or has exacerbated take hold or strengthen. some infectious disease outbreaks.11

TABLE 2: State Public Health Emergency Preparedness State performance, by scoring tier, 2019 Performance Number of States Tier States

AL, CO, CT, DC, DE, IA, ID, IL, KS, MA, MD, High Tier ME, MO, MS, NC, NE, NJ, NM, OK, PA, TN, UT, 25 states and DC VA, VT, WA, WI

Middle Tier AZ, CA, FL, GA, KY, LA, MI, MN, ND, OR, RI, TX 12 states

AK, AR, HI, IN, MT, NH, NV, NY, OH, SC, SD, Low Tier 13 states WV, WY Note: See “Appendix A: Methodology” for scoring details. Complete data were not available for U.S. territories.

Based on our policy research and analysis, consultation with experts, and review of progress and gaps in federal and state preparedness, TFAH is recommending policy action in seven priority areas – see report’s recommendations section starting on page 48.

l Provide stable, sufficient funding l Accelerate development and for domestic and global public distribution, including last health security. mile distribution, of medical countermeasures. l Prevent outbreaks and pandemics. l Ready the healthcare system to l Build resilient communities and respond and recover. promote health equity in preparedness. l Prepare for environmental threats l Ensure effective leadership, and extreme weather. coordination, and workforce.

TFAH • tfah.org 7 HOW DO INEQUITIES REDUCE HEALTH SECURITY?

Health inequities refer to the ways have a disproportionate impact on in which certain population groups older adults or people with medical are prevented from achieving equipment dependent on electricity.17 optimal health due to where they l Those who are limited English live, the discrimination or racism proficient or are worried about they encounter, their social and/ immigration policies may not or economic situation, their age or receive warnings and notifications health condition, where they work, or and/or be reluctant to share the language they speak.12 In terms information with or get assistance of emergency preparedness, health from government agencies.18 inequities put certain population groups at elevated risk of injury, l Those who work for an employer illness, displacement, and death that does not provide any paid leave during an emergency.13 or excused absences, may not be able to take the recommended For example: precautions — such as staying out l Those who live in lower-income of work if they have an infectious households are more likely to disease — to safeguard their health have housing that is sub-par and and that of those around them. vulnerable during a natural disaster. They may also lack adequate heat Recognizing and eliminating or air conditioning. They may live in these and other barriers to health areas more prone to flooding14 or equity is central to reducing the in housing that is not earthquake disproportionate impact of natural resistant. And they may not have the disasters and other health security resources needed to leave an area threats on communities now at when evacuation is necessary.15 greatest risk, including communities of color and low-income households. l Those who are older or have a Public health and disaster response disability, cognitive issue or a complex entities need to work directly with or chronic medical condition may communities, including by ensuring have limited mobility and/or be that community leaders have a seat dependent on medical equipment. at the planning table, in order to They may find themselves in harm’s understand their specific needs and way if they are not provided with the where resources will be most needed 16 necessary assistance or notification. in the event of an emergency.19 For example, power outages can

8 TFAH • tfah.org Report Purpose and Methodology

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

STATE PUBLIC HEALTH FUNDING

TFAH collected data for fiscal year communicable disease control; chronic 2019 and for earlier years from states’ disease prevention; injury prevention; publicly available funding documents. environmental public health; maternal, With assistance from the Association child, and family health; and access to of State and Territorial Health Officials, and linkage with clinical care. TFAH provided data to states for review TFAH excludes from its definition and verification. Informed by the Public of “public health programming Health Activities and Services Tracking and services” insurance coverage project at the University of Washington, programs, such as Medicaid or the TFAH defines “public health Children’s Health Insurance Program, programming and services” to include and inpatient clinical facilities.

TFAH • tfah.org 9 TABLE 3: STATE INDICATORS AND SCORES TABLE 3: STATE INDICATORS AND SCORES Public Health Emergency Management Nurse Licensure Hospital Preparedness Public Health Accreditation Board Accreditation Program Water Security Paid Time Off Seasonal Flu Vaccination Patient Safety Public Health Lab Capacity State Performance Compact (NLC) Program Funding (PHAB) (EMAP) Percent of hospitals Percentage Percent of population who used a Percent of employed Seasonal flu vaccination rate Public health laboratories had a State participated in Accredited by PHAB, Accredited by EMAP, Percentage of hospitals with “A” participating in change, FY community water system in violation population with paid for people ages 6 months and plan for a six- to eight-week surge Scoring tier, 2019 NLC, 2019 2019 2019 grade, fall 2019 coalitions, 2017 2018-19 of health-based standards, 2018 time off, 2019 older, 2018–19 in testing capacity, 2019 Alabama 3 95% 3 3 -5% 3% Alabama 55% 48.3% 23% 3 High Alaska 100% 1% 7% Alaska 60% 44.1% 0% 3 Low Arizona 3 72% 3 3 2% 1% Arizona 48% 45.6% 26% 3 Middle Arkansas 3 81% 3 3 -3% 6% Arkansas 45% 48.8% 14% 3 Low California 70% 3 3 10% 12% California 56% 47.4% 35% 3 Middle Colorado 3 100% 3 3 3% 1% Colorado 56% 51.6% 36% 3 High Connecticut 100% 3 3 4% 3% Connecticut 64% 56.8% 38% 3 High Delaware 3 100% 3 2% 1% Delaware 48% 50.7% 33% 3 High D.C. 100% 3 3 10% 5% D.C. 65% Data incomplete 20% 3 High Florida 3 73% 3 3 1% 1% Florida 54% 40.9% 37% 3 Middle Georgia 3 97% 3 2% 8% Georgia 59% 43.1% 26% 3 Middle Hawaii 100% 6% 0% Hawaii 59% 50.2% 25% 3 Low Idaho 3 98% 3 3 -3% 1% Idaho 51% 43.6% 45% 3 High Illinois 88% 3 3 16% 1% Illinois 55% 45.4% 43% 3 High Indiana 75% 5% 2% Indiana 50% 47.9% 17% 3 Low Iowa 3 80% 3 3 -1% 3% Iowa 60% 54.8% 9% 3 High Kansas 3 96% 3 3 9% 8% Kansas 56% 50.7% 27% 3 High Kentucky 3 93% 3 4% 10% Kentucky 48% 49.6% 26% 3 Middle Louisiana 3 100% 3 3 3% 16% Louisiana 53% 41.6% 31% 3 Middle Maine 3 94% 3 3% 1% Maine 51% 48.8% 59% 3 High Maryland 3 89% 3 3 2% 1% Maryland 61% 57.1% 23% 3 High Massachusetts 82% 3 3 10% 11% Massachusetts 59% 58.9% 42% 3 High Michigan 90% 3 17% 3% Michigan 49% 46.1% 41% 3 Middle Minnesota 100% 3 7% 1% Minnesota 52% 52.7% 23% 3 Middle Mississippi 3 100% 3 3 8% 7% Mississippi 63% 42.0% 31% 3 High Missouri 3 87% 3 3 1% 0% Missouri 53% 50.0% 28% 3 High Montana 3 83% 3 -3% 8% Montana 58% 48.7% 44% 3 Low Nebraska 3 95% 3 3 -4% 3% Nebraska 57% 54.2% 13% 3 High Nevada 100% 40% 0% Nevada 55% 37.8% 26% 3 Low New Hampshire 3 47% -6% 3% New Hampshire 54% 52.0% 31% 3 Low New Jersey 82% 3 3 3% 11% New Jersey 52% Data incomplete 45% 3 High New Mexico 3 71% 3 3 3% 8% New Mexico 61% 49.9% 12% 3 High New York 86% 3 3 -1% 45% New York 61% 51.9% 7% 3 Low North Carolina 3 95% 3 -2% 2% North Carolina 51% 54.9% 47% 3 High North Dakota 3 100% 3 3 9% 16% North Dakota 51% 51.1% 0% 3 Middle Ohio 25% 3 3 7% 2% Ohio 49% 50.4% 39% 3 Low Oklahoma 3 95% 3 3 12% 13% Oklahoma 55% 51.3% 25% 3 High Oregon 100% 3 27% 16% Oregon 63% 48.3% 48% 3 Middle Pennsylvania 86% 3 3 2% 13% Pennsylvania 51% 54.2% 46% 3 High Rhode Island 100% 3 3 9% 38% Rhode Island 56% 60.4% 43% 3 Middle South Carolina 3 56% 3 5% 2% South Carolina 45% 46.8% 37% 3 Low South Dakota 3 100% 2% 1% South Dakota 44% 54.4% 10% 3 Low Tennessee 3 91% 3 4% 3% Tennessee 53% 48.2% 34% 3 High Texas 3 80% 8% 7% Texas 68% 47.9% 38% 3 Middle Utah 3 100% 3 3 0% 2% Utah 45% 45.9% 56% High Vermont 100% 3 3 4% 1% Vermont 56% 51.9% 33% High Virginia 3 100% 3 4% 2% Virginia 58% 54.7% 56% 3 High Washington 100% 3 1% 1% Washington 60% 53.8% 33% 3 High West Virginia 3 97% -2% 16% West Virginia 55% 48.2% 5% 3 Low Wisconsin 3 98% 3 3 0% 5% Wisconsin 56% 50.9% 38% 3 High Wyoming 3 92% -6% 1% Wyoming 47% 40.7% 0% 3 Low 51-state average N/A 89% N/A N/A 5% 6.5% 51-state average 55% 49.5% 30% N/A N/A Note: See “Appendix A: Methodology” for a description of TFAH’s data-collection process and scoring details. Indiana and New Jersey have joined the NLC, but had not yet set a date for implementation as of December North Dakota’s fiscal 2019 funding combines funds for the Department of Health and the Department of Environmental Quality, which were separated, beginning in fiscal 2019. Some state residents use 2019. States with conditional or pending accreditation at the time of data collection were classified as having no accreditation. Nebraska’s year-over-year funding change incorporates a modification to its accounting private drinking-water sources, rather than community water systems. Private sources are not captured by these data. Only regulated contaminants are measured. Paid time off includes sick leave, vacations, methodology—some funds were previously double-counted—that the state was unable to apply retroactively to fiscal year 2018. and holidays. The patient safety measure captures only general acute-care hospitals. 10 TFAH • tfah.org TABLE 3: STATE INDICATORS AND SCORES TABLE 3: STATE INDICATORS AND SCORES Public Health Emergency Management Nurse Licensure Hospital Preparedness Public Health Accreditation Board Accreditation Program Water Security Paid Time Off Seasonal Flu Vaccination Patient Safety Public Health Lab Capacity State Performance Compact (NLC) Program Funding (PHAB) (EMAP) Percent of hospitals Percentage Percent of population who used a Percent of employed Seasonal flu vaccination rate Public health laboratories had a State participated in Accredited by PHAB, Accredited by EMAP, Percentage of hospitals with “A” participating in health care change, FY community water system in violation population with paid for people ages 6 months and plan for a six- to eight-week surge Scoring tier, 2019 NLC, 2019 2019 2019 grade, fall 2019 coalitions, 2017 2018-19 of health-based standards, 2018 time off, 2019 older, 2018–19 in testing capacity, 2019 Alabama 3 95% 3 3 -5% 3% Alabama 55% 48.3% 23% 3 High Alaska 100% 1% 7% Alaska 60% 44.1% 0% 3 Low Arizona 3 72% 3 3 2% 1% Arizona 48% 45.6% 26% 3 Middle Arkansas 3 81% 3 3 -3% 6% Arkansas 45% 48.8% 14% 3 Low California 70% 3 3 10% 12% California 56% 47.4% 35% 3 Middle Colorado 3 100% 3 3 3% 1% Colorado 56% 51.6% 36% 3 High Connecticut 100% 3 3 4% 3% Connecticut 64% 56.8% 38% 3 High Delaware 3 100% 3 2% 1% Delaware 48% 50.7% 33% 3 High D.C. 100% 3 3 10% 5% D.C. 65% Data incomplete 20% 3 High Florida 3 73% 3 3 1% 1% Florida 54% 40.9% 37% 3 Middle Georgia 3 97% 3 2% 8% Georgia 59% 43.1% 26% 3 Middle Hawaii 100% 6% 0% Hawaii 59% 50.2% 25% 3 Low Idaho 3 98% 3 3 -3% 1% Idaho 51% 43.6% 45% 3 High Illinois 88% 3 3 16% 1% Illinois 55% 45.4% 43% 3 High Indiana 75% 5% 2% Indiana 50% 47.9% 17% 3 Low Iowa 3 80% 3 3 -1% 3% Iowa 60% 54.8% 9% 3 High Kansas 3 96% 3 3 9% 8% Kansas 56% 50.7% 27% 3 High Kentucky 3 93% 3 4% 10% Kentucky 48% 49.6% 26% 3 Middle Louisiana 3 100% 3 3 3% 16% Louisiana 53% 41.6% 31% 3 Middle Maine 3 94% 3 3% 1% Maine 51% 48.8% 59% 3 High Maryland 3 89% 3 3 2% 1% Maryland 61% 57.1% 23% 3 High Massachusetts 82% 3 3 10% 11% Massachusetts 59% 58.9% 42% 3 High Michigan 90% 3 17% 3% Michigan 49% 46.1% 41% 3 Middle Minnesota 100% 3 7% 1% Minnesota 52% 52.7% 23% 3 Middle Mississippi 3 100% 3 3 8% 7% Mississippi 63% 42.0% 31% 3 High Missouri 3 87% 3 3 1% 0% Missouri 53% 50.0% 28% 3 High Montana 3 83% 3 -3% 8% Montana 58% 48.7% 44% 3 Low Nebraska 3 95% 3 3 -4% 3% Nebraska 57% 54.2% 13% 3 High Nevada 100% 40% 0% Nevada 55% 37.8% 26% 3 Low New Hampshire 3 47% -6% 3% New Hampshire 54% 52.0% 31% 3 Low New Jersey 82% 3 3 3% 11% New Jersey 52% Data incomplete 45% 3 High New Mexico 3 71% 3 3 3% 8% New Mexico 61% 49.9% 12% 3 High New York 86% 3 3 -1% 45% New York 61% 51.9% 7% 3 Low North Carolina 3 95% 3 -2% 2% North Carolina 51% 54.9% 47% 3 High North Dakota 3 100% 3 3 9% 16% North Dakota 51% 51.1% 0% 3 Middle Ohio 25% 3 3 7% 2% Ohio 49% 50.4% 39% 3 Low Oklahoma 3 95% 3 3 12% 13% Oklahoma 55% 51.3% 25% 3 High Oregon 100% 3 27% 16% Oregon 63% 48.3% 48% 3 Middle Pennsylvania 86% 3 3 2% 13% Pennsylvania 51% 54.2% 46% 3 High Rhode Island 100% 3 3 9% 38% Rhode Island 56% 60.4% 43% 3 Middle South Carolina 3 56% 3 5% 2% South Carolina 45% 46.8% 37% 3 Low South Dakota 3 100% 2% 1% South Dakota 44% 54.4% 10% 3 Low Tennessee 3 91% 3 4% 3% Tennessee 53% 48.2% 34% 3 High Texas 3 80% 8% 7% Texas 68% 47.9% 38% 3 Middle Utah 3 100% 3 3 0% 2% Utah 45% 45.9% 56% High Vermont 100% 3 3 4% 1% Vermont 56% 51.9% 33% High Virginia 3 100% 3 4% 2% Virginia 58% 54.7% 56% 3 High Washington 100% 3 1% 1% Washington 60% 53.8% 33% 3 High West Virginia 3 97% -2% 16% West Virginia 55% 48.2% 5% 3 Low Wisconsin 3 98% 3 3 0% 5% Wisconsin 56% 50.9% 38% 3 High Wyoming 3 92% -6% 1% Wyoming 47% 40.7% 0% 3 Low 51-state average N/A 89% N/A N/A 5% 6.5% 51-state average 55% 49.5% 30% N/A N/A Note: See “Appendix A: Methodology” for a description of TFAH’s data-collection process and scoring details. Indiana and New Jersey have joined the NLC, but had not yet set a date for implementation as of December North Dakota’s fiscal 2019 funding combines funds for the Department of Health and the Department of Environmental Quality, which were separated, beginning in fiscal 2019. Some state residents use 2019. States with conditional or pending accreditation at the time of data collection were classified as having no accreditation. Nebraska’s year-over-year funding change incorporates a modification to its accounting private drinking-water sources, rather than community water systems. Private sources are not captured by these data. Only regulated contaminants are measured. Paid time off includes sick leave, vacations, methodology—some funds were previously double-counted—that the state was unable to apply retroactively to fiscal year 2018. and holidays. The patient safety measure captures only general acute-care hospitals. TFAH • tfah.org 11 SECTION 1: SECTION 1: YEAR IN REVIEW: 2019 SECTION 1: YEAR IN REVIEW: Ready or Not Year in Review: 2019 2020 HEALTH THREATS—INCIDENTS AND ACTIONS Disease Outbreaks Notable Incidents: l Seasonal flu. The 2018–2019 flu l Hepatitis A. In 2019, 29 states season was of “moderate severity” experienced outbreaks of the Hepatitis lasting 21 weeks, the longest season A virus, driven in part by increases over the past decade.20 Over the past among those who reported drug use and five seasons, the flu season lasted homelessness.25 Hepatitis A is a highly between 11-21 weeks with an average transmissible infection.26 The Hepatitis of about 18 weeks.21 The Centers for A vaccine is recommended for certain Disease Control and Prevention’s populations; in February, the Advisory (CDC) preliminary estimates Committee on Immunization Practice found that the flu accounted for updated its recommendations for people approximately 37.4 to 42.9 million experiencing homelessness to receive illnesses and 36,400 to 61,200 deaths the vaccine.27 Hepatis A infections had in the 2018–2019 season.22 The been going down between 2000 and CDC estimates that influenza has 2012 but increased between 2012 and resulted in between 9 million and 45 2013 and again between 2015 and 2016 million illnesses, between 140,000 (2016 is the latest available data).28 Since and 810,000 hospitalizations, and the on-going outbreak began in 2016, between 12,000 and 61,000 deaths there have been 28,466 reported cases annually since 2010, the high end of that lead to 17,217 hospitalizations and that range occurred during the high 288 deaths.29 severity 2017-2018 season. Vaccine l Measles outbreaks, United States. coverage rates increased across all As of December 31, 2019, for the age groups in 2018–2019, possibly year, there were 1,282 confirmed as a result of the prior season’s case of measles in 31 states, the severity, with vaccine rates among highest number of cases since 1992.30 adults increasing by 8.2 percent Measles is a highly contagious disease over the previous season and up 4.7 predominantly affecting young children percent among children.23 At this that can cause serious complications, report’s press time in late December, such as pneumonia, encephalitis, the 2019 – 2020 flu season was hospitalization, and death.31 It can having an impact nationwide as cause up to a 90 percent chance of all regions of the country were disease contraction in unimmunized experiencing evaluated levels of flu- individuals.32 Outbreaks have been

