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This report from the Human Rights Campaign offers a foundation for supporting & respecting others with different marginalized identities.

Partnering with Birthing Hospitals to Protect Babies Against RSV Partnering to Protect Babies Against RSV Susan Kansagra, Michelle Fiscus, Kim Martin Learn how immunization programs partnered with birthing hospitals to expand participation in Vaccines for Children and better protect babies against RSV. In 2023, the Advisory Committee on Immunization Practices (ACIP) recommended the use of monoclonal antibodies (mAbs) to prevent respiratory syncytial virus (RSV) in infants, a major milestone in newborn immunization. Unlike vaccines, which stimulate the body’s immune system to produce its own protection over time, mAbs work right away by giving the body ready-made protection against infection. This is especially important for newborns who do not have the protection of maternal RSV vaccination, which causes them to face a higher risk of severe RSV illness and need protection as early as possible. In response to the 2023 ACIP recommendation, state and territorial immunization programs acted quickly to ensure these new protections reached the babies who needed them most. One of the most effective strategies was partnering with birthing hospitals to expand participation in the Vaccines for Children (VFC) program, a federally funded initiative that provides vaccines to children at no cost to their families who might otherwise be unable to afford them. This program enabled the delivery of RSV mAbs — such as nirsevimab and now clesrovimab — to VFC-eligible newborns without any financial burden on their families. High Stakes, Strong Results The stakes were high, as RSV is the leading cause of infant hospitalizations in the United States. It was previously responsible for an estimated 58,000 to 80,000 hospitalizations and up to 300 deaths in children under age five each year. Data on RSV mAbs showed significant results, reducing RSV-related emergency department visits by 63% and hospitalizations by as much as 80%. Administering RSV mAbs in the first few days after birth, during RSV season, ensures that infants are protected before their first exposure — a critical step in reducing illness and health care burden. Strategies for Success Health departments played a leading role in bringing birthing hospitals into the VFC program. Many hospitals were not previously enrolled, often due to limited awareness, logistical barriers, or concerns about administrative burdens. Immunization programs responded by 1) launching targeted outreach, 2) offering tailored technical assistance, 3) simplifying enrollment processes, and 4) providing guidance on proper storage, eligibility screening, and documentation. The Impact of Stronger Partnerships These efforts have generated measurable results: The number of birthing hospitals enrolled in the VFC program increased from 292 in the 2023 season to 1,012 in 2025, boosting coverage from 10% to 36% of all U.S. birthing hospitals. This clearly demonstrates that these partnerships are effective and make a real difference in protecting infants’ health. State data further highlights this success and shows that collaboration across states, hospitals, and public health partners is crucial for achieving measurable impact: Virginia nearly doubled the number of birthing hospitals enrolled in the VFC program, increasing from six to 11 within one year. The state’s immunization program implemented an innovative Replacement Model to simplify requirements and collaborate closely with hospital teams to overcome barriers. Similarly, California provided resources, developed an enrollment checklist, and communicated the benefits of enrollment to birthing hospitals. Finally, across six states, 33 hospitals, and 400 clinics over two RSV seasons, Intermountain Health coordinated a system-wide approach that developed educational tools, enrolled hospitals in VFC, and addressed supply shortages. It also piloted a Replacement Model where mAb product was purchased by the hospital and doses administered to VFC-eligible babies were replaced with VFC-funded stock. These efforts also strengthened relationships between public health programs and birthing institutions. Trust and communication improved, and hospitals became more engaged in broader immunization goals (e.g., access to other birth-dose vaccines like hepatitis B). This expanded partnership not only protected newborns during RSV season but reinforced the capacity of immunization programs to mobilize quickly, implement new recommendations, and ultimately improve health outcomes. Compared to prior seasons, RSV-associated hospitalization rates were 28%-43% lower in 2024-2025, which was the first season with widespread availability of mAbs and maternal RSV vaccine. Future Opportunities Health departments have used a number of strategies to increase VFC enrollment by hospitals and mAbs coverage as a whole, including: Using birth volume data to prioritize outreach to additional hospitals for enrollment in the VFC program. Ensuring linkage to Immunization Information Systems to determine maternal RSV vaccination status and quickly identify eligible infants. Working with health systems on standing orders and protocols to help providers administer mAbs rapidly to eligible infants. Bringing hospitals and payers together to provide financial models that support universal coverage. While bundled payments for labor and delivery stays have been a barrier for private payer coverage, the high ROI for preventing future RSV-related health care utilization may provide additional opportunities for payers to consider alternative coverage models. Sharing promising practices through a Learning Collaborative webinar series developed by the Association of Immunization Managers, in coordination with CDC. The rapid rollout of RSV mAbs through the VFC program is a model of success. It shows that when public health agencies and health care partners work together, we can deliver lifesaving interventions, even in complex, high-volume settings like birthing hospitals. As new immunization tools emerge in the years ahead, the infrastructure, lessons and relationships built through this effort will continue to support the goal of protecting all children from the very start. article yes

