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States Amending Policies to Slow Congenital Syphilis Increases States Trying Policies that Increase Syphilis Testing Amelia Poulin State are exploring ways to slow the rapid increase of congenital syphilis cases by strengthening policies to require testing at key points during pregnancy. Syphilis among newborns, or congenital syphilis, is preventable. Yet the latest CDC data show that congenital syphilis cases have more than doubled (106%) from 2019-2023. In 2023 alone, there were nearly 4,000 cases of congenital syphilis resulting in 279 stillbirths and infant deaths. Timely testing and adequate treatment during pregnancy might have prevented up to 80% of these cases. Increases in congenital syphilis often mirror increases in syphilis among reproductive-aged women. From 2022 to 2023, the rate of syphilis (all stages) increased 6.8% among women aged 15–44 years; rates also increased in 39 states and Washington, D.C. CDC recommends testing pregnant women for syphilis at the first prenatal visit, as well as at 28 weeks gestation and delivery if they are at increased risk of infection. Syphilis testing recommendations extend to asymptomatic women who are at increased risk for infection as they may face additional barriers to health care. ASTHO’s policy-level interventions for states and territories suggest universal syphilis testing for pregnant women. Additionally, states have been taking action to increase access to syphilis testing for people, including those who are pregnant. The Syndemic Perspective A history of incarceration, sex work, drug use, and geography can all significantly increase risk for sexually transmitted infections (STIs), HIV, tuberculosis (TB), and more. Structural barriers, including housing instability, economic insecurity, stigma, and restricted health care access, create conditions that heighten vulnerability to multiple infections. These conditions do not occur in isolation but rather as part of a syndemic, where overlapping epidemics interact with and exacerbate one another. Health agencies may be positioned to address upstream and root cause issues recognizing and addressing the intersections of these disease areas and related structural and social issues (e.g., drug use and poverty). Health agencies carry a wealth of interdisciplinary expertise, with staff leading efforts around data collection and surveillance, policy, community mitigation, and more, all of which support capacity to identify root causes and design an evidence-based, multifaceted response. Policies that prioritize housing stability, harm reduction services, and access to comprehensive health care, including STI screening, can help mitigate these risks and improve health outcomes. Geography can also increase the chances of syphilis transmission. Some regions with limited health care infrastructure, provider shortages, and limited STI prevention program funding and capacity may have higher rates of infection. Rural areas and certain urban settings may lack accessible clinics or specialized services, creating significant barriers to timely testing and treatment. Rural areas and certain urban settings may lack accessible clinics or specialized services, creating significant barriers to timely testing and treatment. Social and economic differences across different geographic locations contribute to varying levels of disease burden. By adopting a syndemic framework, states can move beyond disease-specific interventions and implement comprehensive strategies that address upstream factors contributing to disease transmission. State Actions Several states have introduced or passed legislation to expand syphilis testing access, with a focus on increasing screening opportunities, mandating insurance coverage, and ensuring appropriate prenatal testing protocols. Syphilis Testing In 2024, Colorado enacted HB 24-1456, which gave the state’s Board of Health rulemaking authority over syphilis testing. This flexibility allows the state to adapt its public health response based on emerging epidemiological trends as new data on syphilis transmission and congenital infections become available. The 2025 legislative sessions have highlighted additional approaches to expanding access to syphilis testing. The New York legislature introduced S 2704, which would require health insurance coverage for certain approved STI home test kits. This policy would provide individuals who face barriers to in-person care a convenient and private way to get tested and stay healthy. Oregon is also addressing testing accessibility through HB 2943, which would require hospitals to test people for HIV and syphilis when they have blood tests done in the emergency department (ED). Since EDs often serve populations who do not routinely access preventive health care (e.g., people experiencing homelessness or struggling with substance use disorders), this legislation would strengthen the role of emergency settings in STI prevention and intervention. Perinatal Syphilis Testing Recognizing the importance of perinatal screening, several states have introduced legislation to add requirements for syphilis testing at key points in pregnancy. Tennessee recently enacted SB 1283, which requires that health care providers take a blood sample to screen for syphilis, hepatitis B, and hepatitis C at the first prenatal examination, ten days after the examination, and at delivery. This approach aligns with CDC recommendations and ensures infections are identified and treated in time to prevent congenital transmission. Similarly, Nebraska LB 41 would require testing for syphilis at the first examination, in the third trimester, and at birth (with the mother’s consent), reinforcing a multi-point screening strategy to detect and treat infections that may develop later in pregnancy. Missouri’s SB 178 would take a comprehensive approach to syphilis prevention during pregnancy by requiring an additional test at 28 weeks, a critical point for intervention. The legislation would also require treatment for mothers who test positive for an STI, reducing the risk of congenital infections. Additionally, it would expand Expedited Partner Therapy by allowing any health care professional authorized to prescribe medications to administer Expedited Partner Therapy as well as include other STIs in the treatment, enabling faster treatment for sexual partners who might otherwise go untreated and continue the cycle of transmission. Policy Considerations Expanding both syphilis and perinatal syphilis testing policies demonstrate a growing recognition of the need for proactive, evidence-based strategies to address the increasing rates of syphilis and congenital syphilis. However, the ability of policies to affect public health outcomes may depend on continued resource allocation, workforce training, and public awareness campaigns. State and territorial health agencies can consider additional measures, such as integrating syphilis screening into routine primary care visits and providing funding for community-based outreach. Conclusion These legislative actions represent various approaches states are taking to addressing syphilis. Implementing screening protocols aligned with current evidence may contribute to efforts to address syphilis and congenital syphilis. By leveraging legislative action and evidence-based interventions, states can improve health outcomes and reduce disparities in syphilis and other STIs. A comprehensive approach that includes additional testing, expanded health care access, and targeted interventions for populations at higher risk for infection or severe disease may ensure better health outcomes for parents and infants alike. ASTHO will continue to monitor and report on this important public health issue. article yes