FEBRUARY 2020 like illness. According to the CDC, linked to the sustained spread of measles as of December 14, 2019 there had among unvaccinated communities: 88 been 3.7 million reported flu cases percent of all cases occurred in close- leading to 32,000 hospitalizations knit, under-immunized communities.33 and 1,800 deaths during the in- In 2019, the United States narrowly progress flu season.24 maintained its measles elimination status, a status it has had for 20 years.34 l Measles outbreaks, global. The World Health Organization (WHO) reported that there were nearly three times as many measles cases from January 2019 to July 2019 as there were during the same period in 2018,35 the highest number for any year since 2006.36 The Democratic Republic of the Congo, Madagascar, and Ukraine reported the highest numbers of cases in 2019, with ongoing outbreaks in other nations.37 In Samoa, an outbreak sickened more than 5,600 people and led to at least 81 deaths, most of the dead were children younger than five.38 The reasons for under-vaccination varied by country, with lack of access, armed conflict and displacement, vaccine misinformation, or low awareness driving down immunization rates in some countries. l The Democratic Republic of Congo 44 outbreak. On July 17, 2019, the survivors are severely brain damaged. to eradicate polio in Pakistan faltered WHO declared the Ebola virus outbreak The previous 10 years, from 2009 when the country experienced an in the Democratic Republic of Congo to 2018, only saw 72 reported cases uptick in the number of cases in 2019. 45 (DRC) a Public Health Emergency altogether. The reasons for the According to public health officials on of International Concern.39 As of the atypical EEEV year are not entirely the ground, efforts to collect reliable end of December, there were 3,380 clear but may be the result of a milder data and increase vaccination rates are 46 confirmed cases and 2,232 deaths.40 winter extending mosquito activity. hindered by widespread resistance to required vaccination.51 l l Candida auris. C. auris is an emerging . Cholera, an acute intestinal l drug-resistant fungus that has led to infection, is rare in the U.S. but Foodborne illnesses. In 2019, severe illnesses in hospitalized patients; globally cases have increased steadily multistate foodborne illness outbreaks 47 a majority of reported cases were in New since 2005 and is a major cause of included infections resulting from Jersey, New York, and Illinois. This multi- epidemic diarrhea in the developing ground beef, ground turkey, romaine drug-resistant fungus has a mortality world. Regions with humanitarian lettuce, frozen ground tuna, and 52 rate close to 60 percent and presents a crises, high rates of poverty and a lack flour. Other outbreaks included serious global health threat.41 At year’s of water and sanitation infrastructure Listeria monocytogenes in deli-sliced end, there were 685 clinical cases of are at higher risk. In 2019, Yemen, meats and cheeses, and salmonella C. auris, and 1,341 patients infected Somalia, and Sudan faced serious in melon, tahini products, and 48 53 with C. auris in the United States with outbreaks. In Yemen, over the past papaya. The CDC estimates that transmission in multiple countries.42 five years, there have been more than 2 48 million people get sick, 128,000 million total cases of cholera and 3,716 are hospitalized, and 3,000 die from l Eastern equine encephalitis virus. In deaths as a result of the disease.49 foodborne illness each year in the 2019, the CDC confirmed 36 cases of United States.54 Campylobacter and l Polio. The world is 99 percent of the Eastern equine encephalitis (EEEV) salmonella were the most commonly way to eradicating polio globally,50 disease across eight states, including 14 identified infections, with the 43 with just two countries that have never deaths. EEEV is a serious mosquito- incidence of Cyclospora increasing stopped the transmission of polio: borne disease in which 33 percent of markedly in 2018.55,56 those infected die and eight out of 10 Afghanistan and Pakistan. The fight TFAH • tfah.org 13 Notable Actions: nation led states—often those most l HIV strategy. In his February 2019 State afflicted with an outbreak—to enact of the Union address, President Donald laws or temporary policy changes to Trump announced a strategy to stop the address vaccine hesitancy. States that spread of HIV by 2030 by concentrating make it easier to opt out of school prevention resources in nationwide hot entry vaccination requirements for spots where half of all new infections nonmedical reasons – sometimes called occur. The announcement did not personal belief or religious exemptions specify a budget for the initiative.57 – are more likely to have lower overall 62 The U.S. Department of Health and vaccination rates. Two states—Maine, Human Services (HHS) has proposed and New York—removed personal- and/ the “Ending the HIV Epidemic: A Plan or religious-belief exemptions for at for America” initiative to end the HIV least some vaccines for public-school 63 epidemic in the United States within entry during the year, bringing the 10 years. The goal is to reduce new number of states nationally that have HIV infections by 90% in the next 10 eliminated such exemptions to five.(See years. To achieve maximum impact, the “Vaccine Hesitancy” side bar on page 15.) first phase of the initiative will focus on A new law in California creates a review geographic areas that are hardest hit by process that gives public health officials HIV.58 In December, Congress approved the final say on medical exemptions, 64 the largest increase to domestic HIV- with the authority to reject them. With AIDS programs in decades.59 the goal of reducing nonmedical-based exemptions, California’s government l U.S. Role in Ebola and global health will review physicians who write five or security. On May 20, 2019, U.S. more exemptions as well as academic Secretary of Health and Human institutions that have immunization rates Services Alex Azar addressed the World below 95 percent beginning in 2020. Health Assembly in Geneva, Switzerland, calling attention to the Ebola outbreak l In September, the President issued in the DRC, vaccine purchasing, and an Executive Order on Modernizing the importance of vaccination. Azar Influenza Vaccines in the United States declared America’s full support for the to Promote and Public implementation of the International Health. The executive order established Health Regulations and Global Health a National Influenza Vaccine Task Security Agenda to better protect the Force charged with creating a 5-year public from health emergencies.60 plan to promote the use of more agile and scalable vaccine manufacturing l Emergency diagnostics task force. The technologies and accelerate the U.S. Food and Drug Administration development of influenza vaccines.65 (FDA), CDC, and Centers for Medicare and Medicaid Services l New CDC Vaccine initiative. In October, (CMS) launched a Tri-Agency Task CDC launched a new “Vaccinate with Force for Emergency Diagnostics to Confidence” strategic framework to “advance the rapid development and strengthen vaccine confidence by deployment of diagnostic tools for identifying pockets of under-vaccination clinical and public health laboratories and by expanding resources for health during public health emergencies.” 61 professionals to support effective vaccine conversations and stop misinformation.66 l Changes in vaccine laws. Measles outbreaks occurring across the 14 TFAH • tfah.org VACCINE HESITANCY: A GLOBAL HEALTH THREAT

According to the WHO, vaccine hesitancy was one of the top 10 global health threats in 2019. The WHO identifies complacency, inconvenience in accessing vaccines, and lack of confidence as three key factors that lead to the underutilization of vaccines, and, estimates that 1.5 million deaths worldwide could be avoided if vaccine rates improved.67

Vaccine hesitancy makes the U.S. more vulnerable to outbreaks of vaccine- preventable diseases and especially more vulnerable during a . During an influenza pandemic or an outbreak of an emerging infectious disease, wide swaths of the population may need to be vaccinated. Resistance to vaccines would put the entire population at risk during a severe outbreak.

Measles outbreaks during 2019 brought attention to the fact that, while generally childhood vaccination rates in the United States are, according to the CDC, “high For the 2018–2019 school year, to attend public school, all states and stable,”68 there is reason to be the measles, mumps, and rubella also allowed medical exemptions, 45 concerned about certain trends, including (MMR) vaccine rate (two doses) for states allowed religious exemptions, lower vaccination rates for uninsured kindergartners nationwide was 94.7 and 15 states allowed philosophical children, misinformation campaigns percent,70 but nine states were below exemptions.74 about vaccine safety, and the impact 92 percent: Alabama, Colorado, Hawaii, of vaccine exemption laws. Additionally, According to the CDC, about 2.5 percent Idaho, Indiana, Kansas, New Hampshire, while state and national data showed of kindergartners nationwide had an Ohio, and Washington.71 According to relatively high overall vaccination rates, exemption to one or more vaccines for infectious disease experts and the pockets of under vaccination place some the 2018–2019 school year, up from WHO, a vaccination rate of 95 percent is communities at risk for measles and 2.3 percent in 2017–2018 and 2.1 necessary to protect a population from other vaccine-preventable diseases. percent in 2016–2017.75 Among young the measles.72 children, vaccination rates were lower In the United States, between January Increases in reported cases of whooping for uninsured children and those insured 1 and December 31, 2019, 1,282 cough and mumps were also up during by Medicaid as compared with children measles cases were confirmed in 31 the year, and some colleges reported covered by private insurance. According states, the most reported cases in any outbreaks of meningococcal disease.73 to the CDC, an expansion of the year since 1992, and the United States “Vaccines for Children” program could narrowly missed losing its measles- As of November 2019, while all states help address these disparities.76 elimination status.69 required for children

TFAH • tfah.org 15 Despite decades of strong science other ways insular, can be at higher Measles is also on the rise globally. that debunks them, myths and risk for infectious diseases due to According to preliminary data reported misinformation about the short- low immunization rates. A measles by the WHO, measles cases rose by and-long term side effects of outbreak in an ultra-orthodox Jewish 300 percent worldwide during the first vaccines persist. In June 2019, The community in Brooklyn, New York, is an three months of 2019 as compared to Washington Post reported on well- example. It accounted for 75 percent the same time frame in 2018.85 financed campaigns driven by online of all the measles cases nationwide, In 2019, the United Kingdom lost its messaging, live events, and high-profile i.e. 934 cases in the New York City/ measles-free status. In England, where spokespersons that have stoked fears New York state area.80 Experts believe vaccinations are not mandatory for about vaccine safety.77 Follow-up that measles cases were introduced school attendance, vaccination rates reporting in November found that two into the under-immunized community for 13 childhood diseases—including anti-vaccine groups funded over half by people who had traveled there measles, mumps, rubella, whopping of the ads on Facebook that contained from Europe and Israel. As a result, cough, and meningitis—have fallen. misinformation about vaccines.78 In New York experienced its most severe Uptake of the MMR vaccine in England March 2019, Facebook announced that measles outbreak in decades.81 Somali- for 2-year-old children has gone down it would no longer accept advertising American communities in Minnesota, every year for the last five years, that included misinformation about Amish in Ohio and Ukrainian-Americans dropping to 90.3 percent in 2018–2019. vaccines. Then, in fall 2019, Facebook, in Washington State have also Health experts throughout England are Instagram, and Pinterest announced experienced measles outbreaks. warning of the serious health risks for changes in their search algorithms to In June of 2019, in the wake of the unprotected children.86 There were 989 ensure their sites return scientifically outbreak in Brooklyn and surrounding confirmed cases of measles in England accurate information for searches areas, New York state ended its and Wales during 2018.87 related to vaccines. All three sites now religious exemption for immunizations, render or will connect site users to the Vaccination rates in Germany are joining four other states that have CDC and/or the WHO for content about reportedly under 90 percent for 13 eliminated such exemptions: California, vaccines and vaccine safety.79 preventable illnesses, and one in five Maine, Mississippi, and West Virginia.82 German 2-year-olds does not have a Most U.S. parents are protecting In 2019, Washington state also vaccination against the measles.88 their children from vaccine- enacted a law removing philosophical preventable diseases by making sure exemptions following two measles Measles is also making a resurgence they are vaccinated. However, in outbreaks,83 although Washington’s in Africa with 10 African nations some communities, those that are policy only applies to MMR vaccine experiencing outbreaks in 2019.89 distrustful of government, that claim requirements.84 a religious exemption, or that are in

16 TFAH • tfah.org l Nationwide Antibiotic Stewardship l Social media platforms and vaccine Requirements. Antimicrobial resistance, disinformation. Some social media the rise of superbugs that are resistant platforms pledged to promote to existing medicines, is a major threat evidence-based decisions about to health. Antibiotic stewardship vaccines and to strive to offer links programs (ASPs) are a coordinated that will lead users to appropriate approach that promotes appropriate online sources.94 In August, Pinterest use of antibiotics in healthcare settings announced that all searches for and reduce antimicrobial resistance.90 “measles” or “vaccine safety” or other CMS finalized new conditions of related terms will return results from participation mandating that U.S. leading public health organizations, hospitals and critical access hospitals including the WHO, the CDC, and the create and implement antibiotic American Academy of Pediatrics.95 In stewardship programs as well as addition, site users will not be able to infection-prevention and -control add comments or recommendations mechanisms. CMS now requires all to the vaccine-related content, and no critical access hospitals to implement advertising will publish with vaccine- antibiotic stewardship programs by related content.96 In September, March 31, 2020. These programs Facebook announced that all searches will follow national guidelines for for vaccine-related content on the appropriate use of antibiotics, in platform (and on Instagram—also order to prevent the transmission and owned by Facebook) will return a development of antibiotic-resistant pop-up box directing the site user organisms.91 In addition, HHS and the to vaccine information on the CDC Office of the Assistant Secretary for website domestically and on the WHO Preparedness and Response (ASPR) website outside the United States.97 are leading an effort to update the l Food Safety and Modernization Act National Action Plan on Combating implementation. In a September Antimicrobial Resistant Bacteria.92 progress statement,98 the FDA l Crimson Contagion functional announced it would establish a exercise. In August, HHS ad ASPR dashboard to publish metrics relating hosted a functional exercise, to the implementation of the Food “Crimson Contagion.” This exercise Safety Modernization Act, including was a multistate, whole-government food safety outcomes and associated and -community effort focused on measures. This act shifted the nation’s policy issues responses, information food safety system from a response exchange, economic and social impact, posture to one of global food safety and other topics based on a scenario and prevention.99 The dashboard’s featuring a novel influenza virus. The initial data showed the majority of goal of Crimson Contagion exercise companies in compliance with the was to practice information exchange, new requirements experienced an coordinate resources, and compare overall improvement in the time from policy decisions across various levels of identifying a recall event to initiating a public and private sector entities in a voluntary recall. pandemic influenza scenario.93

TFAH • tfah.org 17 l The FDA’s new imported food safety biological samples, found over 1,000 strategy. The FDA also released a new new viruses, trained approximately imported food safety strategy guided 5,000 individuals in African and Asian by four goals: (1) food offered for countries, and erected and bolstered import must meet U.S. food safety 60 new medical research facilities.102 requirements; (2) the FDA’s border USAID will transfer some aspects surveillance must prevent the entry of the project to other government of unsafe foods; (3) there must be a agencies. However, the United rapid and effective response to unsafe States could lose the international imported food; and (4) there must be relationships, approaches, and an effective and efficient food import training goals that USAID’s Predict program.100 The United States imports established.103 about 15 percent of its food supply l Global influenza strategy.The from other countries, including about WHO released a global influenza 32 percent of its fresh vegetables, strategy for 2019–2030,104 outlining 55 percent of its fresh fruit, and 94 strategic objectives and actions for percent of its seafood consumed stakeholders. The high-level goals for annually. the strategy include “better global l The Predict program ended. In tools to prevent, detect, control, October, the U.S. Agency for and treat influenza” and to focus on International Development’s (USAID) building stronger country capacities emerging pandemics program, that are integrated within national Predict, ended. USAID designed health security planning and universal Predict to track and research health coverage efforts. deadly zoonotic diseases globally.101 l Polio eradication. On World Polio Specifically, it worked with global Day, October 24, a global commission researchers to collect blood samples declared polio type III eradicated. from animals in order to track and This is the second of three polio understand pathogens. Over 10 strains declared eradicated.105 years, the program collected 140,000

18 TFAH • tfah.org Notable Research Findings, hit the market in the United States. Meetings, and Federal Hearings: This test will take protein samples l Inaugural Global Health Security from living and recently deceased Index finds no country fully prepared individuals to try to obtain an initial for epidemic or pandemic. A joint diagnosis or to refute a suspected project by the Nuclear Threat Ebola case diagnosis. This test Initiative and Johns Hopkins Center will be used in cases where more for Health Security, with research sensitive molecular testing is not by the Economist Intelligence available to try to obtain an initial unit, the Global Health Security diagnosis or to refute suspected 112 Index conducted a comprehensive Ebola cases. In December, the assessment and benchmarking FDA announced approval of Ervebo, of health security and related the first FDA-approved vaccine capabilities across 195 countries.106 for the prevention of Ebola virus disease (EVD) in individuals 18 l Universal flu vaccine study.The years of age and older. In addition, National Institutes of Health (NIH) the NIH awarded funding to the began conducting the first human University of Texas Medical Branch trial of a universal influenza vaccine, at Galveston, Profectus Biosciences, which could confer long-lasting Vanderbilt University Medical immunity from multiple influenza Center, Mapp Biopharmaceutical, subtypes among all age groups. The and Genevant Sciences Corp. to NIH is currently in Phase 1 of the advance the development of vaccines 107 clinical trial. and treatments to address Ebola l Advancements in Ebola medical and Marburg viruses. According to countermeasures. There were the HHS, these viruses contain the several breakthroughs in research highest risk of weaponization by and development of treatments, bioterrorists and will render the most 113 vaccines, and diagnostics to combat catastrophic effects.

