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Continuing ASTHO’s Legislative Prospectus series—which highlights the top 10 public health policy issues for 2022—this post focuses on mental and behavioral health, as well as supporting the public health workforce.

Each year, ASTHO notes the top public health policy issues to watch in the upcoming year. Per- and Polyfluoroalkyl substances are synthetic chemicals that can migrate into soil, water, and air during production and use, and can accumulate in the blood of people and animals over time from exposure.

Do Cottage Foods Really Come from a Cottage? Beth Giambrone Even if you're not familiar with the term "cottage foods," chances are you have purchased them—think getting a loaf of bread from your weekend farmers market or cookies from a friend's home-based baking business. In some cases, they can also be sold online. So, what exactly are they? Cottage foods are home-based, home-made food products prepared outside a commercial kitchen and sold to the public. Cottage food producers operate at a small scale, often from a home kitchen, selling goods in the jurisdiction where they are created. Cottage foods are exempt from many state food and safety regulations, with supporters of expanding cottage food laws asserting that existing laws burden small business and restrict competition and consumer freedom. Those opposing the expansion of cottage foods argue the need to ensure food safety and to protect consumers from food borne illness. Here's a primer on cottage foods and how they're regulated. What's the difference between a cottage food kitchen and a commercial kitchen? Commercial kitchens (sometimes known as shared use kitchens) are large, industrial spaces where food can be produced in high volumes; they can also be rented out for shared use. While every state subjects commercial kitchens to food safety inspection and regulations, a few states require inspection of microenterprise or home kitchens producing cottage foods. Does the government have a role in regulating cottage foods? While several federal agencies regulate commercial food products—such as USDA for meat processing and FDA for produce—cottage foods are not subject to federal regulation because they are typically only sold within a state and not across state lines. At the state level, cottage food producers are subject to the health and safety laws and regulations of the state in which they are operating. Some states require cottage food producers to register their business or to have training and/or certification in safe food handling. Currently, all 50 states and Washington D.C. have some sort of cottage food law in place. Under most state laws, cottage food producers are exempt from food safety laws that apply to food establishments. These exempt rules are usually based on the type of food product produced, the point of sale, and the labeling requirements associated with the food. Although cottage food producers are exempt from certain requirements, all states allow the Department of Health to investigate complaints related to foodborne illness and fine producers if there are violations. Since the 2020 legislative sessions, at least 17 states (Alabama, Arkansas, California, Connecticut, Florida, Iowa, Illinois, Maryland, Missouri, Mississippi, New Hampshire, New Jersey, Oklahoma, Tennessee, Utah, West Virginia, and Wyoming) considered bills related to cottage foods, often centering around product sales, food products, and labeling. An overview of the conditions and a snapshot of the laws passed in states are below. What are common cottage food products? Most state laws limit which food products can be produced and sold as cottage foods. And while specific allowable foods vary state to state, some common restrictions on the type of food sold include foods requiring temperature control (e.g., meat and dairy products) and