Puerto Rico Program Supports Vulnerable Populations ASTHO Island Support Learn how Puerto Rico addresses social determinants of health and promotes equity among vulnerable populations. The Puerto Rico Department of Health’s Health Equity Program implemented an innovative initiative to support diverse institutions, with the goal of addressing social determinants of health and promoting health equity among vulnerable populations. This provided opportunities for a wide range of sectors including private non-profit organizations, universities, and hospitals. The project evolved throughout its duration, demonstrating the power of local funding and the importance of flexibility in program administration. Project Kickoff Grant Awarding and Training Process During the second request for proposal, 30 organizations expressed interest in submitting applications. However, given the detailed and rigorous rubric, six applied, of which four grants were awarded. The team scored the proposals based on the rubric, and allocated funds to support vulnerable populations such as individuals living in rural areas, people with disabilities, pregnant women, and older adults. Implementation and Best Practices Once the Health Equity Program awarded grants, they designed a detailed work plan, including key indicators for monitoring and tracking the progress of beneficiary organizations. They implemented a SharePoint-based system for the submission of reports and documentation. In addition, they held monthly meetings to ensure cohesion and effective communication among all stakeholders. This collaborative approach enabled efficient and transparent monitoring processes. “It was a collaborative process since the institutions know their populations best. We just wanted to ensure a systematic and consistent plan because these matters are crucial for project progress and monitoring.” — Miguel Cruz, PhD, Co-Principal Investigator Project Evolution The program initially funded one institution and due to its positive impact, additional opportunities emerged to provide funding for up to four additional institutions. The main topic revolved around health literacy as a strategy to reach health equity among people living in rural areas, older adults, people experiencing homelessness, individuals with functional diversity, and those experiencing a mental health challenge. These four new institutions covered the west, central, and other rural areas broadening coverage within traditionally underserved communities. Administrative Flexibility and Communication Strategies Administratively, the program had to be flexible during pre-award and award processes, ensuring compliance with state and federal regulations. This included revising announcements and creating plans. Additionally, the program created documentation, like templates, and provided technical assistance to clarify compliance guidelines to ensure transparency and proper use of funds. The program implemented effective communication strategies to inform institutions about funding opportunities, including announcements via mass media and the Department of Health’s official social media platforms. They also created an external technical committee as an official communication channel to evaluate proposals. For this purpose, the creation of a detailed rubric facilitated its proper, unbiased, and timely assessment. Technological Challenges and Solutions One key challenge throughout the project was the use of technology to receive, process, and manage documentation. To mitigate obstacles, a SharePoint webpage facilitated electronic documentation acquisition between each subgrantee and the program. Additionally, the program provided clear instructions and developed a Q&A guide based on the needs that various institutions identified. In case of new inquiries, the Health Equity Program also shared responses collectively to ensure all organizations received consistent information, enabling them to complete the process smoothly and with equal opportunity. Lessons Learned A final evaluation of the process revealed that anticipating challenges was key to the project’s success. However, there are still areas for improvement: One of these is the optimization of financial processes by the organizations. It is critical to submit evidence of fund use in a timely manner and ensure accuracy in reconciling invoices within the allocated period. Organizations should also align internal processes with the parameters set when they receive funds. Adhering to these parameters can streamline the process on the Department of Health's side. Although beneficiaries get an assigned accounting professional, the documentation must still go through the Fiscal Office for review. Another challenge faced by institutions was retaining participants in the training sessions provided as part of the grant. Therefore, mechanisms need to be in place to ensure active and continuous participation in future interventions. The Health Equity Program also identified the opportunity to standardize the evaluation processes for organizations. While each institution worked on diverse projects, evaluations were based on their respective work plans and progress reports. However, a standardized evaluation process could improve efficiency in future interventions. Sustainability and Recommendations Many institutions that received funds have used them as a starting point to develop larger initiatives while others have used them to develop internal resources (i.e., digital libraries, trainings). “Organizations used this funding as seed money for projects that are now receiving greater financial support. Others have developed internal resources that allow them to continue addressing key health issues. For instance, they have optimized the use of digital libraries, expanded training reach, and replicated projects funded by this grant in other municipalities.” — Miguel Cruz, PhD, Co-Principal Investigator For other agencies looking to implement similar programs, the recommendation is clear: Streamline efforts to maintain consistency and coherence. Additionally, explore other agency or office supports for fostering an organizational culture that prioritizes continuous monitoring and process improvement, emphasized Cruz, PhD. Conclusion Clear, transparent communication and flexible administration with a focus on health equity generate a positive impact on vulnerable populations — as evidenced by increased knowledge, improved participant skills, attitude changes, inclusion in services, greater technology use among older adults, and enhanced equity skills among workers. This project demonstrates how health departments can collaborate with other sectors to address social determinants and ensure equitable access to resources. article yes

State and territorial health officials gathered on Capitol Hill to meet with lawmakers and discuss public health priorities—learn more about Hill Day in this blog post.

Good news and bad news on tobacco use: smoking rates are down but e-cigarette use continuing rapid rise among youth. Read how states are combating the problem.

Cases of sepsis and septic shock can be prevented with strong health policies as shown in New York. Several states have taken action to enact mandatory early detection and treatment protocols.

Learn how the Maryland Department of Health leveled up their strategic planning process to improve their critical public health work in this blog post.

Read ASTHO's latest on how appropriations bills and budget cuts could affect the Debt Ceiling and the U.S. economy.

The VDH Internship Academy, funded by PHIG, is a key pipeline for public health careers with paid, growth-focused internships.