the Ebola virus. Researchers found l EEEV vaccine. The National Institute two Ebola treatments utilized in the of Allergy and Infectious Diseases DRC showed promise against the (NIAID) employed researchers to 108 current Ebola strain. The European develop vaccines and treatments to Medicines Agency also announced fight EEEV. Specifically, NIAID’s the world’s first authorization for an Vaccine Research Center has been Ebola vaccine, shown to be effective developing an injection (WEVEE) 109 in protecting people from the virus. that would protect individuals from Preliminary results showed 97.5 equine encephalitis virus. WEVEE 110 percent vaccine effectiveness. A is currently undergoing a Phase second Ebola vaccine, produced by 1 clinical trial to determine if the Johnson & Johnson, began a clinical treatment is safe and successful in 111 trial late in 2019 in the DRC. In inducing a clinical response. So far, October, the FDA permitted a new researchers report that the vaccine Ebola rapid diagnostic test, OraQuick “appears to be safe and tolerable Ebola Rapid Antigen Test, to officially among 30 healthy volunteers.”114

TFAH • tfah.org 19 l Vaccines and treatments to address Sixth Replenishment Conference, smallpox, monkeypox, Marburg and during which donor states pledged Sudan viruses. Also during the year, the $14 billion in funding to continue FDA licensed a novel vaccine for the efforts to eradicate AIDS, tuberculosis, prevention of smallpox and monkeypox and .120,121 as well as a Phase 3 trial of a new l Antimicrobial Resistance (AMR) anthrax vaccine, and the HHS invested Threats Report. In November, a new in the first vaccine development against CDC report, Antibiotic Resistance Threats Marburg virus.115,116,117 In addition, the in the United States, 2019,122 found that Biomedical Advanced Research and drug-resistant germs in the United Development Authority (BARDA) States sicken about 2.8 million people contracted Mapp Biopharmaceutical, annually and about 35,000 die as a to develop a Ab therapeutic for result.123 In addition, 223,900 cases Marburg and contracted with Sabin of Clostridioides difficile occurred in and Public Health Vaccines for the 2017 and at least 12,800 people died. development of vaccines for Marburg This new report found that earlier and Sudan viruses. estimates of the incidence of drug- l Detecting bacteria for bioterrorism- resistant infections underreported the related threats. In March, the FDA number of such infections. Patients issued finalized requirements for the in hospitals and nursing homes with review process of device and diagnostic weak immune systems are at particular test development aimed at detecting risk for drug-resistant infections, but bacteria that could cause bioterrorism- these infections are also becoming related threats. These rules will allow more common among otherwise manufacturers to provide more healthy patients having routine appropriate performance evaluations procedures.124 However, the report and consistent data on testing criteria also found that AMR-prevention for these medical countermeasures.118 activities are working: Prevention efforts have reduced deaths from l African Epidemic Preparedness antibiotic-resistant infections by 18 Index. On August 28, the African Risk percent overall and by nearly 30 Capacity and Africa Centres for Disease percent in hospitals since the 2013 Control and Prevention agreed to a report.125 In Europe, the European partnership to establish the African Centre for Disease Prevention and Epidemic Preparedness Index. This Control recently reviewed and framework establishes an early warning updated their response to AMR in and response platform for member order to encourage member states to states to address all emergencies in aggressively address and control anti- an effective time frame and to build microbial resistance.126 the capacity to alleviate the burden of disease on the African continent. l Congressional Flu Hearing. In The framework uses a collaborative December, the U.S. House of approach that allows member states to Representatives Committee on Energy share knowledge and lessons learned, and Commerce, Sub-committee on strengthen capacity, and provide Oversight and Investigations held technical support to one another.119 a hearing on flu preparedness:Flu Season: U.S. Public Health Preparedness l Global Fund Replenishment. In and Response. October, the Global Fund held its 20 TFAH • tfah.org Severe Weather and Natural Disasters Notable Incidents: l Extreme heat. July 2019 was the hottest month ever recorded on Earth, with a temperature nearly 1.2 degrees Celsius above preindustrial levels.127 What’s more, 2015 to 2019 has been the warmest five-year period since at least the 19th century.128 A summer heat wave in Europe also resulted in the hottest June ever recorded on the continent, resulting experience in future storms.136 HHS created clouds of smoke that triggered in hundreds, if not thousands, of excess Secretary Azar declared public health a “Spare the Air” announcement, deaths.129 According to European emergencies in North Carolina, warning residents that the quality of climate scientists, the heat wave in Georgia, South Carolina, Florida, and air was unhealthy and unsafe and that Europe pushed Arctic temperatures into Puerto Rico as a result of Dorian.137 those exposed to it could experience the 80s (Fahrenheit), melting about 40 Dorian matched or broke records for its detrimental health effects.144 billion tons of Greenland’s ice sheet.130 intensity according to climate scientists l California power outages. In an and was another example of a pattern l Hurricane Dorian. In late August, attempt to reduce the risk of wildfire of the increased likelihood of storms, Hurricane Dorian, which started as a created by the combination of hot, dry fueled by warmer water, that are more tropical storm and quickly intensified winds and sparks from an aging electric likely to stall over land, increasing the to a category 5 hurricane, first made infrastructure, Pacific Gas & Electric amount of wind and rain communities landfall in the U.S. Virgin Islands shutoff power in some high-risk areas experience.138 Meanwhile, 2019 was the causing blackouts and power outages in of the state. These planned blackouts fourth straight year that a category 5 St. Thomas, St. John, and St. Croix.131 created a related health emergency for hurricane formed in the Atlantic, the With winds up to 185 miles per hour, some residents, including presenting longest such streak on record.139 Dorian struck the Bahamas. The storm significant risk to patients in healthcare is believed to have killed approximately l Wildfires in California and other states. and long-term care facilities, people 65 people and caused catastrophic Several states experienced wildfires with electrically-dependent medical damage, destroying an estimated 45 in 2019, including Nevada, Alaska, equipment or medicines, such as percent of the homes on Abaco and Texas, and California.140 California’s oxygen, wheelchairs and insulin, and Grand Bahama islands. The estimated average temperature has increased the safety of food and water.145 cost of the damages caused by Dorian by about 3 degrees Fahrenheit over l Flooding throughout the United is over $7 billion.132,133,134 When Dorian the past century, which is three times States. Many communities in the reached the U.S. East Coast, it had the global temperature increase of Midwest and South experienced weakened to a tropical storm, but it 1-degree Fahrenheit.141 The increase record flooding—in terms of height, still caused catastrophic flooding and in temperature in many areas withered spread, and duration146—as the widespread power outages in and the state’s vegetation, allowing wildfires Arkansas, Mississippi and Missouri around Cape Hatteras, North Carolina, to spread quickly through dry land. Rivers flooded, affecting nearly 14 and stranded 940 residents and possibly During 2019, there were approximately million people.147 As many as 7.9 others.135 Dorian hit Ocracoke, North 6,190 fire incidences in California percent of U.S. counties received Carolina, particularly hard, raising of varying size and intensity, with Federal Emergency Management concerns about whether the island three fatalities.142 As of November 6, Agency (FEMA) natural disaster community would be able to rebuild. approximately 198,392 acres of land declarations as a result of the 2019 According to climate-change experts, have burned and over 700 structures floods, and damages were estimated to Ocracoke’s experience is a bellwether have been destroyed or damaged.143 The exceed $10 billion.148 (See “2019: The for what coastal communities up Circadian Fire in the northern part of Year of the Flood” on page 22.) and down the eastern seaboard may the state and the San Francisco Bay Area TFAH • tfah.org 21 2019: THE YEAR OF THE FLOOD “The year of the flood,” that’s how many will remember 2019. In communities large and small, coastal and non-coastal, flooding created major damage and disruption. The winter of 2018–2019 was the wettest winter on record in the United States.149 The health risks associated with this weather and subsequent flooding required mobilizations by public health emergency preparedness and response teams throughout the nation.

Flooding along coastal areas tends to get Arkansas Secretary of Health Dr. “Planning and training for the most media attention, particularly Nathaniel Smith and Emergency weather-related emergencies when associated with a hurricane or Preparedness Director Dr. Micheal Knox tropical storm. In 2019, there were and their teams prioritized the following enabled our partners to effectively 18 tropical storms and six hurricanes, during the flooding response: immunizing evacuate 98 nursing home three of which meteorologists classified first responders and people who would be as intense, including Hurricane Dorian, temporarily living in shelters (Hepatitis A residents to safety during the whose 185 miles per hour winds and Tdap), ensuring access to healthcare Arkansas River flood of 2019.” devastated the Bahamas and brought for anyone displaced by the floods, insect significant flood damage to North control, communications, and monitoring Nathaniel Smith, MD and MPH Carolina. Other storms that caused major for possible chemical releases or other Arkansas Secretary of Health damage and flooding included Hurricane contaminants in the Arkansas River and Barry, which hit Louisiana, and Tropical in municipal water systems and private Storm Imelda,150 which hit Louisiana and wells. Texas. Imelda led to an astounding three According to Smith and Knox, it was feet of rain in a large region of Texas, fortunate that the state’s health including Houston. department had situational awareness Also noteworthy was an increase in about when the flood would hit and how flooding in non-coastal areas151 as a it would progress. (The flooding was the result of river and lake flooding caused by result of an upriver reservoir release after heavy rainfall, alterations in land usage, heavy rain in Kansas and Oklahoma.) and/or rapid snow melting. A series of But the keys to success involved their record floods occurred in the Mississippi prior planning and collaboration with River tributary basins, including the Ohio, a wide range of governmental and Missouri, and Arkansas Rivers.152 The private agencies, including the Arkansas Arkansas River had its worst flooding in Department of Emergency Management. nearly 30 years during May and June, A test of their preparedness and reaching more than seven feet above emergency planning occurred when the flood stage and leaving downtown Little city had to evacuate patients from a long- Rock inundated with water.153 According term care facility and a major hospital— to Arkansas state health officials, the both evacuations were successful. 2019 flooding was unique in a number of ways, including the length of time before A lesson for the team, which they will the water receded, about 25 days, and incorporate into future planning, was the the fact that the flooding included highly need to provide opioid reversal kits to populated areas. shelters during large-scale emergencies. 22 TFAH • tfah.org While reaching record levels in 2019, the problem of flooding has been growing for a number of years. The U.S. National Weather Service154 recorded 10 rain storms and subsequent flooding in 2015– 2016 that scientists expected to occur only once every 500 years.

The health risks associated with flooding includes drowning, sewage contamination, waterborne diseases (such as Vibrios skin infections or E. coli or salmonella-caused diarrheal disease), mold, and increased risk of mosquito- borne diseases. Following Hurricane Harvey in 2017, the Texas Department of State Health Services attributed 26 deaths155 to a wide range of causes from unsafe or unhealthy conditions related to such factors as loss of electricity and clean water, lack of transportation, electrocutions, and/or infections from flood waters. agencies at the local, state, and federal levels are mobilizing. CDC supports a In addition, floods often increase the website page devoted to flooding with risk of the release of harmful chemicals resources for local and state health and other pollution into the water or departments: www.cdc.gov/disasters/ the air. In 2019, for example, the U.S. floods/index.html. Environmental Protection Agency (EPA) closely monitored floods in areas with The work of the Tulsa, Oklahoma, Superfund sites, taking immediate Health Department is an example of action in Nebraska, Missouri, and other the comprehensiveness of the local locations to prevent the spread of public health response to the 2019 contaminated groundwater.156,157 flooding. Departmental employees staffed the Tulsa County Emergency Additional consequences of flooding Operations and Medical Emergency include loss of or damage to property, Response Centers, opened and/or necessary relocation away from home, expanded vaccination sites, increased and the loss of income due to the mosquito-control efforts to reduce the temporary closing of businesses. Some risks associated with elevated standing people may be more negatively affected. water, monitored drinking-water quality Lower-income people and people of and the risk of exposure to sewage, color may have fewer resources—such sheltered pets and livestock, improved as flood insurance, alternative housing, access to shelters for residents when transportation and cash for essential evacuations were needed, inspected items like food and medicine—to help and reopened food and drink facilities them survive and recover. shuttered by the flood, and used a In response to the growing frequency stress response team to deal with the and severity of flooding, public health trauma that residents experienced.158

TFAH • tfah.org 23 Events and Policy Actions: l National Mitigation Investment Strategy. l Disaster relief bill. In June 2019, In August, FEMA released the National President Trump signed a $19.1 Mitigation Investment Strategy, an billion disaster relief bill providing effort to improve the coordination and 163 aid to communities recovering effectiveness of mitigation investments from hurricanes, flooding, and for state and community officials, wildfires.159 The bill included funds businesses, nonprofits, and others. FEMA to provide nutrition assistance for released the strategy in response to the Puerto Rico, cover crop losses for U.S. Government Accountability Office’s farmers, assist wildfire suppression recommendations, which identified efforts, and repair damaged the need for a coordinated federal and highways and public lands. national investment strategy for risk reduction, following Hurricane Sandy.164 l U.S. officially withdraws from the Paris Climate Agreement. l Oceanic warming. A September In November, President Trump special report by the 195-member formally announced his intention Intergovernmental Panel on Climate to withdraw the United States from Change found that the impact of the Paris Agreement, which aims climate change includes heating the to reduce global greenhouse-gas oceans and altering their chemistry emissions to keep temperatures so dramatically that it is threatening from rising to dangerous levels.160 As seafood supplies, fueling cyclones and of November 11, the United States floods, and posing profound risks to officially entered the agreement the hundreds of millions of people 165 exit process, which will conclude on living along the world’s coastlines. 161 November 4, 2020. l Rising seas. A November report by Climate Central found that rising seas Notable Research Findings, will be a more serious problem than Meetings, and Federal Hearings: previously thought due to an increase l Extreme rain events. The European in the number of people living on Centre for Research and Advanced low ground. The report estimates Training in Scientific Computing that 110 million people are currently estimated that extreme rain events living below sea level and that even with a one in 1,000 chance of “very modest” climate change could occurring in a given year will become increase that number to 150 million by two to five times more frequent if 2050 and 190 million by 2100.166 global temperatures rise 2 degrees l Health effects of climate change. A Celsius higher than preindustrial 2019 report in The Lancet found that levels.162 Of all the regions in the the health effects of climate change United States, New England, the will be unevenly distributed and Southern Great Plains, and the Rocky that children will be among those Mountains are at the greatest risk of especially harmed.167 extreme rainfall.