How New Laws Support Telehealth and Access to Health Care How New Laws Support Telehealth and Access to Health Care Ashley Cram Learn how federal and state policies are improving access to health care by supporting telehealth. Telehealth strengthens the health system by reducing barriers to access to health care and extending services to underserved communities. Federal and state policies — many born out of the COVID-19 pandemic — have increased the use of telehealth by patients and providers. This includes expanded reimbursement to allow more providers to deliver telehealth services in more locations and through more modalities. This Health Policy Update summarizes recent federal and state laws and policies that impact telehealth delivery and access to care. Federal Laws and Policies Rural Health Transformation Program Enacted as part of the One Big Beautiful Bill Act in July 2025, the Rural Health Transformation Program appropriates $10 billion per fiscal year for the Centers for Medicare & Medicaid Services (CMS) to award to eligible states looking to improve rural health care. CMS encouraged state applicants to focus on select strategies, including investment in technology platforms that enhance care delivery. This includes tools and resources that support telehealth overall and remote patient monitoring (RPM), which is a way for providers to monitor and support patients through the use of devices that support data collection and transmission. Applicants that participate in interstate licensure compacts are also incentivized throughout the five-year program period by being awarded additional points for participation, which may lead to states pursuing compact legislation in the coming years. Medicare Telehealth Flexibilities Set to Expire During the COVID-19 pandemic, CMS issued numerous flexibilities that authorized broader telehealth use to expand access to care. Flexibilities included expansion of certain audio-only services, geographic areas and patient locations, and additional provider types eligible to deliver telehealth services. Current policy authorizes these pandemic-related telehealth flexibilities through January 30, 2026. Without permanent extension of these flexibilities, Medicare coverage for telehealth services beyond January 30, 2026, telehealth will again be limited to patients living in rural areas and to certain services, providers, and facilities. Physician Fee Schedule Changes CMS establishes the annual Medicare Physician Fee Schedule (PFS), which sets payment policy for health care services provided by physicians and other professionals to Medicare beneficiaries. The 2026 PFS includes new codes for RPM that allow providers to tailor monitoring frequency and engagement levels to meet patient needs. These codes, and the expansion of RPM, allow providers to effectively monitor health indicators such as weight, blood pressure, blood glucose, and respiratory flow rates, to manage health issues. By regularly monitoring a patient’s health status, a provider can reduce the risk of adverse health outcomes and emergency department visits. Additionally, the PFS streamlined the process for adding eligible telehealth services for reimbursement by removing distinction between permanent and provisional services and focusing review on whether services can be delivered via telehealth. State Legislation Impacting Telehealth Delivery States are also developing policy solutions to enable broader access to telehealth services, including expansion of audio-only and RPM services. Audio-only telehealth services are the use of communications technology, without a visual component, to deliver synchronous health care services. This modality can ensure continuity of and access to care for patients who live in areas with limited broadband and/or those who lack access to a video-enabled device. In 2025, at least four states enacted laws related to audio-only telehealth services. This includes at least three states that extended coverage that would have otherwise expired. In Hawaii, SB 1281 extended the expiration of the state’s coverage of certain audio-only behavioral health services through 2027, while Minnesota (HF 2) took a similar approach to audio-only telehealth services, including certain behavioral health and substance use disorder services, through July 1, 2027. Similarly, Maryland (SB 372/HB 869) removed the sunset date for coverage of audio-only telehealth services. And more broadly, Missouri (SB 79) clarified the state’s telehealth definition to include audio-only technologies. RPM uses digital devices to monitor a patient’s health by collecting and sharing health information with providers. RPM is particularly effective for management of chronic conditions, allowing providers to engage in shared decision making with patients and prevent adverse health outcomes through more regular monitoring. In recent years, several states enacted legislation to expand access to RPM including two bills in Louisiana. Enacted in 2024, HB 896 established the Louisiana RPM program for Medicaid patients with chronic conditions and a history of high-cost services, with the goal of improved care coordination and reduced costs. Then in 2025, SB 70 expanded these criteria to include pregnant and postpartum women and infants following discharge from the NICU. In Maryland, HB 553 specifies that the Medicaid program must cover the equipment and provider oversight of blood pressure monitoring for eligible recipients, including pregnant and postpartum individuals and those with chronic health conditions. Lastly, Virginia enacted SB 843 which directs the state Medicaid agency to develop a plan and cost estimate for expanding Medicaid eligibility for RPM for patients with chronic conditions. State and territorial health agencies can encourage public health programs to incorporate telehealth and propose policy solutions that enable broader utilization of telehealth modalities across the entire jurisdiction. States that are interested in expanding access to telehealth can visit ASTHO’s Telehealth Project Initiation and Scoping Assessment to conduct a review and identify opportunities to expand access to telehealth, particularly related to policy, infrastructure, and funding. UD3OA22890-13-00 article yes