Learn about chairs of key committees in the 119th Congress, their priorities, and what may be in store for public health funding in this federal health policy update.

Explore how states are enacting legislation to help justice-involved people avoid overdose illness and death and foster a smooth transition after release.

2026 Blog Posts article

Explore how community coalitions and public health agencies work together to prevent youth substance use.

Communication, Community, and Power-Sharing: A Conversation with DELPH Scholars Communication, Community, and Power-Sharing Learn how public health leaders are moving from a top-down approach to a collaborative model that builds and sustains trust with community partners. The current public health landscape can feel daunting, uncertain, and increasingly stressful for leaders to navigate. While public health professionals have a wealth of expertise, reliance on expertise isn’t enough; collaborative leadership points the path forward. Moving away from traditional top-down approaches, effective and innovative leaders are learning to share power, practice meaningful community engagement, and create environments where partners, community, and staff feel valued and heard. Three scholars from ASTHO’s Developing Executive Leaders in Public Health (DELPH) program discuss how they apply these principles to strengthen collaboration within public health and build more resilient communities. Meet the Scholars Working in public health is not individualistic; it requires working collectively to achieve a common goal: healthier communities. These three scholars are championing collaboration. Brandon Horvath, Assistant Program Manager of Preparedness at the Philadelphia Department of Health, believes in the power of collaboration to navigate periods of uncertainty and that moving away from top-down leadership allows space for new ideas to flourish. Ethan Greenblatt, Health Education Supervisor at the Saint Louis County Department of Public Health, focuses on building partnerships to combat misinformation, amplify accurate messaging, and support overlooked populations. Halana Kaleel, Public Health Community Engagement Specialist at Austin Public Health, centers her work on developing genuine engagement between partners before making decisions that impact the collective, emphasizing that participation and power-sharing build trust. “When city council, city management, and other departmental leadership attempt to implement programs, policies, and budgetary changes without doing engagement and collaboration with the impacted community first, they lose trust with the communities we are trying to serve.” — Halana Kaleel Brandon, you oversee emergency communications as part of your role with the Philadelphia Department of Public Health. Can you talk more about the strategies and frameworks you have applied and how they help your team manage complex projects during both emergencies and blue-sky days? BRANDON HORVATH: When deciding how best to infuse collaborative leadership principles into our current reporting structure, I wanted to ground my approach in something relatable that staff would typically associate with comfort and relaxation. That’s when I thought back to the activities that worked best for relieving stress during the COVID-19 pandemic response. In my case, those were running, binge-watching a new TV show, or endlessly scrolling through TikTok. Each of these activities has a few key ingredients in common: time and energy set aside to make the activity happen, and controls to customize the experience. I factored these in when developing two activities that encourage staff participation, collaborative leadership, and feedback. The energy check is a self-reflection activity I like to start off our weekly touch-base meetings with, intentionally setting aside time to highlight accomplishments, discuss challenges staff were experiencing, and set attainable goals and priorities for the next week. Let’s talk it out is a collaborative leadership exercise where staff are encouraged to lead the conversation, using a set of functions you’d find on a remote control: Settings, Pause, Rewind, Fast-Forward, Record, and Power On/Off. The conversation begins with Settings, where we establish ground rules and outline expectations, acceptable behaviors, and how decisions will be made. Regardless of how the activity unfolds, it is important to document what’s discussed, identify any successes or pain points, and work together to draft next steps and potential solutions. Some optional functions can be folded in, depending on time and complexity. Pause (Reflect) involves making space for reflection, which can help ensure continuous improvement and make adjustments easier, regardless of where you’re at in a project. Rewind (What Worked) involves looking back at past decisions or progress since the last check-in, which can help ensure successful strategies are repeated and mistakes are avoided. Fast-Forward (What Do We Want to See) encourages discussion of what you would consider a successful partnership or collaboration. This is especially helpful when a project is complex and involves many stakeholders. Power On/Off (Let’s Revisit This) should be considered when a project is not progressing or we’ve identified pain points that require follow-up. This can bring the conversation to an intentional end, and another time can be set when all involved will regroup and resume planning. The strategies and frameworks you choose to apply will likely vary based on the role you play, the collaborations already underway, and the level of buy-in within your organization or team to shift away from the current project management approach. Ethan, in Saint Louis County your department has utilized community-based partnerships for vaccination efforts and to address the opioid epidemic. How does focusing on building community partnerships help address misinformation, reduce stigma, and increase trust? ETHAN GREENBLAT: Community partnerships allow public health agencies to meet people where they are, both physically and culturally. By working with trusted local institutions and leaders, our partners can deliver public health messages with voices that communities already know and respect. These collaborations also provide valuable feedback that helps programs remain responsive, relevant, and grounded in community needs. Halana, you emphasized that collaborative leadership requires a paradigm shift away from performative community engagement. How can governmental public health agencies transition to power-sharing to rebuild trust with community members who have been historically disenfranchised and excluded? HALANA KALEEL: In discussions with community members and stakeholders, time and time again they saw that they were only being consulted after decisions had already been made. Saying things like, “we want to hear from you” is performative engagement when you already know how you are going to approach an issue. At the end of the day, many communities would rather have honesty about a bad system than feel tricked by tokenistic engagement. To share power with community and stakeholders, governmental public health agencies need to provide opportunities for the communities they serve to participate in decision making at the beginning of the process, and we should empower and hire staff or liaisons who reflect the communities we are trying to reach. We also need to meet people where they are through more informal engagement instead of continuing to force community members who have been disenfranchised to come into governmental spaces that may be hard to reach and perceived as too formal. Lessons Learned and Actionable Advice Reflecting on your experiences, how do you actively build and maintain trust with community partners, staff, and stakeholders? HORVATH: Building and maintaining trust with staff requires leaders to be consistent, reliable, and authentic in their approach. For me, it’s always been about showing up and following through. Creating safe spaces, both formal and informal, where staff can share feedback and ideas, is the first step to making two-way communication happen. Recognizing staff for their accomplishments and highlighting team wins reinforces both trust and integrity. These same approaches can be applied when working in the field or communicating with a variety of stakeholders. GREENBLATT: Building trust requires consistent communication, transparency, and a shared sense of purpose. I focus on developing relationships over time and ensuring our partners feel heard and included in decision-making processes. It is also important that teams and stakeholders align around the organization’s mission, vision, and goals. When partners have a role in shaping the direction of an initiative, they are far more invested in its success. KALEEL: One of my best practices is focusing on closing the feedback loop by showing community members exactly how their input and feedback directly inform final plans and policies. What practical strategies can public health leaders use to strengthen partnerships and build more resilient public health systems? KALEEL: Something that can be daunting, especially during times of uncertain funding, is compensating community for their time and expertise, but this can be something as simple as small stipends, gift cards to local grocery stores, or feeding people at events. HORVATH: Start with a clear purpose. Set aside time to meet with your team to talk not only about what each person will be doing but why it matters. Find ways to infuse collaborative leadership into the culture, such as trying out a new approach to staff check-ins or promoting shared ownership of projects. Most of all, it is important to meet your staff and community members where they are and to be flexible with your approach. Mistakes will happen, but how we learn from them and adapt can help us be more prepared and resilient the next time. GREENBLATT: Public health leaders can strengthen partnerships by being intentional about how they engage with communities and partners. An important starting point is understanding the local landscape — specifically the initiatives, organizations, and trusted leaders in your community — so you can build on what’s already working rather than duplicating efforts. It’s also important to identify shared goals, making