fermented or pickled foods. Foods such as dairy-free baked goods (e.g., breads and biscuits), candies, and jams are popular cottage food products. Over the last few years, states have expanded the types of foods that qualify to be a cottage food. In 2021, Illinois enacted SB 2007, amending the types of foods permissible under the cottage food law from a delineated list of canned foods (e.g. jams and syrups) to a general standard that mirrors the FDA definition of "low-acid canned food." The New Jersey legislature passed A 3991 in 2022 to exempt raw, unprocessed honey from the state's cottage food regulations. The bill is currently awaiting action by the governor. Oklahoma enacted its "Homemade Food Freedom Act" (HB 1032) in 2021. This new law allows any packaged food or beverage (excluding alcoholic beverages, unpasteurized milk, or cannabis products) to be considered a cottage food rather than only baked goods made without meat or fresh fruits. Additionally, the law allows beekeepers who produce less than 500 gallons of honey per year to qualify for the state's food freedom exemptions if the honey is produced from hives located in the state and sold directly to the consumer. Similarly, the 2022 "Tennessee Food Freedom Act" (HB 813/SB 693) broadly expands the types of homemade foods eligible for sale under the cottage food law to include any non-time/temperature-controlled food item or non-alcoholic beverage. What limitations do states place on cottage food sales? Most states limit cottage food producers to direct-to-consumer sales, such as at a farmers market or roadside stand. More than half of states allow online and direct-to-consumer sales as long as they are to in-state consumers only. While the producer is usually required to deliver the products, at least five states allow delivery by a third party. Several states have considered allowing the sale of cottage food in retail settings. In 2020, Wyoming enacted HB 84, which increased the gross sales cap for producers and allowed producers of non-temperature controlled foods (e.g., jams, vegetables, dried soup mixes) to use third-party vendors like a retail shop rather than solely relying on gross sales. Furthermore, the Wyoming legislature expanded the use of third-party vendors to include the sale of eggs in 2021 by enacting HB 118. A 2021 Arkansas law (HB 248) also allows for the sale of cottage food products at retail stores. Additionally, many states define cottage foods based on the number of items sold or the annual gross sales. The gross sales cap limits vary greatly across states, ranging from $3,000 to $250,000. At least twenty states have no gross sales limit. At least one state (Ohio) places a limit on meals sold per week from home kitchens. What are common labeling requirements for cottage foods? Most states require cottage food producers label their goods. While specific labeling requirements vary state to state, producers generally must provide the name of the product, a list of ingredients, known allergens (e.g., nuts), contact information of the producer, and a statement declaring the product was made in a kitchen exempt from licensing and inspection regulations. In some states, cottage food producers are allowed to use an identification number in place of contact information on product labels. Maryland enacted HB 1017 in 2020, which allows cottage food producers to use a unique identification number issued by the Department of Health in lieu of the business name and address. Arkansas HB 248 (referenced above) also allows producers to use an identification number. What's next? State policy surrounding cottage foods is constantly evolving, with more foodstuffs exempt from state food and safety regulations increasing the risk of foodborne illness outbreaks necessitating a public health response. ASTHO will continue monitoring these changes and provide relevant updates. website yes