Government Shutdown Effects on Public Health: Lessons from the 2025 and 2018-2019 Closures Catherine Jones Learn about the government shutdown effects on public health, with insights from the 2025 and 2018-2019 closures. When the federal government shuts down, it exposes vulnerabilities in our public health ecosystem. It also brings to light the critical role state and territorial health departments play to protect the health of their jurisdictions. While the political dynamics behind each shutdown may vary, the consequences are unfailingly disruptive. Some federal agencies and programs continue under mandatory or advance appropriations, but the day-to-day machinery that keeps the federal public health system functioning — workforce, oversight, and technical assistance — is impacted. Federal employees from shuttered agencies are either furloughed or required to work without pay if their roles are deemed essential to public safety, as with certain functions of HHS and FDA, among others. The effects of a shutdown can be temporary or long-lasting. In the past, Congress enacted guardrails to reduce the harm of future funding lapses, but the unpredictable nature of each shutdown ensures that disruption, loss, and hardship follow. A comparison of the 2025 and 2018-2019 shutdowns displays this impact — with the 2025 impasse becoming the longest shutdown in U.S. history, surpassing the 35-day record set during the December 2018 to January 2019 closure. Key Differences Between the Shutdowns The 2018-2019 shutdown, which was sparked over a funding fight for the U.S-Mexico border wall, spared HHS because the FY2019 Labor-HHS-Education Appropriations Act had already been enacted before the funding lapse. As a result, core public-health agencies — including CMS, CDC, HRSA, and SAMHSA — continued operating. However, the programs funded through the Agriculture-FDA appropriations bill (e.g., SNAP, WIC, and FDA) were impacted, but the disruptions were somewhat contained: FDA paused some food and drug inspections, while SNAP and WIC administrators worked to stretch timing buffers to sustain benefits. The 2025 shutdown, by contrast, impacted HHS. Disputes over the Continuing Appropriations and Extensions Act, 2026, (H.R. 5371), also known as a continuing resolution (CR) — compounded by an acrimonious stalemate over extending the Affordable Care Act premium tax credits (analyses show premiums could more than double in 2026 without extensions) and reversing Medicaid cuts in the One Big Beautiful Bill — placed health care directly in the shutdown’s epicenter. After 14 failed attempts to move the CR in the Senate, the measure was revised to extend federal funding through Jan. 30, 2026, and to reverse the Reductions in Force (RIFs) enacted during the lapse in appropriations. This CR was combined with three additional minibus appropriations packages, which included the Agriculture-FDA bill that funds SNAP and WIC through FY2026. On Nov. 10, the Senate narrowly mustered the 60 votes needed for passage, with eight Democratic senators joining in support. The bill then cleared the House on Nov. 12 with a 222-209 vote, and President Trump signed it the same day. The result of the 43-day shutdown was a deeper and more systemic breakdown. Furloughs and RIFs swept across agencies. Staffing gaps impacted CDC, SAMHSA, and CMS operations, while lawsuits proliferated over withheld pay, suspended contracts, and SNAP payment distribution. As of now, ACA subsidies remain unresolved, and the full repercussions of the 2025 shutdown continue to emerge. A Closer Look at the Shutdown Impacts Furloughs In 2025, the HHS contingency plan anticipated furloughing roughly 41% of its workforce, with CDC and NIH hit hardest — about 64% and 75% of staff, respectively. During the 2018-2019 shutdown, about 48% of HHS staff were furloughed, with CDC at 61% and NIH at 76%. After the 2018-2019 shutdown, Congress enacted the Government Employee Fair Treatment Act of 2019, ensuring that all furloughed federal employees receive retroactive back pay once operations resume. The current CR provides a provision requiring the payment of federal employees who are furloughed or excepted during the lapse. Government contractors, unlike direct federal employees, are not guaranteed back pay after shutdowns. RIFs During the 2025 shutdown, CDC issued more than a thousand layoff notices, some later rescinded, while SAMHSA reported significant workforce