Ripple Effect: What USPSTF Recommendations Mean for State and Territorial Health Law What USPSTF Recommendations Mean for State and Territorial Health Law Andy Baker-White This Health Policy Update highlights how U.S. states and territories are using policy to codify important public health recommendations. The United States Preventive Services Task Force (USPSTF) is a volunteer panel of national experts that issues evidence-based letter-grade recommendations on clinical preventive services. Under the Affordable Care Act, services with an A or B grade must be covered by most private health insurance plans without cost-sharing, with similar requirements for Medicaid enrollees and Medicare beneficiaries. An estimate by the Department of Health and Human Services concluded that in 2020, these services reached approximately 264 million Americans. States and territories implement these recommendations through statutes and rules. ASTHO identified over 200 state and territorial laws referencing the USPSTF, including in insurance statutes, Medicaid rules, disease-specific laws, and state employee health plan requirements. Over the past year, the stability of USPSTF recommendations has come into question. The U.S. Supreme Court's June 2025 ruling in Kennedy v. Braidwood confirmed the HHS Secretary’s authority to block USPSTF recommendations and remove task force members. News reports in July 2025 indicated that HHS Secretary Kennedy intended to remove all USPSTF members, and in May 2026 fired the chair and vice-chair of the task force. Questions are being raised about whether USPSTF recommendations will be rescinded or downgraded and, if so, what the impact would be on states and territories. In addition, if the USPSTF fails to convene in the future, it cannot review newer data on preventive services, meaning existing recommendations could become outdated and USPSTF can’t make recommendations for new services. To meet these challenges, states and territories are taking steps to ensure the continued scientific basis for preventive health services within their own law. Dynamic References to USPSTF Recommendations States and territories often use dynamic references to USPSTF recommendations in regulating health plan coverage of preventive services. This allows the jurisdiction to automatically require coverage for the most current USPSTF recommendations. Laws in West Virginia (state employee health plans), Oregon (regulated health plans), Hawaii (health director standing orders), and Alaska (adult Medicaid enrollees) use this approach. While dynamic references allow jurisdictions to stay up to date with the recommendations, if the task force withdraws any guidance, then those preventive services would no longer require no-cost coverage without additional action from those jurisdictions. Some jurisdictions address this by specifying that certain USPSTF guidance changes will not apply. For example, Guam’s law requires continued no-cost coverage for colorectal cancer screenings and authorizes the health director to adjust diabetes screening recommendations if USPSTF recommendations cease. Illinois specifies that the 2009 USPSTF recommendations for breast cancer screening and mammography are not to be considered current because national medical bodies created differing recommendations for screening. Another way jurisdictions avoid the unpredictability of using dynamic references is locking in the date of the USPSTF recommendations that are used for coverage requirements. For example, Massachusetts requires its state employee health plan to cover USPSTF A and B recommendations that were in effect by July 1, 2023. Using a version of USPSTF recommendations from a specific date maintains a base level of coverage regardless of future changes, though adopting new recommendations or removing outdated recommendations would require separate action. During this year’s legislative sessions, several states enacted or proposed legislation to remove dynamic USPSTF references. For example, Maryland passed legislation (HB 637 and SB 385) to lock in the USPSTF A and B recommendations that were in effect on December 31, 2024. Washington enacted HB 2242 requiring coverage of USPSTF A and B recommendations in effect on June 30, 2025, as well as recommendations adopted by the state insurance commissioner. A bill passed in Delaware, HB 338, would require the use of the USPSTF recommendations from January 1, 2025. Overall, however, neither dynamic nor fixed references to USPSTF recommendations address how jurisdictions can keep up with new scientific data and advances in preventive services in the absence of ongoing USPSTF review and recommendations. To fill this need, some states have enacted legislation that creates processes for reviewing data and establishing recommendations. For example, the new Maryland law mentioned above also authorizes the state’s health secretary to adopt preventive service recommendations that have not been recommended by or that differ from USPSTF. The new process requires notice and a 30-day comment period, an analysis by the Maryland Health Care Commission, and citations to the authoritative medical body upon which the recommendation is based. Disease-Specific Statutes: USPSTF Grades as Care Standards and Thresholds Many states also use USPSTF grades as thresholds for specific preventive services, establishing the standard of care, or issuing standing orders. For example, Arkansas law defines "follow-up colonoscopy" by reference to a colorectal screening assigned an A or B grade by the USPSTF, while Nevada’s law directs primary care providers to use criteria set out in USPSTF recommendations to screen adult women for BRCA mutations. In Hawaii, the state health director is authorized to issue public health standing orders for current USPSTF A and B recommended services, and in Idaho the law uses USPSTF guidance for applying ocular antibiotic prophylaxis to newborns as the standard for medical practice in the state. Some states are considering legislation to distance preventive service coverage requirements from USPSTF recommendations. For example, while New Jersey's current law requires no-cost coverage for colorectal cancer screenings in accordance with the method and frequency recommended by the USPSTF, introduced legislation (A4916 and S4254) would remove the reference to USPSTF recommendations and instead authorize one screening per year for persons aged 33 or older. More broadly, Hawaii considered legislation (HB 1898 and SB 3133) that would have authorized the state’s health department to “make recommendations relating to clinical preventive service recommendations of the [USPSTF] Force that have been assigned a grade of A or B as of July 1, 2025” and require no-cost coverage for the department’s recommendations. However, this legislation did not pass. State Employee Benefit Plans USPSTF recommendations may also be used to establish preventive health services covered by state employee health plans. A West Virginia statute requires the state’s employee health plans to cover mammograms consistent with "current guidelines from the United States Preventive Services Task Force," while the health plan document further states that preventive services are "subject to change as USPSTF…recommendations are updated.” In Ohio, a regulation requires state employee health benefits include all USPSTF-recommended tobacco cessation services and authorizes the state health director to update covered services if USPSTF guidance changes. Missouri law requires full coverage of USPSTF graded A and B recommended prescription and prescribed over-the-counter drugs for state plan members. The Path Forward USPSTF recommendations have helped millions of Americans receive critical health services at no cost, and states and territories have built practices, programs, and standards on that foundation. From adopting fixed-date references to establishing state-level recommendation authority to creating new state review bodies, legislative activity this year reflects a broad effort to address ripple effects from potential future changes to or lack of USPSTF guidance. Health officials may be asked to assess their jurisdiction’s laws and their use of USPSTF recommendations, and coordinate with insurance commissioners, Medicaid directors, and employee benefits administrators to confirm consistent agency interpretation and identify where action is needed. ASTHO will continue to monitor these policies as they develop. article yes