The recent mass shootings in Buffalo, Uvalde, and elsewhere across the country, have drawn renewed attention to firearm violence as a major public health issue in our nation. It’s a particularly important issue to consider during Men’s Health Month because men are disproportionately victims and perpetrators of firearm violence.

Research confirms that strengthening economic supports can improve parental mental health, children’s health, education, and social outcomes.

State Policies Promote the Importance of Defibrillators and CPR astho, association of state and territorial health officials, automated external defibrillators, heart disease, cpr training, defibrillators and cpr, cardiac arrest, coronary artery disease, sudden cardiac arrest, ventricular fibrillation, heart failure, heart muscle, perform cpr, heart attack, shocks to the heart, heart problem, electrical system, blood vessels, united states, automated external defibrillators, call 911, heart rhythm, cardiopulmonary resuscitation, chest pain, pump blood, cardiac arrest occurs, blood flow Lana McKinney Health Policy Update | Reviewing state policies that promote increased access to Automated External Defibrillators and use of CPR. Heart disease remains the leading cause of death in the United States for men, women, and most ethnic groups—even during the COVID-19 pandemic. And while overall rates of death from heart disease have declined over the past couple of decades, non-Hispanic Black persons are more likely to die from heart disease than other racial and ethnic groups. Additionally, more than 400,000 cardiac arrests occur annually outside a hospital setting.  CDC recently revised its Best Practices for Heart Disease and Stroke, highlighting strategies to improve cardio- and cerebrovascular health. One goal is to increase public access to automated external defibrillators (AEDs). Early use of AEDs by bystanders or emergency medical technicians during out-of-hospital cardiac arrest has been shown to improve survival rates to greater than 50%; those rates can triple if CPR is performed within the first few minutes of cardiac arrest.  Policies to develop and maintain public access to AEDs and CPR training are crucial. Across the country, state legislatures are enacting or considering legislation related to AEDs and CPR that enhance bystander response to cardiac events and improve the chance of survival of persons who experience cardiac arrest. As policymakers develop and adopt these measures, they should also consider health equity and data implications. Legislative Actions to Increase AED Access and CPR Training  So far in 2023, several states have introduced legislation to require the placement of AEDs in certain publicly accessible locations, including highway rest areas (WV HB 3038), county government buildings (MA HD 1842), all public safety vehicles (MA SD 2342), hotels (NJ A 5105), urgent care and retail health clinics (NJ S 1768), and health clubs (MA HD 2574). Additionally, at least four states—Massachusetts (HD 774), Mississippi (HB 203), Missouri (HB 426), and New York (S 1698)—have introduced legislation requiring AEDs in schools this year. New York also proclaimed a CPR-AED Awareness Week. Although relatively uncommon, an estimated 2,000 children each year die from sudden cardiac arrest. As of 2021, 39 states and Washington D.C. required CPR training for high school students. In 2023, at least four states have introduced bills to expand CPR certification and AEDs training. These include a bill to further expand high school education on CPR and AEDs (OK SB 236), and a bill that requires every public and charter school in the state to (1) have at least one employee with a valid CPR certification and (2) to provide annual CPR training for all high school personnel and students (AZ HB 2421).  In Colorado, SB 23-023 encourages each public school to provide CPR and AED instruction to students in grades nine through 12. West Virginia introduced SB 469 to establish a revolving loan fund that provides funding for CPR instruction to high school students. Meanwhile, California legislators are considering   AB 245 to update school-based CPR and first aid training by adding a requirement to rehearse the appropriate responses to the signs and symptoms of concussions, heat illness, and cardiac arrest. Challenges of Equity in CPR and AED training   As the evidence base about the impact AEDs and CPR have as lifesaving measures for cardiac arrest continues to build, the equitable distribution of AEDs equipment, its maintenance, and training for AEDs must also be considered.  Strategies that optimize the location of public access AEDs based on the risk of cardiac arrest associated with the site can help improve accessibility. Such registries can inform the public and emergency dispatchers of the location of publicly accessible AEDs to facilitate use during an emergency. Registries may also contribute to improving AED readiness by informing owners and managers when batteries and pads need replacing.  In 2018, CDC issued a report providing evidence about the training of responders, and the placement and maintenance of AEDs. While jurisdictions recognize the importance of AED devices, their affordability is a continuing concern.  Further Considerations  Understanding how to best measure and influence cardiac event outcomes and their contributing factors is critical to informing policy decisions. There are several ongoing challenges to understanding the national epidemiology of cardiac arrest, including the incidence and outcomes of out-of-hospital cardiac arrest and the reporting of such events. Additional knowledge is needed about out-of-hospital cardiac arrest key components such as geographic incidence, risk factors, and the impacted populations.  Valid data can advance and improve health outcomes by providing appropriate resource allocation and evidence-based service provision. Despite being one of the leading causes of death, there are currently no nationwide standards for surveillance to monitor the incidence and outcomes of cardiac arrest. Public health officials can help policymakers by reviewing their jurisdictions’ current AED laws and by increasing awareness of the positive impact AED policies and CPR training have on responding to a cardiac arrest. Bystanders can improve the survival rate of a person who is experiencing sudden cardiac arrest with increased public access to AEDs and additional CPR training.  Overall, additional policy actions to support AED availability and CPR training will continue to improve health outcomes. It is important to continue to acknowledge American Heart Month and all the improvements policy makes to save lives. Special thanks to ASTHO’s Erin Bayer, Senior Director of Chronic Disease Prevention and Health Improvement and Andy Baker-White, Senior Director of State Health Policy, and Erin Gabert of the American Heart Association for their contributions to this blog post. article yes

Discussing midterm election effects on public health policy and committees.

At ASTHO, we feel that it is incumbent upon us to build diversity, equity, and inclusion into all that we do at. That goal has involved a collaborative effort with executive leadership, human resources, and the Health Equity and Diversity Initiatives team.

Let us make 2023 the year we commit even more to listening to and learning from each other and transforming how we interact with those around us in ways that truly impact state and territorial health agencies’ work of health promotion and disease prevention.