losses. There were no RIFs during the 2018-2019 shutdown. In AFGE v. Donald J. Trump, federal-worker unions challenged the administration’s issuance of mass layoff notices during the 2025 shutdown, arguing that RIFs during a funding lapse violate the Antideficiency Act and are “arbitrary and capricious.” A federal judge issued a preliminary injunction blocking further RIFs for hundreds of employees. This case is currently ongoing. To note, as part of the revised aforementioned CR, RIFs issued during this shutdown were reversed, returning to status quo workforce levels prior to the lapse of appropriations. WIC WIC entered October 2025 with funds from Section 32, providing $300 million as a bridge. Nationally, on average, WIC (a discretionary program) needs about $150 million per week to serve approximately 7 million women, infants, and children. To support access, several states tapped emergency funds and reallocated resources to food banks. In early November, the Trump Administration transferred $450 million from unused customs revenue to fund WIC. During the 2018-2019 shutdown, WIC continued to operate without gaps using prior-year funds. SNAP Roughly 42 million Americans currently rely on SNAP benefits. SNAP is considered mandatory spending, which allows payments to continue temporarily during a shutdown, but when a lapse exceeds 30 days, disruption risk escalates. During the 2025 shutdown, EBT payment delays triggered widespread litigation. In Coalition of States v. U.S. Department of Agriculture, over 25 states sued USDA for suspending benefits despite available contingency funds, citing violations of the Food and Nutrition Act and the Administrative Procedure Act. Federal courts issued temporary restraining orders protecting millions of beneficiaries. The administration appealed to the Supreme Court to halt payments, and the Court granted the request. During the 2018-2019 shutdown, SNAP participants received benefits in December 2018 and January 2019. February benefits were also distributed in late January to avoid disruptions; these were not additional benefits. Tribal Health In 2025, the Indian Health Service remained open due to FY2026 enacted advance appropriations. This funding was in part a reaction to the dire consequences of the 2018-2019 shutdown in which the Tribal and Urban health programs reported having to limit health care services and resources, due to Indian Health Service employees having to work without pay or being furloughed. Unique Implications of the 2025 Shutdown As previously noted, because Congress fully funded HHS in 2018-2019 there was minimal impact on public health programs. However, the length and scope of the 2025 shutdown did impact HHS directly. For example: Mental health: Mental and behavioral health access contracted sharply as SAMHSA’s state-support network lost nearly two-thirds of its staff, due to shutdown RIFs as well as earlier rounds of layoffs and retirements. At-home care and telehealth: During the 2025 government shutdown, hospitals nationwide faced delayed Medicare reimbursements and the temporary suspension of hospital-at-home programs, which had become vital for managing capacity during workforce shortages. Telehealth expansion and remote monitoring efforts were also paused, causing many patients to pay out of pocket. U.S. territories: The pause on SNAP and the Nutrition Assistance Program (NAP) funding in November had disproportionate impacts on the U.S. territories, as higher percentages of their populations depend on SNAP and NAP (20%-40%). In three territories, legislatures passed bills to fund partial or full SNAP and NAP benefits for November. Implications for the Future of Public Health The 2025 shutdown underscored that lapses in government funding disrupt the public health ecosystem. A fully functioning system relies on steady collaboration from federal, state, local, and tribal health departments. The depth of the 2025 crisis has ignited bipartisan discussion about structural fixes to prevent governing by brinkmanship. Proposed congressional legislation includes bills to stabilize federal pay with automatic funding, contain congressional travel and adjournment until appropriations are complete, guarantee pay for federal workers and contractors, prevent disruption to SNAP and WIC programs, and ensure reimbursement to states. Padding Block - Large Related Contnet - Blog - Government Shutdown Effects on Public Health article yes