Learn how Missouri, Michigan, and Tennessee use integrated, accessible, and timely data to prevent the intersection and improve health outcomes.

Learn how states braid funding, build partnerships, and advance policy to tackle ACEs, overdose, suicide, and mental health.

Partner Spotlight: Q&A with Kate Menard on Levels of Maternal Care State Implementation Advancing Levels of Maternal Care: Q&A with Kate Menard Lexa Giragosian Learn how health agencies should approach levels of maternal care implementation, with key insights from Kate Menard, a key leader and expert on the topic. As the maternal health crisis continues nationwide and states face hospital closures and workforce challenges, health agencies are increasingly implementing levels of maternal care (LoMC) to improve access to maternal health services. LoMC provides a standardized way to classify health care facilities based on their ability to manage maternal risk conditions and complications during birth. LoMC implementation helps to ensure that perinatal patients receive the appropriate care for their specific health needs, supporting optimal health outcomes. When states or territories adopt LoMC, it can strengthen access to risk-appropriate care and build more coordinated systems of perinatal regionalization. LoMC implementation is a critical lever in systems level improvement and supports efforts to reduce severe maternal morbidity and mortality. ASTHO spoke with Kate Menard, a key leader in advancing LoMC implementation nationally, to learn more about how health agencies should approach LoMC implementation in their jurisdictions. She co-led the development of the original LoMC guidelines by the American College of Obstetrics and Gynecology/Society for Maternal Fetal Medicine, collaborated with CDC on its Levels of Care Assessment Tool (LOCATeSM), and partnered with the American College of Obstetrics and Gynecology on pilot testing onsite LoMC verification. For jurisdictions beginning implementation of LoMC, what are the critical first actions to take? Establishing a shared understanding of why LoMC matters, and how it supports access to RAC, is vital for sustained commitment. Begin by engaging diverse stakeholders, such as public health leadership (including rural health, maternal child health, minority health, and regulatory agencies), clinical leadership, payers, health administrators, patient advisors, and emergency medical services. I would also recommend conducting a thorough assessment of the existing regionalization system in your jurisdiction, identifying strengths and opportunities. This assessment can help tailor the LoMC implementation process to specific regional needs and contexts. Using CDC LOCATeSM can enable some aspects of this preliminary assessment. Which stakeholders should be involved from the beginning, and how can health agencies effectively engage them? Relevant partners may include clinicians (obstetricians, pediatricians, anesthesiologists, etc.), hospital associations, health system administrators, payers, community representatives, emergency medical services, and legislative authorities. Health agencies are in a unique position to convene stakeholders and bolster early and effective engagement. They can organize stakeholder convenings that bring all parties together and facilitate collaborative discussions, foster relationships, and ensure that diverse perspectives are considered in the planning process. Are there any lessons learned from your experiences that would be beneficial to those in the process of LoMC implementation? I would recommend leading with the ‘why’ as you begin this process. Clearly articulating your jurisdiction’s most urgent maternal health challenges and how LoMC can help address them will create alignment from the beginning. For example, if closure of obstetric services in rural hospitals is a major concern, focus on the design of a regionalized system that supports rural hospitals through education, training, and seamless systems for escalation of care when needed (antenatal consultation/referral or maternal transport). Jurisdictions can use Maternal Mortality Review Committee findings and hospital-based severe maternal morbidities reviews to identify key needs. Building trust is equally critical and strong relationships among stakeholders helps overcome resistance to change. Using data and evidence-based practices will enhance credibility and encourage partner buy-in. What are the key considerations and best practices needed to effectively implement LoMC? Firstly, define specific objectives for the implementation process through collaboration with stakeholders, ensuring they are measurable and achievable within the timelines set. Leverage stakeholder engagement to collaboratively determine how your jurisdiction will implement LoMC (e.g., legislation, regulation, governing body, adoption of the American College of Obstetrics and Gynecology/Society for Maternal Fetal Medicine guidelines as is or with state specific adaptations, designation method, onsite verification). Through this process, maintain open lines of communication among all stakeholders to foster transparency and collaboration. Once your jurisdiction is prepared for implementation, agency leaders should ensure adequate training for health care providers and administrators to understand the LoMC system and their role within it. Don’t forget to embrace quality improvement and utilize data and feedback from the implementation process to make informed adjustments and improvements, confirming that care delivery continuously aligns with best practices. How can jurisdictions use their LoMC data to demonstrate its value and return on investment to hospital leaders and decision-makers? Defining LoMC is the first step. Building shared language to advance collaboration, risk appropriate care, and improved maternal outcomes is how the investment is realized. Jurisdictions should track and report on key performance indicators, such as reductions in maternal morbidity and mortality rates, improved access to care, and increased adherence to best practices in maternal health. To make the business case, highlight cost benefits that effective LoMC implementation creates, such as fewer unplanned ICU admission, shorter hospital stays or readmissions, and avoidance of medical legal claims. Emphasize that effectively utilizing a LoMC system may actually improve retention of providers and staff in rural hospitals. Patient feedback may additionally demonstrate improved experiences for mothers and newborns, reinforcing the need for continuous investment in LoMC. article yes