Cultivating Gen Z as Partners for Healthier Communities astho, association of state and territorial health officials, gen z, young adults, public health campaigns, stronger communities, public health, physically active, gen zers, adults ages, pew research center, members of gen, united states, young adulthood, young people, baby boomers, diverse generation, local communities, digital natives, age 18, people born, entered the workforce, previous generations, birth years, social media, health care, older generations Brandi Hight Bank, Emily Bonaparte, Nick O’Toole ASTHO | The importance of engaging and recruiting Gen Z in public health workforce. As seen in the midterm election results, young adults in Gen Z are a powerful, growing force in electoral politics and our communities. One in every eight voters in this past mid-term election was under age 30. Public health leaders are wise to communicate with this group, as a constituency whose interests—be it climate, economic security, or racial and ethnic equity—often align and intersect with public health. The COVID-19 pandemic introduced many young people to public health for the first time as they witnessed and participated in local response. Interest in public health careers has grown over the past decade, but the desire to contribute spiked during the pandemic. In fact, applications to public health graduate programs applications rose more than 40% in 2021 compared to 2020. Taking stock during pandemic recovery and preparing for the challenges ahead, it is a unique moment to build and strengthen trust in public health with young adults. Why Connect with Young Adults More than 40% of the U.S. population—140 million Americans—is either in the Millennial (born from 1981-1996) or Gen-Z (born 1997-2012) cohort. Not only do young adults have significant influence over our collective future, they also have an uncharacteristically large stake in shaping that future. Debt, the climate crisis, and rapid technology shifts are just a few of the pressing issues waiting for them as they enter the workforce. Young adults are at a nexus of being both digitally native and highly concerned with societal woes. Given their heavy online presence, young adults are a critical audience for public health messaging and a potential powerful amplifier of behavior change and key messaging. Concern over major issues (e.g., mental health care, economic inequality, and racism) primes young audiences to be more aligned with organizations that have a strong mission statement and are passionate about the global good. How To Reach Young Adults It’s not news that young adults spend much of their time online. Young audiences expect public health campaigns to mirror their experience as a consumer, and public health leaders should be familiar with how to develop digital-first approaches. Going digital shouldn’t preclude partnerships and in-person events, but a strong online presence amplifies community engagement. It’s important to define your audience and which platform best reaches them. Snapchat, TikTok, and Instagram rank highest in usership for young audiences, while Baby Boomers (or, simply Boomers) mostly utilize Facebook and YouTube. It’s critical to know both which platforms to use and how to convey your message. A few rules include: Make content digestible, visually appealing, mobile friendly, and video-based. Engage young audiences in co-creating products and messages on issues that affect them. Ask engaging questions, use hashtags, and invite engagement with your organization. Don’t be afraid to think outside the box! Consumer brands often create a noisy online environment and best practices mandate a social media presence. It’s more important than ever to ensure audiences can hear your “voice” and find your content. Luckily, public health officials have two important tools: authenticity and a social mission that naturally connects with many Millennials and Gen Z. These are strong competitive advantages that allow public health messaging to resonate with young audiences and cultivate their trust and engagement in building healthier communities. website yes

ASTHO blog post from Mike Fraser thanking the tireless public health workforce.

ASTHO’s Leadership Trailblazers series shares outstanding public health leaders’ inspirations, motivations, and accomplishments. This post features Jay C. Butler (alumni–AK), Deputy Director for Infectious Disease at CDC.