Learn about the importance of exploring intermediaries that work alongside existing data platforms in addressing ongoing public health challenges.

Read about deference to ACIP vaccine recommendations in state and territorial vaccine policy, following recent changes to the committee.

Whether you're a public health professional, policymaker, or member of the media, ASTHO’s communications are your trusted source for timely, expert-driven information.

Past Events Resources Center Welcome to the health equity summit past events resources center. Information about past health equity summits and related series, recordings, and additional resources are available below. website

ASTHO’s 2025 public health blog features articles on policy, innovation, and leadership to support state and territorial health agencies.

ASTHO's hub for public health learning, training, and development resources.

Upcoming Events, Trainings, and Opportunities website

This blog describes FSM’s efforts to improve access to care in some of the most remote and underserved areas of the Pacific.

State and Federal Actions to Reduce Per- and Polyfluoroalkyl Substances’ Impact on Public Health safe drinking water act, per and polyfluoroalkyl substances, water supplies, contaminated groundwater, chemical companies, pfas contamination, forever chemicals, synthetic chemicals, maximum contaminant levels, industrial pretreatment program, polyfluoroalkyl substances pfas, chemical sales, chemical industry, bottled water, safe drinking water act sdwa, unregulated contaminants, companies in the world, united states, consumer products, 1996 amendments, national primary drinking water, surface water, water system, largest chemical companies, pfas strategic roadmap, primary drinking water regulations, pfas chemicals, pfoa and pfos, drinking water, testing for pfas, astho, association of state and territorial health officials Maggie Davis, Beth Giambrone State and Federal Actions to Reduce PFAS Impact on Public Health Since 2018, when the city of Stuart, Florida filed its lawsuit, communities across the United States have filed lawsuits against manufacturers that produce Per- and polyfluoroalkyl substances (PFAS), alleging that they contaminated groundwater and exposed residents to these harmful chemicals. In June 2023, manufacturer 3M agreed to pay at least $10.3 billion to settle the Stuart lawsuit and others across the country with public drinking water systems. Similarly, chemical companies DuPont, Chemours, and Corteva reached $1.18 billion settlement with local communities that have detected PFAS in their water supplies. PFAS are synthetic chemicals used in products like nonstick cookware and firefighting foam, which can migrate to soil, water, and air during production and use. Most of these chemicals remain in the environment without breaking down—hence the nickname “forever chemicals”—and can cause harmful health effects (e.g., higher risks of kidney or testicular cancer, and pre-eclampsia or high blood pressure among pregnant people) and are prevalent across the nation. Evidence shows the widespread nature of exposure to the chemicals and the economic costs of exposure. For example, a 2023 USGS study estimated that at least 45% of tap water nationwide could have one or more PFAS, while recent research estimates the annual cost of the disease burden attributable to long-chain (i.e., six or more carbon) PFAS exposure to be at least $5 billion. As communities seek restitution for PFAS contamination, federal and state policymakers are working to eliminate PFAS from ground water and drinking water and to mitigate exposure to these forever chemicals. Eliminating PFAS in Drinking Water Under the Safe Drinking Water Act, EPA has the authority to regulate the public drinking water supply in the United States. These regulations establish legally enforceable Maximum Contaminant Levels (MCLs) or Treatment Techniques and non-enforceable Maximum Contaminant Level Goals (MCLGs) for public water systems. EPA’s recently proposed PFAS National Primary Drinking Water Regulation could potentially add six different PFAS compounds to the list of regulated contaminants. Within the PFAS chemical family, PFOA and PFOS are proposed to each have MCLs of 4.0 parts per trillion (ppt), while PFNA, PFHxS, PFBS, and GenX would be regulated collectively as a mixture using EPA's Hazard Index approach. The proposed rule also could require public water systems to monitor and notify the public of PFAS levels and reduce the levels in drinking water if they exceed proposed standards. According to a survey conducted