Workforce Trends in Public Health Preparedness Workforce Trends in Public Health Preparedness Kelsey Tillema, Adrianna Evans Learn about ongoing changes to the public health preparedness workforce and how to best support these workers. Public health preparedness professionals fulfill critical functions in the event of a public health emergency, such as coordinating emergency response planning, managing incident command structures, and ensuring readiness for a multitude of threats. This essential group of workers faces significant strain, especially after the COVID-19 pandemic, which accelerated major workforce changes within public health. The prolonged emergency response intensified staff burnout and increased turnover, prompting many professionals to retire or even leave the field. New data shows the public health preparedness workforce specifically is less tenured and navigating unique challenges when it comes to shifts in funding and policy priorities. When it comes to who’s behind the scenes of preparedness and response, it’s crucial to consider how to maintain an engaged workforce capable of scaling, coordinating, and sustaining response operations under pressure. The Workforce Landscape According to the 2024 Public Health Workforce Interests and Needs Survey, the preparedness workforce makes up roughly 13% of the state and local public health workforce. Of these approximately 30,000 workers, nearly a quarter (23%) are age 35 or younger, and another quarter (28%) are 55 and older. Although this is not unique to the preparedness workforce, this reflects an aging workforce as experienced staff approach retirement and new professionals enter the field. Further, about half of preparedness health agency staff (49%) have been with their agency for less than five years. Considering this transition, health agencies may face the loss of institutional knowledge related to emergency operations, incident command structures, and preparedness and response protocols. As experienced professionals exit the workforce, this may also create gaps in mentorship, leadership, and overall response experience. However, like the rest of the public health workforce, most preparedness staff (73%) show commitment to staying with their organizations for at least the next year. Preparedness staff cited benefits, job stability, and supportive coworkers as their main reasons for staying. On the other hand, the top reasons for leaving are pay, organizational culture/climate, and lack of opportunities for advancement. To gain insight into gaps within the workforce’s expertise, preparedness leaders may want to consider partnering with their agency’s internal workforce development team to conduct a workforce assessment within their program. Regularly assessing a preparedness team’s skillset and needs can give greater clarity on how to best support team development and growth. Agency leadership can create cohesion between tenured and new professionals by offering or supporting both formal and informal mentorship, and establishing avenues to create familiarity with response systems, interagency coordination, and real-world experience. Newer professionals may bring fresh perspectives and diverse skillsets to the workforce but need support from tenured staff to become well-versed in the preparedness sector. At this juncture, succession planning and supporting career advancement pathways are essential components to building up the next generation of leaders in public health preparedness. Knowledge Transfer and New Skills Whether responding to pandemics, natural disasters, or radiological events, working in preparedness requires strategic and cross-disciplinary capabilities that go beyond traditional emergency response. During a public health emergency, staff must rapidly activate response plans, coordinate across agencies, and make high-stakes decisions. Since evidence shows that many workers are new to the field, it’s crucial to ensure that staff are continuously learning internal systems and building preparedness-specific skills. Both new and rising preparedness staff members need a variety of skills to make informed decisions and grow within their organizations. Areas such as administrative preparedness, navigation of policy and legislative processes, and leadership development are all key to creating a cohesive internal workforce system. Leadership skills are crucial for preparedness staff, who must coordinate across agencies, communicate crisis and risk information to a variety of audiences, and operate within the Incident Command System. Other important and emerging topical considerations for skill expansion include data analytics, artificial intelligence, cybersecurity, multimedia risk communication, and specialized areas of preparedness (e.g., accessibility, radiation readiness, climate and animal health), to name a few. While some of this knowledge can be passed on through mentorship or job experience, staff should also have access to structured, high-quality learning opportunities. Continuing education courses, certificate programs, and tuition reimbursement can all support staff development. Policy and Funding Considerations Internal workforce policies have significant influence on an agency’s workforce retention, morale, and skill building. Beyond salary, policies related to flexible working arrangements, paid training time, career advancement opportunities, and recognition and well-being programs all contribute to how supported staff feel in their roles. Agency leadership can also assess their broader levels of policy, such as student loan repayment and tuition assistance, to make preparedness careers more competitive and accessible. Externally, public health preparedness programs rely heavily on federal funding streams such as the Public Health Emergency Preparedness cooperative agreement and the Hospital Preparedness Program. As a result, preparedness hiring and turnover cycles can be influenced by grant timelines. As federal priorities shift, this uncertainty can make it challenging for agencies to sustain long-term workforce investments and main continuity of operations. Many agencies are exploring ways to adapt, using strategies to braid and layer funding streams to stabilize staff, while others use supplemental funds such as the Public Health Infrastructure Grant to invest in foundational capabilities and workforce development beyond just preparedness activities. Preparing for the Future Agencies have an opportunity to address the primary drivers of attrition and strengthen the preparedness workforce. Expanding workforce development opportunities internally and externally will help to maintain institutional knowledge and prepare the workforce for evolving modern day threats. While the future of public health preparedness does rely on funding and policy, it also relies on skilled, committed workers. As the workforce landscape continues to evolve, investing in the development, retention, and lifting up of a generation of new leaders will determine how effectively we respond to future crises. Learn more about strategies and resources to support the public health preparedness workforce from ASTHO’s Inspire Readiness Workforce page and the ASTHO Workforce Resource Center. ASTHO will continue to share promising practices to support preparedness staff. Reviewed by - Allen, Peterson article yes