24 TFAH • tfah.org THE DISPROPORTIONATE IMPACTS OF CLIMATE CHANGE

Climate change affects everyone, where people can live due to rising The impact of wildfires on California are but certain populations and sea levels, what land can be farmed, another example of how a family’s or a communities are at elevated risk for employment opportunities, and community’s resources affect their ability a disproportionate impact. According access to clean water—causing some to rebound and rebuild after a disaster. to the U.S. Global Change Research people to become “environmental In 2018, California fires destroyed nearly Project, the vulnerability of any refugees.”171 Families with the fewest 19,000 homes and led to more than population group is a measure of that resources to relocate will be at higher $12 billion in insurance claims.176 This group’s exposure to climate risks and risk of displacement. high rate of insurance claims is affecting its capacity to respond. The project the current price of insurance, limiting Those of lower socioeconomic has identified 10 “populations of the number of people who can afford status often suffer the most severe concern”—groups at a heightened it. According to industry experts, rate consequences due to a lack of risk for the health consequences of increases to annual premiums between resources to prepare for and rebound climate change: (1) low-income people; 30 and 70 percent are likely, especially for from natural disasters.172 For example, (2) some communities of color; (3) homeowners in areas at high risk of fire.177 people with limited incomes may not immigrant groups, including those Some homeowners may not be able to get be able to afford air conditioning to with limited English proficiency; (4) any coverage through the private market. mitigate the likelihood of hyperthermia indigenous people; (5) children; (6) Their only option may be public insurance during heat waves, a particular pregnant women; (7) older adults; programs with limited coverage, and some vulnerability for older adults. (8) vulnerable occupation groups; may not be able to afford that.178 (9) people with disabilities; and (10) Researchers studying the impact of Adaptation programs can also people with chronic or preexisting climate change on poor people and have unintended consequences on medical conditions.168 Individuals who communities of color in California found lower-income people. Infrastructure are socially, medically, or economically that it has a disproportionate impact improvements in neighborhoods to vulnerable or who are living near the on those communities and coined the make them more climate resilient can coast or on a flood plain are also more term “climate gap” to describe the also make those neighborhoods more likely to be physically at risk.169 unequal climate change impact on attractive to developers and higher- communities least able to prepare for Adverse health effects of climate income residents. A community’s new and recover from climate events.173 change include heat-related disorders; viability can lead to increases in property According to the report, Black residents infectious diseases, such as those values, rents, and property taxes, of Los Angeles are almost twice as spread by contaminated food, often forcing the original lower-income likely to die from a heat-related illness mosquitos, or water; respiratory residents out of the area.179 Post-storm as are other L.A. residents.174 The and allergy disorders; malnutrition; rebuilding in Atlanta, Houston, Miami, authors believe their California findings and mental health issues. People New Jersey, and New Orleans are are representative of the risks facing with chronic health conditions are examples of places where post-event low-income people and communities of more likely to need emergency care investments to protect communities color across the nation. They submit following climate-related events, due against extreme weather have led to that policies and programs to adapt to to a lack of access to medication, the gentrification of some formerly the health impacts of climate change electricity, and primary or behavioral low-income communities and to the need to focus first on those people and healthcare.170 Furthermore, in some displacement of former residents.180,181 communities most at risk.175 places, climate change will affect

TFAH • tfah.org 25 All Hazards Events and Policy Actions Notable Incidents: the illnesses, several states responded to l E-cigarette and Vaping injuries and the outbreak, as well as to the alarming 184 deaths. According to the CDC,182 as rise in youth vaping, by taking of late December, 2,506 e-cigarette emergency actions: Massachusetts or vaping-associated lung injuries declared a public health emergency (EVALI) were reported nationally and a temporary ban on all vaping for the prior 11 months, causing 54 products, and New York implemented a deaths. Additional deaths are under ban on most flavored vaping products. investigation. During the fall, the Michigan, Rhode Island, Montana, injuries and deaths were believed to Washington, California, and Oregon be possibly linked to an additive oil, also passed executive orders or other vitamin E acetate, found in THC- processes to attempt to respond to the containing vaping materials used dual crises of severe lung illness and 185 by many of the people who became the youth vaping epidemic. sick; the substance was identified as a In December the CDC released additional 183 “chemical of concern.” Also during data showing that vitamin E acetate was the fall, as public health officials “closely associated” to EVALI.186 worked to pinpoint the exact source of

26 TFAH • tfah.org A DIFFERENT TYPE OF EMERGENCY: E-CIGARETTE OR VAPING-ASSOCIATED LUNG INJURY

In August 2019, a public health products. There has been at least one around the nation. The EOC worked with emergency arose due to a multistate case in every state. As of December 17, states to create case definitions that outbreak of e-cigarette/vaping-associated 54 deaths were associated with EVALI.190 allowed for the classification of patients, lung injury (EVALI).187 Officials identified tested specimens in its laboratories, The EVALI investigation was made this emergency when local, state, and held regular calls with state and local particularly challenging because federal surveillance found a rapidly health departments, and communicated e-cigarette vaping products are not fully growing cluster of cases of serious lung frequently with the media. Epidemic regulated by the federal government, and injury and death among those who had Intelligence Service officers—who therefore experts did not immediately used e-cigarette or vaping products. are customarily deployed in infectious know or understand the ingredients. disease outbreaks—were deployed to In September, due to the seriousness Furthermore, the products were often work in collaboration with those at the of the health risk, the uncertainty about purchased informally rather than from state and local levels. the cause, and the widespread usage of traditional retailers. So, tracing and these products, including by adolescents testing the products was often difficult.191 As of December, more than 350 and young adults, public health officials CDC staff had mobilized as part Most of those who had serious medical at the CDC and several states activated of the emergency response, with problems were young people—78 percent an emergency response.188 major representation from trained were under 35 years old, with a median epidemiological staff including EVALI was a different type of health age of 24 years. What’s more, 16 percent epidemiologists, clinicians, health risk than is most common public health were under the age of 18, too young communicators, policy analysts, and emergencies. No infectious disease was to even legally purchase the products. others. Because of the relatively suspected, nor was the cause a single Two-thirds were male (67 percent). The unusual nature of this type of emergency catastrophic event, such as a hurricane, majority of those injured did report using operation, it was the first time that many wildfire, or flood. The outbreak illustrated products that contained THC. During the from the non-infectious disease centers the challenges of identifying an emerging fall, experts identified vitamin E acetate participated in an agency-wide response. health threat, building seamless as a “chemical of concern” among people communications between clinical who became ill. Other chemicals have State and local health departments providers and public health amid a not been ruled out.192 In December, mobilized as well. For example, in rapidly changing event, and determining and based on further data, the CDC Washington state, the health department the source of illnesses with limited or said that vitamin E acetate was “closely used its emergency operations center, delayed information. In some ways, the associated” with EVALI.193 drawing on the expertise of both its core EVALI investigation was comparable to emergency preparedness team and its As with other emergencies, the public a contaminated-foodborne outbreak, communicable and non-communicable health sector sought to identify and define during which health officials rush to disease staff. Their work included giving the risk factors; detect and track confirmed identify the likely source. The EVALI information to healthcare providers and probable cases; communicate response benefited from the existence regarding the signs and symptoms of actionable recommendations to state, of a public health emergency system, EVALI; communicating with the local local, and clinical audiences and the trained personnel, and well-established health departments to which providers public; and establish procedures that could communication mechanisms that had reported likely cases; developing assist with the public heath investigation been used for other emergencies. standardized forms to be used for patient and patient care. interviews; conducting patient interviews The CDC, FDA, state, and local health On September 16th, CDC activated its to determine the vaping products used; departments as well as other clinical and Incident Management System and used collecting sample products from the public health partners began coordinated the Emergency Operations Center (EOC) patients and regularly informing the public investigations, ultimately identifying to coordinate activities and assist states, through email updates press events, more than 2,000 people with EVALI189 public health partners, and clinicians interviews, and updated web-based data. due to their use of e-cigarette or vaping

TFAH • tfah.org 27 l Lead in the water. Throughout the Technology Directorate worked year, some residents of Newark, New with their associates in the United Jersey, had to rely on bottled water Kingdom and Canada to examine due to high levels of lead in their tap the recently updated Science Advisory water. The problem began in 2017 Guide for Emergencies. The officials when the city changed its water’s focused on potential public health acidity, which experts believe caused threats to promote a department-wide lead from aging pipes within the water approach that fosters a coordinated system to enter the water supply.194 response. Specifically, officials participated in an activity that l Mass shootings. As of December assessed communication obstacles and 27, in the United States, there were highlighted each country’s strengths 410 mass shootings—defined as an and shortcomings.201 incident in which at least four people are shot, excluding the shooter— l National Health Security Strategy. In in 2019.195 Mass shootings, such as January, the Office of the Assistant those in Dayton, El Paso, Gilroy, and Secretary for Preparedness and Virginia Beach, require an emergency Response released the 2019–2022 health response, including mass- National Health Security Strategy. The casualty healthcare management, strategy outlines steps the nation communications, family assistance, should take to strengthen its ability and mental health first aid.196 In to prevent, detect, assess, prepare addition, these events have long-term for, mitigate, respond to, and recover health effects on communities and from disasters and emergencies. survivors, including post-traumatic The strategy identifies five potential stress disorder, substance abuse, threats: (1) extreme weather and anxiety, and depression.197 natural disasters; (2) a chemical, biological, radiological, or nuclear Notable Events and Policy Actions: (CBRN) incident; (3) infectious l Advancements in chemical disease with pandemic potential; (4) medical countermeasures. Some cyber threats that could destabilize significant advancements in the healthcare system; and (5) medical countermeasures against advances in biotechnology that could chemicals and other threats included be misused to cause harm. The an evidence-based chemical strategy articulates three objectives: decontamination decision tool, (1) prepare, mobilize, and coordinate a fast-acting spray for chemical a whole-of-government approach to decontamination,198,199 and an health security; (2) protect against agreement to bolster the supply of emerging and pandemic infectious medical countermeasures against diseases and CBRN threats; and (3) chemical warfare agents.200 leverage the capabilities of the private sector as partners in the effort to l Advisory guide for emergencies. protect the nation against health The U.S. Department of Homeland security threats.202 Security (DHS) Science and

28 TFAH • tfah.org l Pandemic and All-Hazards October.207 The updated framework Commerce Committee asked the Preparedness and Advancing included additional emphasis on U.S. Government Accountability Innovation Act. In June, President nongovernmental capabilities, Office to evaluate a new system to Trump signed the Pandemic and All- including the role of individuals and detect airborne infectious disease Hazards Preparedness and Advancing private-sector partners in responding agents, BioDetection 21, which is Innovation Act, which ensures that to disasters. A new Emergency Support intended to replace the BioWatch the United States is better equipped Function also focused on leveraging system,210 after reports questioned to respond to a range of public health coordination between government the effectiveness and accuracy of emergencies.203 The passage of this and infrastructure owners/operators. the new system. At an October legislation expands funding for congressional hearing—“Defending critical areas, such as strengthening Notable Research Findings, the Homeland from Bioterrorism: the National Health Security Strategy, Meetings, and Federal Hearings: Are We Prepared?”—experts testified improving preparedness and response, l WHO’s 10 threats to global health. before the U.S. House Homeland advancing the emergency response The WHO identified 10 major Security Subcommittee on Emergency workforce, prioritizing a threat- threats to global health that Preparedness, Response, and based approach, and enhancing demand attention from the WHO Recovery about BD21 and other communication and technologies for and its partners in 2019: (1) air bioterrorism concerns. Officials from 204 medical countermeasures. pollution and climate change, (2) the U.S. Government Accountability Office testified that obstacles l Pediatric disaster care centers. noncommunicable diseases, (3) global pertaining to the nation’s ability to In September, the Office of the influenza pandemic, (4) fragile and adequately defend against biological Assistant Secretary of Preparedness vulnerable settings, (5) antimicrobial threats include: (1) assessing and Response allocated $6 million resistance, (6) high-threat pathogens, enterprise-wide threats; (2) situational to create a pilot program for two (7) weak primary healthcare, (8) awareness and data integration; (3) Pediatric Disaster Care Centers of vaccine hesitancy, (9) dengue, and bio-detection technologies; and Excellence. The centers will model (10) HIV. The report was part of the (4) biological laboratory safety and programs designed to decrease the WHO’s strategic plan, which strives security. While strategies such as the impacts of exposure to trauma, to ensure 1 billion more people 2018 National Biodefense Strategy infectious disease, and other public benefit from access to universal health have been established to address some health emergencies on children by coverage, 1 billion more people have of these challenges, implementation providing pediatric-specific care (that protection from health emergencies, and, 1 billion more enjoy better and monitoring of these strategies are is, specialized training, equipment, 211 208 still in the process. Other experts supplies, and pharmaceuticals) during health and well-being. 205 asserted that the country’s efforts public health emergencies. l DNA screening system. Researchers at to develop new threat-detective l Repeal of clean water regulations. Battelle National Biodefense Institute technologies, such as BD21, were In September, the administration developed a DNA screening system focused in the wrong direction.212 announced the repeal of major clean that compiles more than 10,000 In addition, public health experts water regulations that had placed sequences of concern and streamlines testified as to the importance of the limits on polluting chemicals that the review process of detecting and role of public health in detection, companies could use near certain characterizing pathogens that pose prevention, and mitigation of 209 bodies of water.206 threats to . events but said that federal-local

l coordination, equipment, workforce, l National Response Framework. Congressional oversight of and training are needed.213 FEMA released the National BioWatch replacement. Bipartisan Response Framework, Fourth Edition in members of the House Energy and

TFAH • tfah.org 29 Interview with Germán Luis Parodi

Germán Luis Parodi is the Co-Executive Director of The Partnership for Inclusive Disaster Strategies and works with the United Nations Disaster Risk Reduction Focal Point for Persons with Disabilities in the Americas

assistive technology and durable medical equipment. Nationwide, rarely do you see an American Sign Language interpreter next to officials in disaster related press conferences and many emergency shelters are not accessible for people with access and functional needs. Then, for those people with disabilities lucky enough to survive the initial event, post event they must cope not only with their disability and possible post-traumatic stress, which is rarely attended to, but with aid processes and protocols of emergency management agencies that are, in my experience, intentionally discouraging.

Q: As you indicate, when disasters happen, people with disabilities are disproportionately affected. What needs to be done to protect the health and safety of people with disabilities during a disaster? Germán and co-executive director of the Partnership for Inclusive Disaster Strategies, Shaylin Sluzalis, A: Government, community-based at the general assembly of the UN during the CRPD State Parties convention. and volunteer organizations must involve us, people with disabilities Q: You have deployed as a disaster- and other subject matter experts in responder, what have you seen and planning before an emergency or experienced first-hand about what disaster! This is established law that happens to people with disabilities has been ignored for years. Individuals during an emergency? with disabilities and advocates must be A: As a first responder and a disabled encouraged to be part of the planning person, I’ve witnessed first-hand how process, including involvement in those who are marginalized, isolated, or exercises and drills. During a disaster is not part of the local planning process, no time to be introduced “for the first are left behind in an emergency. More time” to emergency planners. often than not, children and adults with Disaster risk reduction can be achieved disabilities are left to the good intentions through inclusion. People with disabilities of family, neighbors and friends, while need to be included at the federal responders learn of and find people level all the way down to the municipal with disabilities, those who need rescue, level. Including our voices in all mitigation last. Often, people with disabilities are and preparedness work will be the best forced to evacuate without essential way to help ensure that emergency

30 TFAH • tfah.org procedures will help to protect our health silently process the trauma of a disaster, and safety when a disaster strikes. or quietly observe religious prayer time. A couple of big areas that

People need a place to go and a way to come up when we talk about Q: What are your main concerns for get there. Having reliable and accessible those who are either quadriplegic people with access and transportation that can help individuals or paraplegic? Are there specific functional needs are building get to an accessible shelter (including preparations or responses necessary for the bathrooms!), is often not available. evacuations and accessible people with these conditions? Are there other disabilities you would highlight as transportation and shelters. Q: A lot of your work is advocating for requiring specialized care? policy change. What is your highest A: All people with disabilities must plan priority for action steps by policymakers for themselves, as if no one is coming to to ensure that the health and safety of assist or evacuate them. In most cases, people with disabilities are considered that is exactly what happens. People during emergency planning and with disabilities, most age-related, were response? What legislation needs to the highest percentage to lose their lives be passed? What should the federal in the Camp wildfire that devastated government do? What do state and local Paradise, California. After a disaster, need to do? during the recovery process, people A: The Partnership for Inclusive Disaster who use assistive technology or durable Strategies has worked with Senator medical equipment often go without Bob Casey’s (PA) office and other supplies, which leads to involuntary and members of Congress to introduce unnecessary institutionalization. and build support for bicameral bills, While there certainly might be the Real Emergency Access for Aging additional training and knowledge and Disability Inclusion for Disasters responders need, much of what might Act (REAADI) and the Disaster Relief be called “specialized” training or Medicaid Act (DRMA). REAADI and planning should actually be a part of DRMA create and expand policies any routine and inclusive training. If which focus on inclusion of the disability that were the case less “specialized” community in federal response efforts. care would be needed. A couple big There is also already legislation that areas that come up when we talk about requires inclusion and communication people with access and functional needs with the disability community, as well are building evacuations and accessible as access requirements for anything transportation and shelters. When we funded with federal dollars. We need think of the elevator warnings in case of increased compliance and enforcement emergency, use stairs, we can immediately of the policies that already exist and help see a barrier for some quadriplegics or to rectify the harm caused by current paraplegics that might need specialized response mechanisms. States and U.S. care like the knowledge of how to use territories have centers for independent an evacuation chair. However, accessible living, protection and advocacy responses to evacuating in a building organizations, ADAPT chapters and with stairs would also be useful for other disability centered organizations anyone with mobility issues, endurance that can connect the state or city restraints, small children, etc. Similarly, emergency management agencies with a quiet room for people with sensory disabled people to inform, collaborate, sensitivity could be useful for people to and save lives when disasters strike.

TFAH • tfah.org 31 SECTION 2: SECTION 2: ASSESSING STATE PREPAREDNESS Ready or Not Assessing State Preparedness

2020 While it is important that every state be ready to handle public health emergencies, each faces its own mix of threats, and some are more prepared than others. To help states assess their readiness and to highlight a checklist of top-priority concerns and action areas, this report examines a set of 10 select indicators that we strive to use consistently year to year. The indicators, drawn heavily from the National Health Security Preparedness Index (NHSPI), a joint initiative of the Robert Wood Johnson Foundation, the University of Kentucky, and the University of Colorado, capture core elements of preparedness. Based on states’ standing across the 10 indicators (see “Appendix A: Methodology” for scoring details), TFAH placed states into three performance tiers: high, middle, and low. (See Table 4.)

TABLE 4: State Public Health Emergency Preparedness State performance, by scoring tier, 2019 Performance Tier States Number of States

AL, CO, CT, DC, DE, IA, ID, IL, KS, MA, MD, ME, MO, High Tier 25 states and DC MS, NC, NE, NJ, NM, OK, PA, TN, UT, VA, VT, WA, WI

Middle Tier AZ, CA, FL, GA, KY, LA, MI, MN, ND, OR, RI, TX 12 states

Low Tier AK, AR, HI, IN, MT, NH, NV, NY, OH, SC, SD, WV, WY 13 states Note: See “Appendix A: Methodology” for scoring details. Complete data were not available for U.S. territories.

Importantly, the implications of and administrators. Moreover, some this assessment, and responsibility indicators are under the direct control for continuously improving, extend of federal and state lawmakers, whereas beyond any one state or local agency. improvement in other indicators Such improvement typically requires requires multisector, statewide efforts, sustained engagement and coordination including by residents.