by the Environmental Council of the States, state guidelines vary; at least eleven states have established statewide MCLs for PFAS in drinking water. Some states prohibit their agencies from setting standards more stringent than federal ones and, in the absence of a federal standard, state agencies may hesitate to establish one that could easily be invalidated. In other cases, a lack of resources inhibits the agency’s capacity to set and enforce a PFAS standard. When a federal standard is established by EPA’s final rule, expected by the end of 2023, state primacy agencies will need to enforce the federal standard and adopt standards aligned with the federal standard or stronger within two years. Additional State Efforts to Reduce PFAS Exposure Even without MCLs, states are finding ways to mitigate the public’s exposure to PFAS. In 2023, states enacted legislation on banning PFAS in consumer products, increased requirements for testing and reporting of PFAS, and PFAS mitigation. Banning PFAS in Products Indiana enacted HB 1341 prohibiting fire departments from purchasing gear unless it contains a permanent label indicating whether it does or does not contain PFAS as of June 30, 2024. Minnesota’s HF 2310 prohibits selling or distributing products containing intentionally added PFAS beginning January 1, 2026. An exception may be made if the manufacturer submits information to the commissioner of the Pollution Control Agency such as the product, the amount of PFAS used, and the amount of PFAS in the product. The Oregon legislature enacted SB 543, which prohibits the selling or using polystyrene foam containers for prepared food, food containers containing intentionally added PFAS, and polystyrene packaging peanuts. Washington enacted HB 1047, which prohibits manufacturing, distributing, and selling cosmetic products with PFAS and other chemicals or chemical classes as of January 1, 2025. Testing/Reporting Indiana enacted HB 1219, establishing a pilot program that collects blood samples of previous or current firefighters, analyzes the samples for serum PFAS levels, and determines whether there are corresponding health implications associated with elevated serum PFAS levels. Maine’s LD 1248 requires bottlers who extract water from the state to sell as bottled water to test, regularly monitor, and report the presence of PFAS to the Department of Health and Human Services and post the results on a public-facing website. Sales of bottled water are prohibited if PFAS levels in the water source exceed the state or federal community water system standards, whichever is lower. Currently, Maine has an interim MCL standard of 20 ppt. Virginia’s HB 2189 directs the State Water Control Board to adopt regulations requiring industrial users of publicly owned treatment works to test waste streams for PFAS before and after cleaning, repairing, refurbishing, or processing items the user knows or reasonably should know uses PFAS chemicals. West Virginia’s HB 3189 requires its Department of Environmental Protection to identify and address sources of PFAS in raw sources of public drinking water systems. It also requires facilities to report the use of PFAS if they discharge to surface waters under a National Pollutant Discharge Elimination System (NPDES) permit or to a Publicly Owned Treatment Works under an industrial pretreatment program. Mitigation Connecticut enacted SB 100 establishing a PFAS testing account, which provides municipalities with grants or reimbursements for testing and remediating PFAS in drinking water. Maine enacted LD 289, which requires the state to purchase the real estate of a commercial farm found to be contaminated by PFAS before January 1, 2023 at the assessed fair market value but at no less than $20,000 per acre, and provides that the fair market value assessment cannot take PFAS contamination into consideration. Two enacted bills in Rhode Island (SB 724 and HB 5861) amend current law to add that if PFAS in drinking water exceed the state’s interim standard of 20 ppt, the state and the public water supply will enter into an agreement that requires dates for submittal of water treatment plans that will reduce the PFAS levels to or below the interim level. As more information emerges about the health effects of PFAS, states will be sure to continue their work to combat, mitigate, and report on their presence in the environment. ASTHO will continue to monitor and report on all legislative and regulatory activity around this issue. Special Thanks-Blog - State and Federal Actions to Reduce PFAS Impact on Public Health website yes