ASTHO Statement on Appointment of Texas Commissioner Jennifer Shuford, MD, MPH, as CDC Deputy Director ASTHO Statement on the Appointment of Jennifer Shuford as CDC Deputy Director ARLINGTON, VA — The Association of State and Territorial Health Officials (ASTHO) issued the following statement after the appointment of ASTHO board member and Texas Department of State Health Services Commissioner Jennifer Shuford, MD, MPH, as CDC deputy director and chief medical officer: “We applaud the appointment of Dr. Shuford to serve as deputy director and chief medical officer for CDC,” says ASTHO CEO Joseph Kanter, MD, MPH. “She is widely respected within the public health and governmental leadership communities. As the current commissioner of the Texas Department of State Health Services and a valued member of the ASTHO board of directors, Dr. Shuford has demonstrated exceptional leadership and a steadfast commitment to evidence-based public health. Her experience leading one of the nation’s largest and most complex state health agencies — particularly her work as a frontline infectious disease physician and chief state epidemiologist — makes her uniquely qualified to help lead CDC.” “Dr. Shuford understands the vital relationship between federal, state, local, territorial and tribal public health departments. We are confident that her clinical expertise and proven track record in crisis management and health promotion will be invaluable assets to CDC and the nation,” Kanter added. Dr. Shuford graduated from Colorado College in Colorado Springs with a bachelor’s degree in chemistry. She received her Doctor of Medicine degree from the University of Texas Southwestern Medical School. She completed an internal medicine residency at Presbyterian Hospital of Dallas, where she served as chief resident. Dr. Shuford completed an infectious disease fellowship at the Mayo Clinic in Rochester, Minnesota, and earned her Master of Public Health degree from the Harvard School of Public Health. Dr. Shuford serves on the faculty of the DSHS Preventive Medicine and Public Health Residency Program. She is a member of the Travis County Medical Society, the Texas Medical Association, and the Infectious Diseases Society of America. ASTHO Press Release Boilerplate website yes

ASTHO Members Advocate for $1 Billion Investment in Public Health Infrastructure During Annual Spring Leadership Forum ARLINGTON, VA — The Association of State and Territorial Health Officials (ASTHO) will convene state, territorial and freely associated state health leaders in Washington, D.C., March 2-5 for its annual Spring Leadership Forum. Attendees will meet with members of Congress and federal partners to advocate for sustained funding and long-term investments in the nation’s public health infrastructure. During meetings, ASTHO members will stress the importance of a strong, resilient public health system. ASTHO urges Congress to invest $1 billion in FY27 in public health infrastructure — or about $3 per person nationwide — to ensure health agencies can maintain core capabilities such as disease surveillance, laboratory capacity, data modernization and workforce development. “This week, ASTHO members will meet with Congress to highlight the essential role federal funding plays in protecting the health of communities in every state and territory as well as the impact of grant pauses and terminations,” says Joseph Kanter, MD, MPH, ASTHO CEO. “Sustained, predictable investments allow health agencies to maintain the workforce, laboratories and data systems that keep the public healthy and safe.” As part of this convening, senior leadership from the U.S. territories and freely associated states (T/FAS) will participate in island-focused meetings. On Capitol Hill, ASTHO’s T/FAS members will discuss the impact of the recently renegotiated Compacts of Free Association, as well as emphasize the importance of territorial Medicaid funding and the challenges associated with the Section 1108b cap on territorial Medicaid funding. With federal agency partners, T/FAS members will discuss emerging and priority public health issues, including veterans' access to care. "ASTHO’s Spring Leadership Forum offers an invaluable platform for T/FAS health leaders to engage directly with decisionmakers in Washington, D.C. We welcome the opportunity to share island perspectives and collaborate with Congress and federal agencies on shared public health priorities," says Justa Encarnacion, RN, MBA, HCM, the commissioner of health in the U.S. Virgin Islands and director on the ASTHO Board. ASTHO Press Release Boilerplate website yes