FEBRUARY 2020 by a broad range of policymakers INDICATOR 1: ADOPTION Workforce shortages can impair a state’s The NLC has been crucial to response 215 OF NURSE LICENSURE ability to effectively manage disasters or efforts after several recent disasters. disease outbreaks, potentially resulting In 2017, when Hurricane Harvey struck COMPACT in poorer health outcomes for those Texas, the storm’s effects overwhelmed affected. Therefore, the capacity to healthcare systems and nurses from many KEY FINDING: 32 states quickly surge qualified medical personnel member states were able to immediately is critical. The ability to bring in additional assist those in need. In 2018, when participate in the Nurse healthcare workers from out of state is a Hurricane Florence left severe damage in Licensure Compact. key component of healthcare readiness. South Carolina from rain, flooding, and high winds, DaVita Renal Dialysis Centers This indicator examines whether states were in dire need of nurses. Thanks to have adopted legislation to participate South Carolina’s membership in the in the Nurse Licensure Compact (NLC). compact, DaVita was able to recruit nurses Launched in 2000 by the National from other NLC states without delay. A few Council of State Boards of Nursing, weeks later, when flooding from Hurricane the NLC permits registered nurses and Michael forced at least one hospital in licensed practical nurses to practice with the state to evacuate, nurses from other a single multistate license—physically or member states were able to assist. remotely—in any state that has joined the compact. The NLC provides standing As of November 2019, 32 states had reciprocity, with no requirement that an adopted the NLC, with Alabama’s emergency be formally declared. membership taking effect on January 1, 2020.216 This was a net increase of one To help make participation in the since 2018 and six since 2017. Karen C. compact more viable for states, the Lyon, the chief executive officer of the National Council of State Boards of Louisiana State Board of Nursing, which Nursing enhanced its requirements joined the compact on July 1, 2019, said in 2017–2018, standardizing licensure that doing so was a “large step toward requirements among participating advancing professional nursing practice states, in addition to other changes.214 in Louisiana and surrounding states.”217

TABLE 5: 32 States Participate in the Nurse Licensure Compact Participants and nonparticipants, 2019 Participants Nonparticipants Alabama Louisiana Oklahoma Alaska Nevada Arizona Maine South Carolina California New Jersey Arkansas Maryland South Dakota Connecticut New York District of Colorado Mississippi Tennessee Ohio Columbia Delaware Missouri Texas Hawaii Oregon Florida Montana Utah Illinois Pennsylvania Georgia Nebraska Virginia Indiana Rhode Island Idaho New Hampshire West Virginia Massachusetts Vermont Iowa New Mexico Wisconsin Michigan Washington Kansas North Carolina Wyoming Minnesota Kentucky North Dakota Note: Alabama began implementing the NLC in January 2020. Indiana and New Jersey have joined the NLC but had not yet set a date for implementation, as of December 2019. Source: National Council of State Boards of Nursing.218 TFAH • tfah.org 33 INDICATOR 2: HOSPITAL The federal Hospital Preparedness Florence knocked out communication PARTICIPATION IN Program (HPP), which is managed capabilities at a major regional hospital by the HHS Office of the Assistant in North Carolina in 2018, the area HEALTHCARE COALITIONS Secretary for Preparedness and coalition established a backup system Response, provides grants to states, within eight hours.224 localities, and territories to develop KEY FINDING: Widespread On average, 89 percent of hospitals in regional coalitions of healthcare states belonged to a healthcare coalition hospital participation in organizations that collaborate to in 2017, with universal participation, prepare for, and in many cases respond healthcare coalitions was meaning every hospital in the state was to, medical surge events.219 Coalitions part of a coalition, in 17 states (Alaska, common in 2017; only prepare members with critical tools, Colorado, Connecticut, Delaware, four states (California, New including medical equipment and Hawaii, Louisiana, Minnesota, Mississippi, supplies, real-time information, Hampshire, Ohio, and South Nevada, North Dakota, Oregon, Rhode enhanced communication systems, and Island, South Dakota, Utah, Vermont, Carolina) reported 70 percent exercises and training for healthcare Virginia, and Washington) and the personnel.220 A healthcare coalition or fewer of their hospitals District of Columbia. (See Table 6.) must contain a minimum of two acute- However, some states, such as Ohio participated in coalitions care hospitals, emergency medical (25 percent) and New Hampshire (47 services, emergency management, supported by the HHS Hospital percent) lagged behind. and public health agencies.221 HPP Preparedness Program. invests in local capacity to prepare Recent events such as Hurricane Maria, for and respond to events, reducing the California wildfires, mass shootings, jurisdictions’ reliance on federal and even a severe seasonal flu season medical assets during disasters. have exposed gaps in healthcare preparedness at the individual facility, Broad and meaningful participation coalition and systems levels.225 Some by hospitals in healthcare coalitions major gaps in healthcare preparedness means that when disaster strikes, include pediatric surge capacity226 and systems are in place to coordinate the coordinating surge capacity across response, freeing hospitals to focus on the healthcare system;227 building and clinical care. For example, when a train maintaining preparedness for high- derailed on the border of two counties consequence infectious diseases,228 and two coalitions in Washington state such as Ebola; burn capacity and other in December 2017, nine participating specialty care needed for emerging hospitals across three counties used a threats; ongoing stress on the healthcare shared tracking system to streamline system’s ability to provide emergency the documentation and distribution care; preparedness of facilities that serve of 69 patients and to aid family people at higher risk, such as long-term reunification.222 The Houston area’s care facilities; and lack of training and coalition, which comprises 25 counties preparedness for events in healthcare.229 that are home to 9.3 million people and While healthcare coalitions can help 180 hospitals, coordinated activities, address some of these vulnerabilities, such as evacuations and patient systemwide approaches to preparedness transfers, during and after Hurricane are needed. Harvey in 2017.223 After Hurricane

34 TFAH • tfah.org TABLE 6: Widespread Participation of Hospitals in Healthcare Coalitions Percent of hospitals participating in healthcare coalitions, 2017 States Percent of Participating Hospitals AK, CO, CT, DC, DE, HI, LA, MN, MS, NV, ND, 100% OR, RI, SD, UT, VT, VA, WA ID, WI 98% GA, WV 97% KS 96% AL, NE, NC, OK 95% ME 94% KY 93% WY 92% TN 91% MI 90% MD 89% IL 88% MO 87% NY, PA 86% MT 83% MA, NJ 82% AR 81% IA, TX 80% IN 75% FL 73% AZ 72% NM 71% CA 70% SC 56% NH 47% OH 25% Note: This indicator measures participation by hospitals in healthcare coalitions supported through the federal Hospital Preparedness Program of the Office of the Assistant Secretary for Preparedness and Response. The latest data available are for participation in 2017. Source: NHSPI analysis of data from the Office of the Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services.230

TFAH • tfah.org 35 INDICATORS 3 AND 4: The Public Health Accreditation Board a range of health threats. The priority ACCREDITATION (PHAB), a nonprofit organization that capabilities that the PHAB and the EMAP administers the national public health test include identification, investigation, accreditation program, advances quality and mitigation of health hazards; a KEY FINDING: Most states are within public health departments by robust and competent workforce; providing a framework and a set of incident, resource, and logistics accredited by one or both of evidence-based standards against which management; and communications two well-regarded bodies—the they can measure their performance. and community-engagement plans.234,235 Public Health Accreditation Among standards with direct relevance to (States sometimes aim to meet emergency preparedness are assurances applicable standards, but do not pursue Board and the Emergency of laboratory, epidemiologic, and accreditation.) environmental expertise to investigate Management Accreditation As of November 2019, both the PHAB and contain serious public health and the EMAP accredited 28 states and Program—but nine are not problems, policies, and procedures for the District of Columbia—an increase accredited by either. urgent communications and maintenance of three (Iowa, Louisiana, Pennsylvania) of an all-hazards emergency operations since October 2018—and an additional plan.231 Through the process of 13 states received accreditation from accreditation, health departments identify one or the other. (See Table 7.) “This their strengths and weaknesses, increase is a very important milestone in our their accountability and transparency, and continued efforts to promote healthy improve their management processes, lifestyles, prevent injury and disease, which all promote continuous quality and assure the safe delivery of quality improvement.232 healthcare to Pennsylvanians,” said Emergency management, as defined Dr. Rachel Levine, Pennsylvania’s by the Emergency Management secretary of health. “Public health is Accreditation Program (EMAP), an ever-changing landscape. … We are encompasses all organizations in a given committed to preparing for each of jurisdiction with emergency or disaster these concerns and also being aware of functions, which may include prevention, new potential issues that could affect the mitigation, preparedness, response, and health of Pennsylvanians each day.”236 recovery. The EMAP helps applicants Just nine states (Alaska, Hawaii, Indiana, ensure—though self-assessment, Nevada, New Hampshire, South Dakota, documentation, and peer review— Texas, West Virginia, and Wyoming) that they meet national standards for received no accreditation from either emergency response capabilities.233 body. (Nevada was previously accredited The PHAB and the EMAP each by the EMAP.) This analysis includes provide important mechanisms for state-level accreditations only, it does improving evaluation and accountability. not include accredited local or tribal Accreditation by these entities health departments. In some instances, demonstrates that a state’s public health local public health departments have and emergency management systems an accreditation in states that may not are capable of effectively responding to have one.

36 TFAH • tfah.org TABLE 7: 41 States and the District of Columbia Accredited by the PHAB and/or EMAP Accreditation status by state, November 2019 PHAB and EMAP PHAB only EMAP only No Accreditation

Alabama Iowa New York Delaware Kentucky Alaska

Arizona Kansas North Dakota Georgia Michigan Hawaii

Arkansas Louisiana Ohio Maine North Carolina Indiana

California Maryland Oklahoma Minnesota South Carolina Nevada

Colorado Massachusetts Pennsylvania Montana Tennessee New Hampshire

Connecticut Mississippi Rhode Island Oregon Virginia South Dakota

District of Columbia Missouri Utah Washington Texas

Florida Nebraska Vermont West Virginia

Idaho New Jersey Wisconsin Wyoming

Illinois New Mexico

28 states + D.C. 7 states 6 states 9 states Note: These indicators track accreditation by the PHAB and the EMAP. TFAH classified states with conditional or pending accreditation at the time of data collection as having no accreditation. States sometimes aim to meet applicable standards but do not pursue accreditation. Sources: NHSPI analysis of data from the PHAB and the EMAP.237

TFAH • tfah.org 37 INDICATOR 5: STATE Funding for public health programs 4. Environmental public health. Public PUBLIC HEALTH that support the infrastructure and health services related to air and water workforce needed to protect health— quality, fish and shellfish, food safety, FUNDING TRENDS including the ability to detect, prevent, hazardous substances and sites, lead, and control disease outbreaks and onsite wastewater, solid and hazardous KEY FINDING: Most states held mitigate the health consequences of waste, zoonotic diseases, etc. disasters—is a critical ingredient of 5. Maternal, child, and family health. their public health funding preparedness. General public health Public health services related to capabilities—such as those pertaining steady or increased it in fiscal the coordination of services; direct to epidemiology, environmental hazard service; family planning; newborn year 2019, but 11 reduced detection and control, infectious screening; population-based funding. disease prevention and control, and maternal, child, and family health; risk communications—and targeted supplemental nutrition; etc. emergency response resources are necessary to ensure that officials 6. Access to and linkage with clinical maintain routine capabilities, and that care. Public health services related to surge capacity is readily available for beneficiary eligibility determination, emergencies. A trained and standing- provider or facility licensing, etc. ready public health workforce, and one The overall infrastructure of public that knows its community, is critical health programming supports to the surge capacity that is so often states’ ability to carry out emergency necessary during an emergency. responsibilities. But public health According to the Public Health funding is typically discretionary, Activities and Services Tracking project making it vulnerable to neglect or at the University of Washington, state retrenchment, especially when times are public health programming and services tight. This can undermine emergency span six core areas:238 preparedness activities and weaken response and recovery efforts. 1. Communicable disease control. Public health services related to Fortunately, most states (39) and the communicable disease epidemiology, District of Columbia maintained or hepatitis, HIV/AIDS, immunization, increased public health funding in sexually transmitted diseases, fiscal year 2019. (See Table 8.) But 11 tuberculosis, etc. states reduced the money they directed to these vital activities, increasing the 2. Chronic disease prevention. Public likelihood that they will be less prepared health services related to asthma, and less responsive in the moments cancer, cardiovascular disease, that matter most. Nevertheless, this diabetes, obesity, tobacco, etc. was a notable improvement over fiscal 3. Injury prevention. Public health year 2018, when public health funding services related to firearms, motor was cut in 17 states and the District of vehicles, occupational injuries, Columbia. (This indicator does not senior fall prevention, substance- assess the adequacy of states’ public use disorder, other intentional and health funding.) unintentional injuries, etc.

38 TFAH • tfah.org TABLE 8: State Public Health Funding Held Stable or Increased in 39 states and DC Public Health Funding, by state FY 2018 - 2019 State Percentage Change Alabama -5% Alaska 1% Arizona 2% Arkansas -3% California 10% Colorado 3% Connecticut 4% Delaware 2% District of Columbia 10% Florida 1% Georgia 2% Hawaii 6% Idaho -3% Illinois 16% Indiana 5% Iowa -1% Kansas 9% Kentucky 4% Louisiana 3% Maine 3% Maryland 2% Massachusetts 10% cnicbc Michigan 17% Minnesota 7% Mississippi 8% Missouri 1% Montana -3% Nebraska -4% Nevada 40% New Hampshire -6% New Jersey 3% New Mexico 3% New York -1% North Carolina -2% North Dakota 9% Ohio 7% Oklahoma 12% Oregon 27% Pennsylvania 2% Rhode Island 9% South Carolina 5% South Dakota 2% Tennessee 4% Note: Nebraska’s year-over-year change incorporates a modification Texas 8% to its accounting methodology—some funds were previously double- Utah 0% counted—that the state was unable to apply retroactively to fiscal 2018. Vermont 4% North Dakota’s fiscal 2019 funding combines funds for the Department Virginia 4% of Health and the Department of Environmental Quality, which were Washington 1% separated, beginning in fiscal 2019. Owing to differences in organizational West Virginia -2% responsibilities and budgeting, funding data are not necessarily comparable Wisconsin 0% across states. See “Appendix A: Methodology” for a description of TFAH’s data-collection process, including its definition of public health funding. Wyoming -6% Source: TFAH analysis of states’ public funding data.

TFAH • tfah.org 39 INDICATOR 6: Access to safe water is essential for of blood cells.244 These incidents could COMMUNITY WATER consumption, sanitation, and the have long-term consequences on the efficient operation of the healthcare health and brain development of SYSTEM SAFETY system. In the United States, the children, as well as the mental health vast majority of the population and trust of the community. gets water from a public water KEY FINDING: Few Americans Other water-related emergencies and system, and the EPA sets legal concerns in the United States include drink from community water limits on contaminants in drinking harmful algal blooms,245 which impact water, including microorganisms, systems that are in violation the safety of seafood, damage the disinfectants and their by-products, of applicable health-based economies of affected communities, chemicals, and radionuclides;239 the increase the presence of toxic standards required by the Safe EPA also requires states to periodically chemicals like per- and polyfluoroalkyl report drinking-water quality Drinking Water Act. But room substances, and reduce the availability of information.240 Water systems must clean water during power outages,246 a for improvement remains. report any violations, such as failing particular concern in rural areas where to follow established monitoring and smaller utilities may not have enough reporting schedules, failing to comply backup power to meet the demands of with mandated treatment techniques, the water and sewage services. Water violating any maximum contaminant shortages can have a particularly dire levels, and failing to meet customer- impact on healthcare systems, which rely notification requirements.241 on clean water for many procedures and The United States has one of the hygiene practices. safest public drinking-water supplies According to the EPA, across the in the world, but some communities, nation, 7 percent of state residents particularly low-income communities, on average used a community water are at greater risk for lack of access to system in 2018 that failed to meet all safe water. When water safety issues applicable health-based standards, up occur, it can require a multisector slightly from 2017. That share was 0 to 1 emergency response, as well as a long- percent in Arizona, Colorado, Delaware, term public health response. The Florida, Hawaii, Idaho, Illinois, Maine, most prominent water-contamination Maryland, Minnesota, Missouri, Nevada, crisis in recent years occurred in Flint, South Dakota, Vermont, Washington, Michigan, where a 2014 change in and Wyoming. (See Table 9.) But in water supply caused distribution pipes six states (Louisiana, New York, North to corrode and to leach lead and Dakota, Oregon, Rhode Island, and other contaminants into the drinking West Virginia), more than 15 percent water. Tens of thousands of residents, of residents used a community water including young children, have been system with health-based violations. exposed to high levels of lead and other These data do not include water safety toxins.242 In 2019, residents of Newark, on Indian reservations. New Jersey, had to rely on bottled water due to high levels of lead in their tap It is important to note that the EPA water.243 In children, even low levels estimates that about 13 million American of exposure can damage the nervous households get their drinking water from system and contribute to learning private wells.247 The data reported by this disabilities, shorter stature, hearing loss, indicator do not reflect the quality of the and impaired formation and function drinking water used by those households. 40 TFAH • tfah.org TABLE 9: Few Americans Used Contaminated Community Water Systems Percent of state populations who used a community water system in violation of health-based standards, 2018 States Percent of Population HI, MO, NV 0% AZ, CO, DE, FL, ID, IL, ME, MD, MN, SD, VT, WA, WY 1% IN, NC, OH, SC, UT, VA 2% AL, CT, IA, MI, NE, NH, TN 3% DC, WI 5% AR 6% AK, MS, TX 7% GA, KS, MT, NM 8% KY 10% MA, NJ 11% CA 12% OK, PA 13% LA, ND, OR, WV 16% RI 38% NY 45% Note: Some state residents use private drinking-water supplies, rather than community water systems. These data do not capture private supplies. Only regulated contaminants are measured. According to health officials in New York, a drinking water system in New York City is in violation because of an uncovered reservoir, but it has no current violations with respect to contaminants. Source: NHSPI analysis of data from the EPA.248