Whatever stage agencies are in addressing the intersection of suicide, overdose, and ACEs, ASTHO’s SPACECAT Capacity Elements Toolkit simplifies action ideas for health agency staff and leadership to begin or continue their efforts.

In the current legislative cycle, there are several policy strategies that support the development and integration of community health workers into the public health workforce, including dedicated federal funding and state laws supporting workforce development programs, certification standards, and Medicaid coverage.

Six DELPH scholars give their insights to learn more about how the data modernization initiative and DEI intersect with public health.

Forming Partnerships to Increase Rural Immunization Rates ASTHO, Association of State and Territorial Health Officials, national immunization awareness month, farmworker communities, vaccine equity project, increase rural immunization, immunization rates, healthcare access, community action agencies, barriers to vaccine uptake, community partnerships, underlying medical conditions, back-to-school vaccinations, national community action partnership, vaccination strategies, vaccination importance, farmworker communities, challenges to healthcare access, vaccination rates, national center for farmworker health, rural immunization, preventable disease Shalini Nair, Heather Tomlinson ASTHO | Learn how public health partners with community organizations to bring vaccines to rural communities that otherwise would have difficulty accessing care in this blog. Rural communities face many challenges in accessing health care, like limited provider availability, gaps in insurance coverage, transportation issues, language barriers, and limited internet access. Additionally, rural populations are more likely to have underlying medical conditions, less likely to have insurance, and live farther from medical facilities. During the COVID-19 pandemic, overall routine vaccination coverage remained stable; however, there was a notable 4–5% drop in vaccination rates among young children living below the federal poverty level and in rural areas. In response, CDC developed the Let’s Rise initiative and a back-to-school campaign to provide actionable strategies and resources for getting Americans back on schedule with their routine vaccines. This month is National Immunization Awareness Month, highlighting the importance of vaccination for people of all ages. Boosting vaccine access and confidence is crucial to limit the spread of vaccine-preventable diseases. Barriers to Vaccine Uptake While they only account for 14% of Americans, rural communities represent nearly two-thirds of primary health care shortage areas. Due to the lack of providers, rural Americans often live over 10 miles from their closest health care facility and do not always have access to reliable transportation. Additionally, rural communities also have a larger proportion of people who are uninsured and underinsured. Studies have shown that primary care visits and strong provider recommendations can greatly enhance utilization of preventative health measures, such as vaccination, while limited access to these aspects can reduce health outcomes. The COVID-19 pandemic exacerbated this disparity as many rural hospitals closed and the country faced national workforce shortages. Rural communities were significantly impacted, with 76% of rural adults knowing someone who had COVID-19 and 38% contracting COVID-19 themselves. Despite this impact, the majority of those polled reported this did not change their intent to get vaccinated. Furthermore, the gap in COVID-19 vaccination coverage between urban and rural areas more than doubled between April 2021 and January 2022, despite rural communities having disproportionately higher COVID-19 disease incidence and mortality. The digital divide also limits access to accurate information on the safety and efficacy of vaccines. States and community groups have taken various actions to address these barriers. Successful Strategies to Address Low Vaccination Rates in Rural Communities With support from CDC, ASTHO is working with the National Community Action Partnership and five community action agencies (CAAs) on the Partnering for Vaccine Equity project. A recent blog showcases some of the work the CAAs have implemented to improve vaccine acceptance and uptake and to customize evidence-based strategies to their own communities and neighborhoods. Two project partners, Pickens County Community Action and Enrichment Services Program, are working to build trust and increase vaccine uptake in rural Alabama by leveraging existing networks and taking a whole-health approach to outreach efforts. In Russell County, Enrichment Services deployed a highly successful paper- and social media-based messaging campaign centered around messages that emphasized three points: Vaccines are Safe, Vaccines Save Lives, and Vaccines Save Money. By reaching out to local churches, Enrichment Services was able to greatly expand the reach of their health promotion messages. In addition, to increase the number of available