ASTHO Partners with Veritas Data Research and HealthVerity to Launch the First-of-its-Kind Public Health Data Consortium ARLINGTON, VA — The Association of State and Territorial Health Officials (ASTHO) announced today a partnership with Veritas Data Research and HealthVerity that establishes a first-of-its-kind public health data consortium. This novel consortium brings together ASTHO, jurisdictional health departments and private partners united in a shared mission to improve public health outcomes through enhanced data access and quality, and to address long-standing challenges that hinder our nation’s public health data infrastructure. “There is tremendous opportunity when we connect the strengths of private industry with the mission of public health,” said Joseph Kanter, MD, MPH, ASTHO CEO. “By working together in a structured way, we can close long-standing data gaps and build a stronger, more responsive system for the future.” The consortium’s central mission is to improve the quality of and access to real-world data and public health data relied upon by a broad range of stakeholders to drive public and population health decisions and understand longitudinal outcomes. State health agencies, providers, payers, researchers, and others rely on this data, which is often difficult to obtain. Through this public-private partnership, members aim to expand access in ways that strengthen communities and support health care and public health systems. “Our nation and communities need a robust, sustainable model that leverages the capabilities and expertise across both private industry and public health. For too long, there have been challenges in bringing private and public entities together to address the gaps that plague our nation’s public health data and technology infrastructure,” said Jen Layden, MD, PhD, ASTHO senior vice president of population and innovation, and former CDC and state public health leader. “This consortium, by uniting on a common mission and placing governance in the hands of public health, is primed to be a game changer.” Jurisdictional health departments will gain access to real-world data and technical capabilities and will play a key role in strengthening the quality and availability of critical data. The consortium will initially focus on mortality data, a foundational asset for a variety of use cases. "This consortium represents an excellent example of public-private partnerships in healthcare," said Jason LaBonte, CEO at Veritas Data Research. "Under the governance of ASTHO, all state and territorial health agencies can securely pool their data to improve clinical practice and innovation. In return, the agencies can combine their data with national real-world data to power better public health. Veritas is pleased to facilitate these data exchanges using our robust ingestion and delivery platform, and to make appropriate data available to a wider group of stakeholders with use cases pre-approved by the state and territorial health agencies.” “We are proud to serve as a founding operating partner, applying our expertise in identity resolution and data privacy to solve the 'linkage' problem that has long plagued public health,” said Andrew Kress, CEO of HealthVerity. “Through this consortium, we are enabling a standard of data exchange that respects patient privacy while providing a level of clinical truth that will accelerate research and improve the speed of public health interventions.” To support the consortium, ASTHO is creating an advisory network to provide organizations with opportunities to stay informed and offer guidance as the initiative evolves. To learn more about the consortium or advisory network, please contact phdc@astho.org. ASTHO Press Release Boilerplate   Veritas Boilerplate   HealthVerity Boilerplate website yes

Public Health Review Public Health Review Podcast Public Health Review is our podcast that features public health and thought leaders who tackle everyday issues impacting the communities they serve. The series capitalizes on current public health trends and provides listeners with valuable information. Over the years we have explored innovative topics ranging from time-sensitive updates on COVID-19 related concerns to social and behavioral health, emergency preparedness, infectious disease, environmental impacts, and health disparities. We also help listeners stay informed by answering driving questions like the future of health care and the public health workforce, how COVID-19 has affected the mental well-being of the population, and what roles governments should play in ensuring public health safety. Our guests include state and territorial health leaders, health agency staff, federal government officials, and ASTHO leadership. Listen on Apple Podcasts, Amazon Music, and Spotify. website

In this episode of the Public Health Review, learn about the accomplishments of the Healthy Brain initiative inaugural cohort, working to enhance brain health.

A Blueprint for Establishing a Health Equity or Minority Health Office 30:37 minutes Learn how to form and manage an office of health equity or minority health, based on several firsthand experiences. Listen to the podcast episode now. <!-- Podcast Embed ep 93 --> There are many considerations when forming and managing an office of health equity or minority health. The National Association of State Offices of Minority Health shares how agencies across the United States have overcome common challenges and benefited from having a dedicated health equity office. In addition, the United States Virgin Islands Department of Health discusses initial successes and challenges experienced while establishing their office. Finally, the California Department of Public Health, with a well-established office of health equity, shares how their office utilized health equity liaisons and supported rural/tribal communities. This podcast episode complements the recently published ASTHOReport “Establishing an Office of Health Equity or Minority Health,” which examines different approaches to sustainability. Show Notes Guests Rohan Radhakrishna, MD, MPH, MS, Former Deputy Director and Chief Equity Officer, California Department of Public Health Justa Encarnacion, RN, MBA, HCM, Health Commissioner and Chief Public Health Officer, United States Virgin Islands Department of Health Veronica Halloway, Executive Director, National Association of State Offices of Minority Health Resources Establishing an Office of Health Equity or Minority Health | ASTHO Islands Health Equity Framework | ASTHO Office of Health Equity | California Department of Public Health United States Virgin Islands Department of Health National Association of State Offices of Minority Health Podcast Transcript ep 93 website yes

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In this episode of Public Health Review learn how different states maximize federal and state programs for improved housing, transportation, and other social determinants of health.