TFAH • tfah.org 41 INDICATOR 7: ACCESS TO When workers without paid leave get sick, costlier treatments. Workers without PAID TIME OFF they face the choice of going to work and paid sick days are less likely to get a flu potentially infecting others or staying shot, and their children are less likely to home and losing pay—or even their receive routine checkups, dental care, KEY FINDING: Just over half of jobs. Similarly, when workers without and flu shots.255 Lack of paid sick days paid leave have children who get sick, can disproportionately impact lower- workers in states, on average, they face the choice of sending their sick income workers. had some type of paid time child to school and potentially infecting In 2019, 55 percent of workers in states, others or, again, staying home with their off (for example, sick leave, on average, had some type of paid time child and losing pay or even their jobs. off—the same percentage as in 2018— vacation, holidays) in 2019. Most Furthermore, paid time off to care for a according to the Current Population child has been associated with reductions states were closely clustered to Survey, which is sponsored jointly by the in infant mortality, low birth weight, and U.S. Census Bureau and the U.S. Bureau that midpoint, with few outliers. premature birth. Therefore, paid time of Labor Statistics.256 Connecticut (64 off, especially dedicated paid sick leave, percent), the District of Columbia (65 can strengthen infection control and percent), Oregon (63 percent), and Texas resilience in communities by reducing (68 percent) stood out as states where the spread of contagious diseases and relatively high percentages of workers had bolstering workers’ financial security. This such benefits, whereas fewer workers had is particularly important for industries them in Arkansas (45 percent), South and occupations that require frequent Carolina (45 percent), South Dakota contact with the public. For example, (44 percent), Utah (45 percent), and people working in the food-service and Wyoming (47 percent).257 (See Table 10.) childcare industries commonly have no paid sick leave.249 This often leads service An important question is what policies employees to work throughout a bout lead to a higher percentage of workers of the flu or return to work before their having access to paid time off? More symptoms have fully subsided, when one research is needed to fully answer this or two days off could have dramatically question, as no single explanation reduced workplace infections.250,251 is known. For example, Connecticut At a societal level, flu rates have been and Maryland, two states in the top shown to be lower in cities and states quadrant, have laws requiring paid that mandate paid sick leave.252,253 When sick leave.258 However, as of May 2019, employees who previously did not have Texas and Mississippi, also in the top access are granted paid or unpaid sick quadrant (Texas ranking at the top), leave, rates of flu infections decreased by did not, though large cities such as 10 percent.254 Austin, Dallas, and San Antonio had enacted such requirements. Some states Paid time off also increases access have a disproportionate number of to preventive care among workers employers who offer paid time off. For and their families, including example, a large share of Mississippi’s routine checkups, screenings, and workforce is employed by the military immunizations. Delaying or skipping or other government (federal, state and such care can result in poor health local) entities.259 outcomes and can ultimately lead to

42 TFAH • tfah.org TABLE 10: 55 Percent of Workers, On Average, Received Paid Time Off Percent of employed population with paid time off, 2019 States Percent of Workers TX 68% DC 65% CT 64% MS, OR 63% MD, NM, NY 61% AK, IA, WA 60% GA, HI, MA 59% MT, VA 58% NE 57% CA, CO, KS, RI, VT, WI 56% AL, IL, NV, OK, WV 55% FL, NH 54% LA, MO, TN 53% MN, NJ 52% ID, ME, NC, ND, PA 51% IN 50% MI, OH 49% AZ, DE, KY 48% WY 47% AR, SC, UT 45% SD 44% Note: Paid time off includes sick leave, vacations, and holidays. Data are estimated based on a survey of a sample of the general population. Source: NHSPI analysis of data from the Annual Social and Economic Supplement of the Current Population Survey.260

TFAH • tfah.org 43 INDICATOR 8: FLU Vaccination is the best prevention illnesses, including young children – VACCINATION RATE against the seasonal flu. The CDC especially those with special healthcare recommends that, with few exceptions, needs, pregnant women, people with everyone ages 6 months and older certain chronic health conditions, KEY FINDING: Flu vaccination get vaccinated annually; yet, year and older adults. In addition to after year, even with a steady increase protecting Americans from the seasonal coverage rose for the 2018– among adults over the past three flu, establishing a cultural norm of 2019 season, with a greater decades, coverage estimates indicate vaccination, building vaccination 261 share of every age group that less than half of Americans do. infrastructure, and establishing policies Healthy People 2020 sets federal 10-year that support vaccinations can help analyzed receiving a vaccine. benchmarks for improving the health prepare the country to vaccinate all Overall, 49 percent of U.S. of all Americans including an overall Americans quickly during a pandemic seasonal influenza vaccination-rate or disease outbreak. residents ages 6 months and target of 70 percent annually.262 The Under the Affordable Care Act, all older received vaccinations— 2017–2018 flu season in the United routine vaccines recommended by the States was the deadliest in nearly 40 still well below the overall Advisory Committee on Immunization years; it is estimated that more than Practices, including flu vaccines, are target level of 70 percent of the 800,000 people were hospitalized, and fully covered when provided by in- about 61,000 people died—tragically population vaccinated annually. network providers, except in states underscoring the importance of annual that have not expanded their Medicaid vaccination.263 programs in accordance with the law. Vaccination is particularly important for Some barriers to flu vaccination may people at high risk of severe flu-related include a belief that the vaccine does

44 TFAH • tfah.org TABLE 11: Less than Half of Americans not work very well; misconceptions about the safety of the 264 265 Received a Seasonal Flu Vaccination vaccine; or a belief that the flu does not carry serious risks. States seasonal flu vaccination rates for people ages State laws may also make it more difficult for parents to get 6 months and older, 2018–2019 their children vaccinated by a pharmacist—three states do not Vaccination Rate, State allow children to get flu vaccines at a pharmacy and 23 states Ages 6 Months or Older Rhode Island 60.4 and the District of Columbia have age restrictions,266 while 12 Massachusetts 58.9 states also require a physician’s prescription. Maryland 57.1 Connecticut 56.8 During the 2018–2019 flu season, 49 percent of residents ages North Carolina 54.9 6 months or older were vaccinated, according to the CDC. Iowa 54.8 This rate was up substantially from 42 percent during the Virginia 54.7 South Dakota 54.4 2017-2018 flu season. The CDC cautioned that the increase Nebraska 54.2 might be due, in part, to limitations in its data collection Pennsylvania 54.2 process.237 Another possible explanation is the increased Washington 53.8 awareness of the public, clinicians, and public health officials Minnesota 52.7 New Hampshire 52 about the importance of vaccination due to the high number New York 51.9 of illnesses and deaths the year prior. Vermont 51.9 Colorado 51.6 Across the country, states have taken noteworthy actions. For Oklahoma 51.3 example, during the 2018-2019 flu season, the Tennessee North Dakota 51.1 Department of Health organized statewide Fight Flu TN events Wisconsin 50.9 Delaware 50.7 with vaccination clinics, and this year it launched a statewide Kansas 50.7 media campaign.267 The state’s flu vaccination rate (age 6 Ohio 50.4 months or older) increased from 36.4 percent during the 2017- Hawaii 50.2 2018 flu season to 48.2 percent during the 2018-2019 season. Missouri 50 New Mexico 49.9 Indiana’s Department of Health has also engaged in focused Kentucky 49.6 efforts to increase vaccination rates, particularly among people Arkansas 48.8 who are uninsured or underinsured. One way it has done this Maine 48.8 Montana 48.7 is by partnering with local health departments and pharmacies Alabama 48.3 to provide vaccinations, and by working with the Indiana Oregon 48.3 Immunization Coalition to create education and outreach Tennessee 48.2 materials and social media messaging.268 Indiana’s flu vaccination West Virginia 48.2 Indiana 47.9 rate (6 months or older) improved from 37.0 percent for the Texas 47.9 2017-2018 flu season to 47.9 percent for the 2018-2019 season. California 47.4 South Carolina 46.8 Rhode Island (60 percent), Massachusetts (59 percent), Michigan 46.1 Maryland (57 percent), and Connecticut (57 percent) had Utah 45.9 the highest coverage, while vaccination rates were lowest Arizona 45.6 Illinois 45.4 in Nevada (38 percent), Wyoming (41 percent), Florida Alaska 44.1 (41 percent), Louisiana (42 percent), and Mississippi (42 Idaho 43.6 percent). (Data were not available for the District of Columbia Georgia 43.1 Mississippi 42 or New Jersey.) (See Table 11.) Louisiana 41.6 Children, particularly young children, were more likely to Florida 40.9 Wyoming 40.7 receive vaccinations than were adults. Nearly 63 percent of Nevada 37.8 those ages 6 months to 17 years received vaccinations in 2018– District of Columbia No data reported 2019, compared with just 45 percent of adults.269 New Jersey No data reported Note: Data are calculated from a survey sample, with a corresponding sampling error. Adult data were not publicly reported for the District of Columbia or New Jersey. Source: Centers for Disease Control and Prevention.270,271 TFAH • tfah.org 45 INDICATOR 9: PATIENT SAFETY IN TABLE 12: Hospital Patient Safety Scores HOSPITALS Vary Significantly by State States percentage of hospitals with “A” grade, fall 2019 State Percent of Hospitals KEY FINDING: On average, 30 percent of hospitals Maine 59% Utah 56% received an “A” grade in the fall 2019 hospital Virginia 56% safety assessment administered by the Leapfrog Oregon 48% North Carolina 47% Group, a nonprofit advocate for safety, quality, and Pennsylvania 46% Idaho 45% transparency in hospitals. New Jersey 45% Montana 44% Rhode Island 43% Illinois 43% Every year, hundreds of thousands of people die from Massachusetts 42% hospital errors, injuries, accidents, and infections, collectively Michigan 41% making such incidents a leading cause of death in the United Ohio 39% States.272,273 Keeping hospital patients safe from preventable Wisconsin 38% Texas 38% harm is an important element of preparedness; those hospitals Connecticut 38% that excel in safety are less likely to cause or contribute to a South Carolina 37% public health emergency and are better positioned to handle Florida 37% any public health emergencies that put routine quality Colorado 36% California 35% standards to the test. Tennessee 34% The Leapfrog Group calculates the Hospital Safety Score by Delaware 33% Vermont 33% using 28 evidence-based metrics that measure the success Washington 33% of healthcare processes and outcomes. The measures track Mississippi 31% such issues as healthcare-associated infection rates, the Louisiana 31% number of available beds and qualified staff in intensive- New Hampshire 31% Missouri 28% care units, patients’ assessments of staff communications Kansas 27% and responsiveness, and a hospital’s overall culture of error Nevada 26% prevention.274 These measures are especially critical for health Arizona 26% systems’ readiness for emergencies and outbreak prevention Kentucky 26% Georgia 26% and control, which includes workforce training and availability, Hawaii 25% surge capacity, and infection-control practices. Oklahoma 25% Minnesota 23% In the Leapfrog Group’s fall 2019 assessment, 30 percent Alabama 23% of general acute-care hospitals across the United States, on Maryland 23% average, met the requirements for an “A” grade—a slight District of Columbia 20% Indiana 17% increase from fall 2018, when the share was 28 percent. But Arkansas 14% results varied widely state to state, from no hospitals in Alaska, Nebraska 13% North Dakota, or Wyoming receiving the top score, to a New Mexico 12% majority of hospitals doing so in Maine (59 percent), Utah (56 South Dakota 10% Iowa 9% percent), and Virginia (56 percent). (See Table 12.) New York 7% West Virginia 5% Alaska 0% North Dakota 0% Wyoming 0% Note: This measure captures only general acute-care hospitals. Source: The Leapfrog Group275

46 TFAH • tfah.org INDICATOR 10: STATE Public health laboratories are essential to require staff movement or reassignment, PUBLIC HEALTH emergency response and effective disease extra shifts, and hiring. Labs also have surveillance systems. They help detect and to plan for infrastructure factors, such as LABORATORY SURGE diagnose health threats as they emerge, sufficient biological safety cabinets and CAPACITY and they track and monitor the spread chemical fume hoods; amount and type of of those threats, which can help public supplies; space for intake, processing, and health officials learn how to control them. storage of samples; versatility and capacity KEY FINDING: Virtually every state Public health labs exist in every state and of analytical equipment and instruments; reported having a plan in 2019 territory and are the backbone of the personal protective equipment; and Laboratory Response Network (LRN), power supply.278 for a six- to eight-week surge in a national network of laboratories that Some challenges to the effectiveness of laboratory-testing capacity to provide the infrastructure and capacity to public health laboratory preparedness respond to public health emergencies.276 respond to an outbreak or other include funding gaps, workforce public health event. When a disaster or disease outbreak shortages, a lack of standardized strikes, public health laboratories must platforms to exchange data electronically, be able to surge to meet increased and a limited ability to detect radiological, demand, just like hospitals and other nuclear, and chemical threats.279 responders. The Association of Public In 2019, the District of Columbia and Health Laboratories defines internal all states except Utah and Vermont surge capacity as a “sudden and sustained reported to the Association of Public increase in the volume of testing that a Health Laboratories that they had a plan LRN reference laboratory can perform for a six- to eight-week surge in testing in an emergency situation, implementing capacity, a net increase of four since 2017 substantial operational changes as defined and 2018. (See Table 13.) This indicator in laboratory emergency response plans tracks only the existence of a plan, not and using all resources available within its quality or comprehensiveness, or the the laboratory.”277 Surging capacity can frequency in which it is used or tested.

TABLE 13: Nearly Every State Planned for a Laboratory Surge State public health laboratories had a plan for a six- to eight-week surge in testing capacity, 2019 Had a Plan No Plan Alabama Illinois Montana Rhode Island Utah Alaska Indiana Nebraska South Carolina Vermont Arkansas Iowa Nevada South Dakota Arizona Kansas New Hampshire Tennessee California Kentucky New Jersey Texas Colorado Louisiana New Mexico Virginia Connecticut Maine New York Washington Delaware Maryland North Carolina West Virginia District of Columbia Massachusetts North Dakota Wisconsin Note: The last edition of Ready or Not (2019) reported on states’ plans in 2017. In 2018, Florida Michigan Ohio Wyoming Arkansas, Montana, Oregon, Utah, Vermont, and Georgia Minnesota Oklahoma West Virginia reported that they did not have a plan Hawaii Mississippi Oregon for a six- to eight-week surge in testing capacity. Source: Association of Public Health Laboratories.280 Idaho Missouri Pennsylvania

TFAH • tfah.org 47 SECTION 3: SECTION 3: RECOMMENDATIONS FOR POLICY ACTIONS Ready or Not Recommendations for 2020 Policy Actions

Saving lives during a disaster or disease outbreak requires a proactive approach. As public health emergencies become more frequent, it becomes more urgent for all jurisdictions to have the underlying capacity, policies and people in place to prepare for, mitigate and recover from such emergencies. Effective preparedness and response also require a multipronged, multisector approach. No single entity or agency will improve the nation’s preparedness on its own: cross-sector coordination, ongoing investment, and community engagement need to be high priorities at the federal, state and local level. TFAH’s policy recommendations are based on the organization’s research and analysis, consultation with experts, and a review of progress and gaps in federal and state preparedness policies and programs.