Partnership as the Foundation for Advancing Adolescent Health in American Samoa Partnership Advances Adolescent Health in American Samoa Gabby Ruiz Learn how American Samoa advances adolescent health in American Samoa through collaboration among state and local health and education agencies. Cross-sector partnerships are essential to advancing adolescent health, particularly in school-based settings. The intersection between public health, education, and clinical health is vital to the delivery of integrated services. In the United States, it is estimated that children in grades K-12 spend at least 1,231 hours each year in school, not including time dedicated to clubs or extracurricular activities. When schools function as trusted environments where health and learning meet, they become powerful access points for early identification of needs, preventive services, and supportive relationships. The public health sector brings expertise in prevention, population-level data, and community engagement. Meanwhile, the education sector provides youth engagement and the ability to creatively embed health into learning environments by leveraging diverse resources. When sectors work in isolation, resources are used inefficiently and adolescents may experience gaps in care, fragmented supports, and inconsistent access to essential services. With support from CDC’s Division of Adolescent and School Health, ASTHO leads the Leadership Exchange for Adolescent Health Promotion Plus Community of Practice, an initiative that promotes collaboration among state and local health and education agencies to strengthen health education, connect schools to services, and foster safe, supportive learning environments. This initiative provides a space for teams to share ideas, troubleshoot challenges, and build sustainable partnerships. Through this effort, the American Samoa team built a strong partnership between the Department of Health and the Department of Education to expand and enhance effective communication about sexual and reproductive health to reduce risk taking behaviors and promote protective factors. Peer-to-Peer Learning as a Catalyst for Youth Engagement Grounded in the belief that young people are often the most trusted messengers for their peers, the American Samoa team launched the Students Promoting Education, Awareness, and Knowledge (SPEAK) project: a student-led, peer mentor collaborative effort between the American Samoa Department of Education (ASDOE), the American Samoa Department of Health (ASDOH), and youth peer leaders. The project builds a network of trained peer educators who engage students on topics such as healthy relationships, personal responsibility, privacy, consent, HIV, STI, and pregnancy prevention. SPEAK peer leaders are students in grades 10 through 12, with two or more representatives from each grade level. High school counselors help identify students suited for this role, which includes: Co-creating educational materials that reflect their identities (i.e., their values, abilities, and lived experiences). Fostering safe spaces for support and dialogue. Managing online platforms that allow youth to ask questions anonymously. Collaborating with schools, communities, and health care providers to develop and promote educational campaigns through social media channels. SPEAK promotes student leadership, shared accountability, and open, stigma-free dialogue. Forging Strong Relationships Alignment and Sustainability From the beginning, ASDOH and ASDOE committed to building a unified team to support adolescent sexual and reproductive health. This collaboration became one of their greatest strengths. The team noted that establishing a shared vision early on helped them maintain momentum through challenges. Donation Ape, ASDOE Program Director, played a pivotal role in bridging agencies and strengthening the network that supported the project’s success. While Ape’s dedication and tenacity have been key to nurturing this partnership, both sides of the team are working to ensure that this partnership is sustainable. “With the right network, we were able to do it.” — Donation Ape, ASDOE Program Director Thoughtful Health Education In addition to coordinating across school systems and community partners, long-standing cultural values that emphasize privacy around family and personal matters made open discussion of adolescent health topics more challenging. Prior to SPEAK, students were not receiving structured health education in this area. ASDOE staff and leadership initially expressed understandable concerns about ensuring any peer-led approach would be age-appropriate, culturally respectful, and aligned with community standards. A key strategy for addressing these concerns was thoughtfully engaging youth alongside educators, families, and community stakeholders to help demonstrate the need and shape a solution to delivering health education. “When you see young people not just as children but as contributors to society, you start to see what’s possible.” — Fatih Seiuli, Health Educator, ASDOH Key Considerations for State and Territorial Health Agencies American Samoa’s experience offers key insights for other jurisdictions seeking to strengthen adolescent health through school-based partnerships: Integrate public health into education, clinical health, and mental and behavioral health to ensure a more holistic and sustainable cross-sector approach. Together, these sectors form a coordinated system that has the capacity to address pertinent adolescent health concerns. In addition, youth hold a critical role in their own care, and engaging them as part of these cross-sector partnerships is essential to adolescent health program uptake and understanding. Involve essential community voices by engaging key stakeholders and end users early on. Creating a peer educator network and creating space for youth-led engagement ensures programs reflect young people’s lived realities — increasing relevance and reach, and fostering trust and ownership among students who may otherwise feel disconnected from traditional health messages. Adapt curricula with cultural responsiveness. Integrate bilingual materials and tailor them to the unique needs of communities — expanding reach across cultural contexts and addressing stigma or other social and structural barriers. Additionally, ensure the framing of the program is appropriate for audiences and helps to overcome cultural barriers. Looking Ahead American Samoa’s journey demonstrates how intentional partnerships, youth leadership, and culturally grounded approaches can advance adolescent health in meaningful and sustainable ways. Their work reinforces that collaboration is a critical strategy that serves as the foundation for lasting impact. ASTHO will continue supporting jurisdictions through the Leadership Exchange for Adolescent Health Promotion Plus Community of Practice by fostering connections, strengthening multi-sector partnerships, and creating spaces where teams can learn from one another. As American Samoa’s experience shows, meaningful progress in adolescent health is possible when sectors and systems align around a shared purpose. Reviewed by - Akbarali, Mackie, Vance article yes