access points for vaccination, Enrichment Services co-located outreach at schools and engaged local EMT representatives from the National Association of Emergency Medical Technicians for their first-hand knowledge of the community. Sample graphics from Enrichment Services' vaccine equity messaging campaign. In Pickens County, Pickens Community Action relied on existing partnerships with over 30 community organizations to kickstart their vaccine equity efforts. To address access-related barriers, Pickens sponsored rides to and from their vaccine clinics and partnered with local physicians to provide personalized counseling to individuals receiving vaccinations. Notably, they established both a faith-based and a disability services advisory committee to further assist their outreach efforts. Some of their existing partners in the community include the local National Association for the Advancement of Colored People (NAACP), the Black Belt Community Foundation, Whatley Health System, Hill Hospital of Sumter County, The University of Alabama, and elected officials. Left: A food table being set up for Pickens’ Community Health Fair at the Tom Bevill Lock and Dam in Pickensville, AL. Right: A mobile outreach van from partner the University of Alabama rolls in to assist at Pickens’ Community Health Fair. For both agencies, offering services that address the social determinants of health greatly increased engagement. Both sites found success in offering incentives—such as food or gas gift cards and free food giveaways—but their greatest success has been from co-locating vaccine events with service offerings that address essential needs such as housing, utility assistance, or education. This model has proven highly successful not only for COVID-19 vaccines, but also as a sustainable strategy for general vaccine outreach. Increasing Vaccination Rates in Farmworker Communities Numerous successful strategies have been implemented in rural communities largely comprised of immigrants—with a special focus on migrant farmworkers, who labored throughout the pandemic due to the critical nature of their work. In addition to facing barriers related to transportation, health insurance, and language access, many farmworkers are not able to visit a clinic or pharmacy due to their long working hours. The National Center for Farmworker Health, in collaboration with CDC and over 40 different organizations, worked to diffuse funding, trainings, and tools for building capacity to act during the public health emergency. This network generated over 1.3 million COVID-19 related educational interactions with farmworkers and supported the distribution of over 108,000 COVID-19 vaccine doses during 2020 and 2021. The network also documented effective practices undertaken by community-based organizations and agricultural employers to distribute vaccines, dispel myths, and build vaccine confidence. Photos courtesy of the Guatemalan-Maya Center (left) and National Center for Farmworker Health (right). State Considerations for Implementation Collaboration with trusted community groups can amplify state efforts to vaccinate communities, particularly in those with low vaccination rates. Working with CAAs and organizations that understand their communities and utilize innovative outreach strategies can help states expand the reach of their messaging. Communications should be tailored to include multilingual messaging and images that resonate with targeted communities. The National Governors Association developed a guide that provides valuable strategies for states to increase vaccine uptake in their rural communities. To help address the digital divide in their communities, several states have made investments in their digital infrastructure. Partnering with local pharmacies, federally qualified health centers, and emergency medical services to offer alternative vaccination sites in communities has been integral in improving awareness and access. Holding mobile vaccine clinics with after-hours availability or offering transportation to and from vaccine clinics can help address transportation issues and make vaccines accessible in communities with limited health care facilities. Addressing immunizationinequities in rural communities requires understanding the community and implementing innovative strategies tailored to these populations. Partnering with community-based organizations can help states reach critical audiences and ensure that vaccine efforts are addressing relevant barriers. article yes

As the overdose epidemic continues, it is imperative for the medicolegal death investigative community to understand the importance of continuous training and the role that accurate death certification plays in protecting the nation’s health.

Sandra Powell, deputy director of Rhode Island Department of Health, how her department was able to increase the number of permanent positions to meet critical public health needs.

As AI adoption grows in public health, understanding its uses and ensuring responsible application are key to protecting privacy, minimizing bias, and improving outcomes.