TFAH offers the following recommendations for federal, state and local policymakers and other stakeholders to improve readiness:

Priority Area 1: Provide Stable, Sufficient Funding for Domestic and Global Public Health Security Despite growing health risks from cut by over 20 percent since fiscal year preventable outbreaks, emerging 2010, adjusting for inflation.282 The infectious diseases and extreme weather, HPP, the only federal source of funding investment in health security remains to help the healthcare delivery system relatively stagnant. The Public Health prepare for and respond to disasters, Leadership Forum estimates a $4.5 has been cut by 46.5 percent over the billion annual shortfall in the spending same time period, after adjusting for necessary to achieve comprehensive inflation.283 Insufficient funding leads to public health capabilities across the higher public health workforce turnover nation.281 Funding for the Public Health and an inability to modernize to face FEBRUARY 2020 Emergency Preparedness cooperative new threats.284 The United States simply agreement, the main source of funding cannot sustain the level of preparedness for health departments to build its residents expect if the nation fails to capabilities to effectively respond to a adequately invest in its health security range of public health threats, has been infrastructure every year. RECOMMENDATIONS FOR FEDERAL GOVERNMENT: l Invest in cross-cutting public to release a five-year budget plan: this to multiple federal agencies. However, health foundational capabilities plan should include a strategic vision and differing agency policies and practices can and preparedness programs. Strong multiyear budget estimate for the funding impede the coordination of funding across foundational capabilities would improve needed to upgrade bio-surveillance agencies. This can lead to disconnected the protection of all communities capacity and interoperability, to reduce and less effective emergency responses during emergencies. However, a and integrate siloed surveillance systems, on the ground. To prevent this inefficiency, nationwide funding shortage prevents and to invest in state and local capacity policymakers should adopt practices that health departments from developing to adapt to updated systems. allow for braiding funding from various and maintaining these cross-cutting sources to support a single initiative l Accelerate crisis responses through capabilities, and health departments or strategy at the state, community, or a standing public health emergency receive very little funding that is not program level. Braided funds remain in response fund and faster supplemental tied to specific diseases or categories. separate and distinguishable strands funding. In public health emergencies, Congress should invest in cross-cutting for tracking purposes but can have the response may overwhelm health public health capabilities and increase coordinated application processes and departments and other response entities funding for specific programs that funding cycles, jointly funded line items, beyond existing resources, and there is support health security, including the and uniform reporting mechanisms. often a lag between when resources are Public Health Emergency Preparedness The Office of Management and Budget, needed and the congressional approval cooperative agreement and the HPP. HHS, and FEMA should allow waivers of of supplemental appropriations to provide These state and local preparedness regulatory or administrative requirements such resources. In addition to stable programs have demonstrated their value to awardees of emergency response core funding, the federal government by saving lives, improving the speed and funding to allow funding braiding, needs readily available funds on hand to quality of response, and ensuring that to encourage coordination between enable a rapid response while Congress local authorities can adequately respond programs and funding streams with assesses the need for supplemental to most local health emergencies and similar goals, to provide flexibility to funding. Congress should continue a outbreaks without federal assistance. best meet the needs of the affected no-year infusion of funds into the Public populations, and to increase efficiencies l Revamp public health data capabilities. Health Emergency Rapid Response and reduce administrative duplication, One of the most foundational capabilities, Fund or the Infectious Disease Rapid such as in grant reporting. affecting nearly every aspect of public Response Fund to serve as available health, is . Yet, funding that would provide a temporary l Demonstrate a long-term commitment to some health departments are still bridge between preparedness and global health security. In September, the dependent on 20th-century methods— supplemental emergency funds. Congress Global Preparedness Monitoring Board such as phone and fax—for disease should replenish such funding on an warned that the world is dangerously reporting.285 These archaic methods annual basis, and it should not come unprepared for a serious pandemic,286 and delay the identification of and response from existing preparedness resources, as the Global Health Security Index found to outbreaks, endangering lives. A 21st- response capacity cannot substitute for that none of the 195 nations assessed century public health data initiative is adequate readiness. The HHS Secretary were fully prepared for pandemics or necessary to transform the systems and should only use such funding for acute .287 The international donor workforce into a state-of-the-art, secure, emergencies that require a rapid response community must help develop the core and fully interoperable system. Congress to save lives and protect the public. Some health security capacity of other countries appropriated a down payment on data emergencies may also require emergency to prevent and contain the threat of health modernization in FY20 and should provide supplemental funding, as the H1N1 or emergencies. Congress should solidify at least $100 million in the next year Zika outbreaks did; Congress should take America’s role as a global health leader, to build upon these new investments these public health emergencies seriously commit to implementing the Global to transform CDC, state, local, tribal, by quickly allocating supplemental funding Health Security Strategy,288 and provide and territorial data systems and should when necessary for extraordinary events. sustained annual funding for global increase funding for the Epidemiology health security programs across HHS, l Enable efficient use of emergency and Laboratory Capacity Cooperative including CDC, and The U.S. Agency for funding. Congress may allocate Agreement. Congress also directed CDC International Development. emergency funding following an event TFAH • tfah.org 49 Priority Area 2: Prevent Outbreaks and Pandemics Infectious diseases represent a threat $60 billion for potential pandemics.289 preventable outbreaks are becoming to the health, safety, and economic And there is evidence that the threat more frequent, and antibiotic resistance and social stability of the country. A of a global pandemic is growing due kills thousands of Americans every year. deadly pandemic could upend the to urbanization, global travel, and In order to save lives and prepare for nation’s social fabric through lives lost environmental degradation.290 Yet, the next pandemic, the United States and economic instability. Estimates the nation’s prevention of everyday must address preventable ongoing show that pandemics are likely to cost outbreaks betrays weaknesses in the infectious disease threats through $6 trillion in the next century, with nation’s defenses: seasonal influenza infrastructure, policy, and innovation. an expected annual loss of more than vaccination rates remain low, vaccine-

RECOMMENDATIONS FOR FEDERAL GOVERNMENT, HEALTHCARE, AND AGRICULTURE: l Support the vaccine infrastructure. l Ensure first-dollar coverage for providers on appropriate antibiotic use, CDC’s immunization program supports recommended vaccines under Medicaid, and advocate for other innovations. These state and local immunization systems Medicare, and commercial insurance. investments have already had an impact, to increase vaccine rates among Public and private payers should ensure helping contribute to an 18 percent uninsured and underinsured adults and that vaccines recommended by the reduction in deaths from resistant children, to respond to outbreaks, to Advisory Committee on Immunization infections since 2013.298 However, educate the public, to target hard-to- Practices (ACIP) are fully covered, as progress varies across states. In reach populations, to improve vaccine cost sharing, such as co-pays, can be addition, increases in funding are needed confidence, to establish partnerships, a significant barrier to vaccination.295 to build global capacity to prevent and and to improve information systems. Congress should require zero cost detect resistant infections and combat Funding has not kept up with needs sharing in Medicare Part D and B plans, this threat to national security. as states have to spend immunization and CMS should incentivize Part D plans l Create incentives for discovery of new dollars to respond to outbreaks,291 to eliminate cost sharing and increase products to fight resistant infections. deal with increases in the numbers of receipt of vaccines.296 An example of There should be robust public/private residents who lack health insurance,292 legislation that takes steps to improve investment in antibiotic discovery and attempt to manage the impact senior vaccination rates is the Protecting science, diagnostics, early stage of vaccine underutilization, including Seniors Through Immunization Act. product development, and research HPV and flu vaccines. Congress CMS should encourage state Medicaid through the Biomedical Advanced should increase funding for CDC’s plans in states that have not expanded Research and Development Authority, immunization program, which supports Medicaid to cover all ACIP-recommended Combating Antibiotic-Resistant Bacteria state and local infrastructure, outbreak vaccines without cost sharing.297 Biopharmaceutical Accelerator, and prevention, and response, as well l Significantly increase investments other programs. The HHS should enable as the seasonal influenza program. in public health initiatives to combat additional Medicare reimbursement Congress should also provide needed antimicrobial resistance. Congress solutions that come closer to covering resources to the HHS to study the should increase funding for innovative the cost of new antibiotics for patients causes of vaccine resistance and to methods of detecting and containing who need them without posing educate clinical providers on methods outbreaks supported by the Antibiotic hurdles for appropriate prescribing. for improving vaccine acceptance. Resistance Solutions Initiative at the Stakeholders, including payers, should Several legislative proposals, including CDC. CDC is investing in every state to continue to work toward decoupling the VACCINES Act293 and Lower Health strengthen lab capacity, track infections antibiotic reimbursement from drug Care Costs Act294 included such across healthcare systems, detect new sales so that drug developers have an provisions in 2019 to better promote threats and disrupt pathogens, coordinate incentive to innovate, despite efforts to vaccine acceptance. prevention strategies, educate healthcare conserve antibiotics.

50 TFAH • tfah.org l Eliminate overuse of antibiotics in and preventing infections could save and enforcing the FDA’s Food Safety agriculture. The FDA should enforce 37,000 lives over five years.300 CMS Modernization Act to improve prevention rules regarding veterinary oversight should finalize, implement, and enforce and detection of outbreaks. Recent and the judicious use of antibiotics in requirements for all CMS-enrolled foodborne illness outbreaks have food animals, ensure data collection facilities to have effective antibiotic demonstrated challenges to the FDA’s and publication, promote antibiotic stewardship programs that align with ability to quickly identify contaminated stewardship programs, and track the the CDC’s Core Elements guidance and food products. The agency must do impact of these policies on resistance to work with public health stakeholders more to help establish effective food- patterns. Farmers and the food industry to track progress in prescribing rates product traceability systems, including should stop using medically important and resistance patterns.301 All relevant guidance for the food industry. antibiotics to promote growth and facilities must drastically improve l Fund CDC to support state and local prevent disease in healthy animals, as their reporting of antibiotic use and public health laboratories. CDC should recommended by the WHO,299 and they resistance through the National be sufficiently funded to support state should invest in research to develop Healthcare Safety Network and should and local public health laboratories and adopt husbandry practices that adopt stewardship programs that meet at levels which would allow them to reduce the need for routine antibiotics. the CDC’s Core Elements.302 conduct active surveillance of foodborne l Decrease over-prescription of l Modernize food safety practices pathogens; currently, the ELC grant is antibiotics through implementation of and policies and work toward better only funding approximately half of what antibiotic stewardship and antibiotic- coordination across agencies. Congress is requested by laboratories and health use reporting. The CDC estimates and state lawmakers should devote department epidemiologists nationwide. that improving prescribing practices sufficient funding to implementing

RECOMMENDATIONS FOR FEDERAL AND STATE GOVERNMENT: l Provide job-protected paid sick leave. effective and scientifically based methods diseases. This includes eliminating Earned paid sick leave is an important for reducing the rate of infectious nonmedical exemptions and opposing infection-control measure, protecting diseases like Hepatitis B, Hepatitis C, legislation to expand exemptions.307 both workers and customers. Workers and HIV.304,305 All states should authorize States should ensure medical vaccine without earned sick leave are less likely syringe-access programs and remove exemptions are only given when to use services, barriers to those programs like drug- appropriate and are not used as a such as flu vaccinations, and workers paraphernalia laws. Experts estimate that de facto personal-belief exemption in are more likely to go to work or send their there would be a return on investment of states where those exemptions have children to school when sick.303 Congress as much as $7.58 for every $1 spent on been eliminated. States should require should pass a federal paid sick days syringe-access programs due to averted healthcare personnel to receive all law, and states should ensure effective HIV treatment costs.306 ACIP-recommended vaccinations in implementation by passing paid sick order to protect staff and patients, l Minimize state vaccine exemptions for days laws and/or removing preemption assure continuity of operations in the schoolchildren and healthcare workers. exemptions. event of an outbreak, and achieve States should enact policies that necessary healthcare infection control. l Provide comprehensive syringe-access enable universal childhood vaccinations Healthcare facilities should ensure programs. Congress and states should to ensure children, their classmates, access to vaccines for all staff and fund comprehensive syringe-service educators, and the general public are contractors and should remove barriers programs, which are among the most protected from vaccine-preventable to staff receiving vaccines.

TFAH • tfah.org 51 Priority Area 3: Build Resilient Communities and Promote Health Equity in Preparedness Social, economic, and health disparities ensuring that all receive appropriate impact how people within specific services, regardless of circumstance. communities experience disasters Policymakers and public health officials and how quickly they are able to cannot assume that preparing for the recover. Addressing underlying entire community means applying a inequities and intentionally and uniform approach to all neighborhoods meaningfully engaging with the and members of the community. people and communities most likely Some communities have taken steps to be impacted throughout the to integrate principles of equity emergency planning process are throughout public health emergency critical to reducing vulnerability and activities,308 but more needs to be done.

52 TFAH • tfah.org RECOMMENDATIONS FOR FEDERAL, STATE, AND LOCAL GOVERNMENT l Invest in policies and capacity to and mitigate disparities that place on capacity building for community- address the social determinants of some people at greater risk during based organizations, providing health. People at highest risk during disasters.310 community leaders the opportunity to disasters and those who have the fully participate in planning activities, l Empower communities to enhance hardest time recovering are often allowing organizations to hire and equity and resilience before, during, those with unstable housing, those engage community members so and after an event. Federal grant with limited access to transportation, emergency plans better reflect the makers and states should ensure and those who live in low- community, and ensuring that data that grants and sub-awards reach the socioeconomic-status communities.309 collection reflects social determinants grassroots level and communities State and local emergency planners and demographic factors and that data most in need. Such funding and should consult tools like the Social are available for all communities. technical assistance should focus Vulnerability Index to understand

RECOMMENDATIONS FOR STATE AND LOCAL GOVERNMENT AND COMMUNITY LEADERS: l State and local governments should behavioral health concerns, disrupt greatest risk. Additionally, localities build health equity leadership and access to ongoing care, increase risk should ensure that staffing and adopt strategies to incorporate equity for domestic violence, and cause long- protocols are such that they reflect into preparedness. All state and term anxiety, post-traumatic stress, and the diversity of and are relevant to the local governments, including health other issues. Young children and people community they serve. departments, should build up internal with pre-existing mental disorders are l Plan with communities, not for them. infrastructure to drive equity, including at particular risk for mental health Local emergency planners must identifying a chief health equity or issues following a disaster.312 State conduct meaningful engagement (such health resilience officer. Health equity and local emergency and public health as by ensuring response teams mirror and emergency preparedness officials planners should incorporate immediate and are engaged with the community) should work across programs to and long-term behavioral health needs as well as ongoing inclusion and hiring incorporate equity issues and goals into into disaster plans, as required by the of community members (especially from preparedness policies and plans;311 to Pandemic and All-Hazards Preparedness communities typically at higher risk improve staff capacity to understand and Advancing Innovation Act.313 in disasters) in emergency planning. how the legacies of discrimination, l Ensure access to care for people at Officials should establish relationships current-day racial trauma, and other disproportionate risk. States, insurers, with services and organizations structural inequities affect disaster and HHS should employ waivers that serve these populations resilience and recovery; and to collect when needed to ensure all residents before emergencies take place. and leverage data to identify unique who need care are able to access it Health departments and emergency community assets and advance equity following a disaster, regardless of proof management agencies should rely before and during events. of insurance or if evacuations force on the expertise of those who may l Address behavioral health resource a resident out of network over state bear a disproportionate risk, such as gaps and incorporate mental health lines. All localities should undertake older adults, people with disabilities, first-aid and long-term behavioral health community and subpopulation risk- and individuals with chronic health treatment into disaster response and and asset-assessment training before conditions to ensure emergency plans, recovery strategies. Emergencies an emergency happens and invest procedures, and evacuation shelters can exacerbate existing mental and resources in communities at the meet the needs of all in the community.

TFAH • tfah.org 53 Priority Area 4: Ensure Effective Leadership, Coordination, and Workforce Perhaps more important than any the frontline responder to the top of leadership—elements that governments technology or invention is the presence government. Effective crisis response must build and sustain over time. of trained, experienced people, from requires coordination, cooperation, and

RECOMMENDATIONS FOR FEDERAL GOVERNMENT: l The White House should ensure the Team.316 The White House should release roles and guidance, engaging success of federal preparedness a more detailed implementation plan of with private-sector and volunteer strategies. The implementation of the the National Biodefense Strategy and the organizations, maintaining systems and Pandemic and All-Hazards Preparedness Modernizing Influenza Vaccines executive policies that are working well, avoiding and Advancing Innovation Act;314 the order, including assigned roles and duplicative efforts, and keeping experts National Biodefense Strategy, which responsibilities, milestones, opportunities connected to key functions. directs biodefense priorities and for stakeholder feedback, and an l Fund the recruitment and training of goals for multiple agencies; and the integrated biodefense budget.317,318 public health personnel. The health Executive Order on Modernizing Influenza l HHS, the CDC, the Office of the security enterprise requires trained, Vaccines315 will only be successful if Assistant Secretary for Preparedness experienced personnel. Federal, state, they are backed by adequate funding and Response (ASPR), DHS, and FEMA and local governments must prioritize and programmatic support, meaningful should clarify roles and address gaps stable, long-term funding for recruitment stakeholder engagement, and within the government’s emergency and retention of such a workforce, involvement of relevant public health support functions. HHS and DHS including one with experience in public and related agencies. The White House agencies should continue to clarify health informatics, laboratory science should ensure senior advisors to the roles and responsibilities to improve and epidemiology. Governments should president have a strong background in the efficiency and effectiveness of also fund investment in workforce public health and/or biodefense, and responses and to ensure no community development and retention programs, they should ensure that senior-level or population group falls through the such as student loan repayment and interagency cooperation is progressing cracks during a response. The ASPR other incentives. Public health schools before, during, and after public health and the CDC should coordinate and should incorporate health equity emergencies, including through regular align their preparedness and response and cultural competency into their meetings of the Biodefense Steering activities, including by communicating preparedness curricula. Committee and Biodefense Coordination effectively with stakeholders about

RECOMMENDATION FOR STATE GOVERNMENT: l Update personnel policies to allow for expedited emergency responses. State policymakers should review and update hiring policies to facilitate the rapid hiring of emergency response workers when a disaster strikes.

54 TFAH • tfah.org egdigital Priority Area 5: Accelerate Development and Distribution of Medical Countermeasures An effective medical countermeasure (MCM) enterprise could negate a range of health threats, but a drug or vaccine is only effective if it reaches the right person at the right time. The short time window for responding to many public health threats—such as an anthrax attack—demonstrates the urgency of the right-product/ right-time equation. The nation must reinforce the discovery of new products, including novel vaccines, antibiotics, and diagnostics, and be accompanied by the development, practice with and maintenance of appropriate distribution and dispensing capabilities.