(More) Recent Shifts in HHS Leadership: June 2026 More Recent Shifts in HHS Leadership: June 2026 Catherine Murphy Get the latest updates on changes in leadership at CDC, FDA, HHS, and more in this Federal Health Policy Update. This provides updates to a previous Federal Health Policy Update: Recent HHS Leadership Changes That Impact Public Health. As Congress heads into a busy summer of work on FY27 appropriations, a potential reconciliation package, and looming midterm elections, the Trump Administration continues shaping HHS to the President’s Make America Healthy Again agenda. Since our last update in April, there have been a handful of new leadership shifts within HHS agencies. CDC Since the departure of Susan Monarez from her role as CDC Director in August 2025, the position has been covered by acting directors. In April, President Trump announced Erica Schwartz as his new pick for CDC Director. Schwartz brings experience as a physician in the U.S. Navy, as chief medical officer in the Coast Guard, and helped lead the government’s response to the COVID-19 pandemic as deputy surgeon general. The Senate HELP Committee has not yet noticed a hearing to review her nomination. Public response to her nomination, though, has been generally positive. In the same announcement, President Trump also highlighted his appointment of Jennifer Shuford as the CDC Deputy Director and Chief Medical Officer, and Sean Slovenski as CDC Deputy Director and Chief Operating Officer. Shuford, an ASTHO alumni member, is the former commissioner of the Texas Department of State Health Services and an infectious disease physician. Before her tenure as commissioner, she was the chief state epidemiologist. Slovenski brings a background as a health care executive and entrepreneur, with experience ranging from telehealth and wellness incentives, major companies and brands, and advocacy. Surgeon General The confirmation proceedings of President Trump’s previous pick for Surgeon General, Casey Means, stalled as senators deliberated on her statements on vaccine safety after her appearance before the Senate HELP Committee in February. At the end of April, the President announced his nomination of Nicole Saphier, a radiologist, director of breast imaging at Memorial Sloan Kettering Monmouth, and former medical contributor to the Fox News Channel. Saphier is viewed as a more mainstream nominee given that she is generally supportive of vaccines. Her priorities also include building trust in public health recommendations, combating chronic disease, and reducing ultra-processed foods. FDA In early May, it was announced that Commissioner Marty Makary would be leaving his role. Kyle Diamantas, formerly FDA’s Deputy Commissioner for Human Foods, has taken over as Acting Commissioner for the agency. Before joining FDA, Acting Commissioner Diamantas practiced law, focusing on food, drug, and life sciences regulatory matters. A nominee for FDA Commissioner has not yet been announced. Donald A. Prater has taken over as acting head of the Human Foods Program. ASPR In April, Sean Kaufman was announced as the White House nominee to lead ASPR as the Assistant Secretary for Preparedness and Response. He specializes in preventing spread of infectious disease and brings experience as a Senior Advisor for Global Affairs at CDC and, in previous roles, responded to infectious disease outbreaks including anthrax, SARS, and West Nile virus. HHS Additionally, Sara Brenner was announced as Senior Counselor for Public Health to Secretary Robert F. Kennedy, Jr. In her past roles, she served within FDA as Acting Commissioner and Principal Deputy Commissioner within the Office of the Commissioner. She is a preventive medicine and public health physician with extensive experience in federal health policy. In her broad federal experience, she has worked on COVID-19 response, within the White House Office of Science and Technology Policy, and worked on medical countermeasures and preparedness efforts. Leadership Promotes Trust in Public Health Minimizing leadership turnover bolsters stability in the public health continuum and allows for a more robust response to current and emerging public health threats. Ongoing changes within HHS can create uncertainty for the entire health ecosystem, from practitioners awaiting public health guidance to the broader public. In an environment where stability, clear communication, and transparency are needed, confirming leadership that promotes concise, well-researched advice will help continue efforts to rebuild trust in our governmental public health enterprise. These recently announced leaders bring a wealth of experience to their roles and have an opportunity to promote strong, evidence-based public health guidance for Americans. The Senate HELP Committee has not yet noticed confirmation hearings to review the nominations of the Senate-confirmed positions: the CDC Director, Surgeon General, and Assistant Secretary for Preparedness and Response are expected to be reviewed by the panel. ASTHO will continue to track updates to HHS leadership and confirmations. Reviewed by - Ekoma, Staley article yes