RECOMMENDATIONS FOR FEDERAL GOVERNMENT: l Provide significant, long-term funding the ASPR in 2018.321 As HHS formalizes for the entire MCM enterprise. The these transitions, the agency must strive MCM enterprise involves research, to improve the programs by evaluating manufacturing, surveillance, delivery, the impact of the transition of Strategic training and monitoring. Long-term National Stockpile on procurement, coordinated and transparent funding replenishment, efficiencies of contracts, would offer more certainty to the and state and local MCM capabilities; biotechnology industry and researchers enabling regular input of state and local and would strengthen public-private public health officials, as required by the partnerships. The United States should Pandemic and All-Hazards Preparedness grow its investment in innovative, and Advancing Innovation Act, as well as flexible technologies and capabilities the input of private-sector supply-chain that will enable faster production of partners into the Public Health Emergency products for a range of biothreats.319 Medical Countermeasures Enterprise process; aligning with CDC’s support l Evaluate and ensure success of the of state and local MCM dispensing Public Health Emergency Medical capabilities; improving transparency with Countermeasures Enterprise and the state, local, tribal, and territorial partners; Strategic National Stockpile operations. clarifying roles between the CDC and The Pandemic and All-Hazards the ASPR in day-to-day activities and Preparedness and Advancing Innovation incident response; avoiding administrative Act codified the Public Health Emergency duplication and delay; and restoring Medical Countermeasures Enterprise,320 necessary funding and staff to the CDC and administration of the Strategic that were lost due to the transition. National Stockpile moved from the CDC to

TFAH • tfah.org 55 RECOMMENDATIONS FOR FEDERAL, STATE, AND LOCAL GOVERNMENTS AND PARTNERS: l Prioritize the distribution and children, older adults, people with dispensing of MCMs. It is important disabilities, and people who are that MCMs reach the right person at homebound. Officials should also the right time during emergencies, but take additional target groups, such as gaps remain if a mass vaccination or pregnant and postpartum women and dispensing were needed, according infants, into consideration. Guidance to the CDC’s MCM Operational should include dosing instructions Readiness Review.322,323 The HHS for those who cannot swallow pills. and state, local, tribal, and territorial And HHS and state, local, tribal, health departments should be properly and territorial agencies should work resourced and require integration with organizations that reach the of private-sector healthcare supply public, especially communities at distributors and supply-chain partners disproportionate risk—such as groups into planning, exercises, and emergency representing older Americans, people responses to better leverage existing with disabilities, and limited English- systems and resources. The CDC and proficient communities—to improve ASPR should continue to assess and communications around MCM issues improve the training of state and local before an event. Communities need personnel to ensure well-coordinated to be engaged before an outbreak or MCMs deployments from the Strategic event to ensure their understanding National Stockpile and from the of the risks, benefits, and distribution private sector, as recommended challenges of introducing a medical by the Bipartisan Commission on product to a large portion of the Biodefense.324 population and ultimately improving acceptance and access to MCMs. l Improve MCM guidance and It is important to provide clear and communications for groups at accurate guidance to the public in higher risk during an event. HHS, multiple formats and languages, including the CDC, should consult via trusted sources and multiple with experts and work with healthcare communications channels including professionals and state and local and formats that are accessible to people tribal partners to develop standardized with hearing or vision loss. guidance for dispensing MCMs to

56 TFAH • tfah.org Priority Area 6: Ready the Healthcare System to Respond and Recover A major shortfall persists in the nation’s healthcare readiness, especially medical surge capacity, for the tremendous number of patients likely to result from a pandemic or other large-scale biological event. The NHSPI has consistently found that healthcare delivery readiness scores are in the lowest levels among preparedness domains measured, with little progress in the past five years.325 Recent events— like lives lost in a nursing facility following Hurricane Irma,326 the need for extensive federal medical response during Hurricanes Irma and Maria,327 and the surge of patients from seasonal flu in 2018328—have illustrated that much remains to be done to prepare the healthcare system for ongoing scenarios, let alone a major event.

A gap analysis by the Center for Health healthcare system with emergency Security concluded that the United response. Many emergency departments States is fairly well prepared for small- see shortages of critical medicines on a scale events, but less well prepared day-to-day basis and report that they are for large-scale and complex disasters, not fully prepared for a disaster or mass- such as mass shootings, and poorly casualty incident.330 Some emergency prepared for catastrophic health events, preparedness entities, including such as severe pandemics.329 Existing healthcare coalitions and public health programs—such as the HPP and the departments, lack situational awareness CMS Preparedness Rule—have created of the healthcare delivery system in preparedness structures that would a disaster, and states and territories not have otherwise been built, but continue to depend on federal assets many states have not provided enough such as the National Disaster Medical incentive to create true engagement System during disasters, rather than of healthcare leadership, surge building mutual support within a capacity and training, cooperation region. Policymakers need to strengthen across the healthcare systems and existing systems and consider long- across the spectrum of providers, and term mechanisms to create sustainable collaboration and integration of the healthcare readiness.

TFAH • tfah.org 57 RECOMMENDATIONS FOR FEDERAL GOVERNMENT AND HEALTHCARE: RECOMMENDATIONS FOR STATE l Strengthen the HPP. In the near term, measures over time. CMS should also GOVERNMENT AND HEALTHCARE: Congress and HHS should reinforce the strengthen preparedness standards by l Integrate healthcare delivery into HPP to build strong healthcare coalitions adding medical surge capacity and other emergency preparedness and response. capable of engaging and supporting capabilities, stratified by facility type, as States should remove barriers to members during disaster responses. a necessary requirement within the next participation of the healthcare sector 334 These models help ensure members have iteration of the rule. in emergency responses, including the equipment, supplies, information, l Create incentives and ramifications plugging healthcare coalitions and other and personnel to respond to disasters to build sustainable preparedness entities representing private healthcare and the federal government must support and surge capacity across healthcare and the healthcare supply chain into them. Congress must provide more systems. In a serious large-scale event, emergency planning and response and robust annual funding—which it has cut such as a pandemic, there will likely be incident command. Health systems, in half over the past decade. HHS and shortages of beds, healthcare personnel, healthcare coalitions, and public awardees should ensure healthcare and equipment, requiring cooperation health should develop memoranda of leaders takes the lead on HPP planning among healthcare entities, across understanding ahead of disasters to and implementation to the extent systems, and across geographic borders. improve situational awareness across possible, with support and coordination Although there has been progress in healthcare and to enable movement of from public health, emergency developing healthcare coalitions in many patients, personnel, and supplies. management, and others, and awardees regions and meeting CMS and other should ensure as much funding as l accreditation preparedness standards Strengthen state policies regarding possible is reaching healthcare coalitions. by individual healthcare facilities, these disaster healthcare delivery. States Healthcare administrators should ensure existing mechanisms have not provided should review credentialing standards their facilities have tools and support for enough incentive for many healthcare to ensure healthcare facilities can meaningful participation in healthcare facilities to create meaningful surge receive providers from outside their coalitions, including the ability to share capacity and cooperation across states, and health systems should information and resources across the competing entities. Similarly, the Joint ensure they can receive outside coalition. Congress should provide Commission’s preparedness standards providers quickly during a surge additional funding for a tiered regional apply to individual facilities and not to the response. States should also adopt disaster system to coordinate across readiness of the healthcare system as policies that promote healthcare coalitions and states, as authorized a whole.335 In addition to strengthening readiness and ease the ability to surge by the Pandemic and All-Hazards healthcare preparedness grants and care and services, such as the NLC, the Preparedness and Advancing Innovation CMS standards, Congress and HHS Interstate Medical License Compact, Act,331 to map specialized disaster care should consider long-term sustainability (such as burn or pediatric care) across the Recognition of EMS Personnel for building healthcare readiness across 337 the country and to leverage those assets Licensure Interstate CompAct, the system, including meaningful in a coordinated way.332 Additional funding the Uniform Emergency Volunteer incentives and disincentives: 338 is also needed to sustain progress made Health Practitioners Act, emergency in establishing Ebola and other high • An external self-regulatory body, in prescription refill laws and protocols, consequence pathogen treatment centers alignment with federal policy goals, and implementation and education of and training.333 could set, validate, and enforce providers regarding crisis standards of standards for healthcare facility care guidelines.339,340 Governors should l Strengthen CMS Preparedness readiness, stratified by facility type, with work with public health officials to Standards and improve transparency. authority for financial ramifications.336 incorporate public health considerations An external review by the Government and messaging into all emergency Accountability Office or a similar entity • Payment incentives could sustain declarations, including clarification of should assess how CMS preparedness preparedness, surge capacity, emergency waivers around healthcare. standards have affected overall regional disaster partnerships, healthcare readiness, and HHS should and reward facilities that maintain begin tracking progress on preparedness specialized disaster care.

58 TFAH • tfah.org Priority Area 7: Prepare for Environmental Threats and Extreme Weather Environmental health involves detecting and protecting communities from hazardous conditions in air, water, food, and other settings, and it is therefore a critical component of the nation’s health security. Increasingly, states have found that unsafe water341 and changes in disease vectors, such as mosquitos,342 require emergency response capacity. At the same time, climate impacts on health—including extreme weather events, flooding, droughts, and food-, water-, and vector-borne diseases—are growing.343 Climate change can exacerbate health disparities and intensify threats. Environmental hazards impact communities differently, with people living in poverty, people of color, people with underlying health conditions, and children and older people at particular risk.344

RECOMMENDATIONS FOR FEDERAL AND STATE GOVERNMENT: l Support public health climate-adaptation l Develop sustainable state and local between health departments and local efforts. Funding for the CDC’s Climate vector-control programs. As the environmental and water agencies. The and Health program stands at $10 million threat and geographic distribution of CDC should include national guidance per year, while the annual health costs mosquitos, ticks, and other vectors and metrics for planning for a range of of climate change events were estimated changes, Congress should expand water-related crises. Measures to protect to be more than $14 billion in 2008.345 funding for the vector-borne disease a safe water supply include: addressing Climate-informed health interventions program at the CDC to support state the ongoing problem of lead, per- and include identifying likely climate impacts, and local capacity to prevent and detect polyfluoroalkyl substances, and other potential health effects associated with vector-borne diseases, such as Zika, toxins in drinking water, and taking these impacts, and the most at-risk West Nile Virus, and Lyme disease. steps, such as those in the EPA’s Clean populations and locations.346 Congress Water Rule, to reduce the potential for l Guarantee clean water for all U.S. should increase funding for environmental waterborne illnesses and to increase residents, including after disasters. All health programs, including the CDC’s protection against potential acts of states should include water security and Climate and Health program and biological and chemical on sewage removal in their preparedness environmental health tracking to conduct America’s drinking and agricultural water. plans, and they should build relationships surveillance and target interventions.

RECOMMENDATIONS FOR STATE GOVERNMENT: l Every state should have a risk-management and communications, communities. State and local public comprehensive climate vulnerability and prioritize necessary capabilities health officials should incorporate assessment and adaptation plan that to reduce and address threats. States environmental health into emergency incorporates public health. Public health and localities should investigate what operations planning and incident and environmental agencies should work additional capacities are necessary command. together to track concerns, coordinate and identify vulnerable populations and

TFAH • tfah.org 59 APPENDIX APPENDIX: METHODOLOGY Ready or Not Methodology

2020 Trust for America’s Health (TFAH) made major refinements to its methodology for Ready or Not in 2018. For more information, see the 2019 edition of the series, Appendix A: Methodology.347

To meet TFAH’s criteria, each indicator Using these criteria, TFAH aims to select must be: a broad set of actionable indicators with which it—and other stakeholders, l Significant. The indicator needed to be including states themselves—can a meaningful measure of states’ public continue to track states’ progress. health emergency preparedness. The (Complete data were not available for NHSPI first measured significance U.S. territories.) TFAH will strive to by using a multistage Delphi process retain all or most of these indicators for with a panel of experts and then again multiple years to assist states in tracking by TFAH through interviews with their progress against each measure. additional experts. TFAH seeks measures that are l Broadly relevant and accessible. The incorporated into the NHSPI and that indicator needed to be relevant—and most closely meet TFAH’s criteria. timely data needed to be accessible— There is one exception: a measure of for every state and the District of state public health funding-level trends, Columbia. which the NHSPI does not track. l Timely. Data for the indicator needed TFAH wishes to more directly track to be updated regularly. readiness for extreme weather, which l Scientifically valid.Data supporting nearly all experts expect to worsen and the indicator needed to be credible become more frequent due to global and rigorously constructed. climate change. Ready or Not did not include such a measure this year, but l Nonpartisan. The indicator, and data TFAH expects to release a separate supporting the indicator, could not report in 2020, in partnership with be rooted in or seen as rooted in any Johns Hopkins University, that addresses political goals. these issues in depth. FEBRUARY 2020 Indicator Data Collection l Injury prevention. Public health The NHSPI provided TFAH with data for services related to firearms, motor every indicator except five (those data vehicles, occupational injuries, tied to the NLC, public health funding, senior falls prevention, substance- flu vaccination, hospital patient safety, use disorder, other intentional and and laboratory surge capacity). In cases unintentional injuries, etc. where newer data were available than l Environmental public health. Public those modeled in the 2019 edition of health services related to air and water the NHSPI, TFAH collected and verified quality, fish and shellfish, food safety, figures from their original sources. hazardous substances and sites, lead, onsite wastewater, solid and hazardous Public Health Funding Data waste, zoonotic diseases, etc. Collection and Verification l Maternal, child, and family health. To collect public health funding data Public health services related to for this report, TFAH used states’ the coordination of services; direct publicly available funding documents. service; family planning; newborn With assistance from the Association of screening; population-based maternal, State and Territorial Health Officials, child, and family health; supplemental TFAH provided data to states for review nutrition; etc. and verification. Informed by the Public Health Activities and Services l Access to and linkage with clinical Tracking project at the University of care. Public health services related to Washington, TFAH defines public health beneficiary eligibility determination, programming and services as inclusive of provider or facility licensing, etc. communicable disease control; chronic TFAH excludes from its definition disease prevention; injury prevention; insurance coverage programs, such environmental public health; maternal, as Medicaid or the Children’s Health child, and family health; and access Insurance Program, as well as inpatient to and linkage with clinical care. clinical facilities. Specifically, this definition includes: TFAH, under the guidance of state l Communicable disease control. respondents, revised data for the base Public health services related to year. (In this report, that was fiscal year communicable disease epidemiology, 2018.) For some states, this was necessary hepatitis, HIV/AIDS, immunization, to improve comparability between sexually transmitted diseases, the two years when a reorganization tuberculosis, etc. of departmental responsibilities had l Chronic disease prevention. Public occurred over the period. health services related to asthma, All states and the District of Columbia cancer, cardiovascular disease, verified their funding data. diabetes, obesity, tobacco, etc.

TFAH • tfah.org 61 Scoring and Tier Placements l Percent of population who used a TFAH grouped states based on their community water system that failed performance across the 10 indicators, to meet all applicable health-based and beginning in 2019, gave partial standards: TFAH scored states according credit for some indicators to draw finer to the number of standard deviations distinctions among states and within above or below the mean of state results. states over time. TFAH placed states • Within one standard deviation above into three tiers—high tier, middle tier, the mean (and states with 0 percent and low tier—based on their relative of residents who used a noncompliant performance across the indicators. community system): 1 point.

Specifically, TFAH scored each indicator • At the mean, or within one standard as follows: deviation below the mean: 0.75 point. • Between one and two standard l Adoption of the NLC: 0.5 point. No deviations below the mean: 0.5 point. adoption: 0 points. • Between two and three standard l Percent of hospitals participating in deviations below the mean: 0.25 point. healthcare coalitions: TFAH scored • More than three standard deviations states according to the number of below the mean: 0 points. standard deviations above or below the mean of state results. l Percent of employed population with • Within one standard deviation above paid time off: TFAH scored states the mean (and states with universal according to the number of standard participation): 1 point. deviations above or below the mean of state results. • At the mean, or within one standard deviation below the mean: 0.75 point. • More than one standard deviation above the mean: 1 point. • Between one and two standard deviations below the mean: 0.5 point. • Within one standard deviation above the mean: 0.75 point. • Between two and three standard deviations below the mean: 0.25 point. • At the mean, or within one standard deviation below the mean: 0.5 point. • More than three standard deviations below the mean: 0 points. • Between one and two standard deviations below the mean: 0.25 point. l Accreditation by the PHAB: 0.5 point. • More than two standard deviations Not accredited: 0 points. below the mean: 0 points. l Accreditation by the EMAP: 0.5 point. l Percent of people ages 6 months Not accredited: 0 points. or older who received a seasonal l Size of state public health budget flu vaccination: TFAH scored states compared with the past year according to the number of standard (nominally, not inflation-adjusted). deviations above or below the mean of • No change or funding increase: 0.5 state results. point. • More than one standard deviation • Funding decrease: 0 points. above the mean: 1 point.

62 TFAH • tfah.org • Within one standard deviation above TFAH placed states whose scores the mean: 0.75 point. ranked among the top 17 in the high- • At the mean, or within one standard performance tier. TFAH placed states deviation below the mean: 0.5 point. whose scores ranked between 18th- highest and 34th-highest in the middle • Between one and two standard tier. TFAH placed states whose scores deviations below the mean: 0.25 point. ranked between 35th-highest and 51st- • More than two standard deviations highest in the low-performance tier. below the mean: 0 points. (Ties in states’ scores prevented an even Flu vaccination data for the 2018–2019 distribution across the tiers.) season were not available for the District This year, states in the high tier had of Columba or New Jersey. TFAH scores ranging from 5.75 to 6.75; states imputed their scores by comparing their in the middle tier had scores ranging average rates from 2010–2011 to 2016– from 5.25 to 5.5; and states in the low 2017 (District of Columbia) or 2017– tier had scores ranking from 3.5 to 5. 2018 (New Jersey) with the average vaccination rate over that period in the Assuring data quality 50 states and the District of Columbia. Several rigorous phases of quality l Percent of hospitals with a top-quality assurance were conducted to strengthen ranking (“A” grade) on the Leapfrog the integrity of the data and to improve Hospital Safety Grade. TFAH scored and deepen TFAH’s understanding of states according to the number of states’ performance, especially that of standard deviations above or below the outliers on specific indicators. During mean of state results. collection of state public health funding • More than one standard deviation data, researchers systematically inspected above the mean: 1 point. every verified data file to identify incomplete responses, inconsistencies, • Within one standard deviation above and apparent data entry errors. Following the mean: 0.75 point. this inspection, respondents were • At the mean, or within one standard contacted and given the opportunity to deviation below the mean: 0.5 point. complete or correct their funding data. • Positive number, more than one standard deviation below the mean: 0.25 point. • No hospitals with a top-quality ranking (“A” grade): 0 points. l Public health laboratory has a plan for a six- to eight-week surge in testing capacity: 0.5 point. Did not report having a plan: 0 points

The highest possible score a state could receive was 7.5 points.

TFAH • tfah.org 63 Endnotes

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