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This ASTHOReport serves as a primer for state and territorial health agencies seeking to assess the public health impacts of lead exposure in drinking water.

Under the Tenth Amendment, states have the power to protect the health and welfare of their populations, including the authority to implement isolation and quarantine orders to limit the spread of disease. This post is an examination of state public health authority for isolation and quarantine.

Anticipating a rapid deployment of COVID-19 vaccines as they are authorized, the CDC developed COVID-19 Vaccination Program Operational Guidance in collaboration with state and local jurisdictions to outline how each jurisdiction will make an authorized vaccine widely available. In addition to the operational plans, there is a legal framework of federal and state laws supporting the distribution and administration of the FDA-authorized vaccines.

The 2020 holiday season is coinciding with a nationwide surge of COVID-19 cases. With great concern that holiday travel to see loved ones may exacerbate community spread of the virus, many states are increasing public health measures before the winter holiday season. As of November 16, 2020, 13 states and D.C. had a quarantine requirement for out-of-state travelers. The U.S. territories also have instituted travel restrictions to limit the spread of COVID-19.

Several states and territories, as well as many local governments, are going beyond recommendations and requiring individuals to wear face coverings when they are in public settings and spaces (i.e. grocery stores, retail stores, restaurants, public and private transportation services, parks, etc.). Ongoing research and evidence suggests the relationship between mandatory face coverings and declines in daily COVID-19 growth rates is statistically significant.

How the Emergence of Xylazine Impacts Overdose Prevention Policy overdose prevention policy, overdose crisis, fatal overdoses, emergence of xylazine, illicit drug supply, toxicological testing, withdrawal symptoms, xylazine test strips, drug paraphernalia laws, drug checking, legislative action, drug supply, substance use disorders, controlled substance, opioid use disorder, centers for disease control, health care, harm reduction services, psychoactive substances, department of public health, illegal drug, type of drug, opioid crisis, prescription opioid, astho, association of state and territorial health officials JoAnne McClure, Victoria Pless How states are considering overdose policy changes as xylazine continues to emerge in the illicit drug market. Developing and adopting policies to reduce fatal overdoses can help public health leaders address the ever evolving and complex national overdose crisis. More than 109,000 fatal overdoses occurred in 2022, with the majority involving illicitly manufactured fentanyl. Adding to the overdose challenge is the emergence of xylazine, a non-opioid tranquilizer (i.e., sedative), that is being increasingly mixed with fentanyl in the illicit drug supply. As of November 2022, xylazine was found in the illicit drug supply in 48 of 50 states and Puerto Rico. Xylazine is currently associated with one in ten fatal fentanyl (11%) overdoses, a near-threefold increase from 2.9% in 2019. Toxicological testing for xylazine is not uniform and, as a result, its involvement in fatal overdoses may be underestimated. Some states have taken initiatives such as Indiana (HB 1286) and South Carolina, to improve the consistency of toxicological testing for xylazine. With xylazine’s addition to the overdose crisis, states are beginning to adopt laws to better regulate the supply of xylazine and detect its presence in the illicit drug supply. What is Xylazine? Xylazine, also known as “tranq” or “tranq dope,” is a central nervous system depressant causing drowsiness, slowed breathing, reduced heart rate, and hypotension, which can increase the risk of a fatal overdose. Xylazine is approved for veterinary use in the United States but is not FDA-approved for human medicine. Xylazine, can be added to substances that are ingested orally, snorted, sniffed, or—mostly commonly—injected intravenously, and has been added to or used to cut heroin and fentanyl to prolong their effects. People who use drugs may be unaware of xylazine’s presence, which can put them at a higher risk of fatal overdose. Xylazine use is associated with skin ulcers, lesions, abscesses that left untreated, can lead to amputation. People who develop a physical dependency on xylazine may develop severe withdrawal symptoms. Although symptoms of xylazine use and opioid use are similar—making it difficult to differentiate whether someone has used one or both substances—overdose reversal agents (e.g., naloxone) do not counteract the effects of xylazine. Public health leaders still recommend that naloxone be administered for a suspected opioid overdose because xylazine has been detected in substances alongside fentanyl. For a person experiencing a xylazine-involved overdose, public health leaders emphasize the need to seek treatment beyond naloxone. In addition to public health’s work to address xylazine in the illicit drug supply, some state and territorial legislatures are expanding or protecting access to xylazine test strips as well as steps to limit access to xylazine through the state drug schedule. Legalizing Drug-Checking Equipment Drug-checking equipment, such as fentanyl test strips, are evidence-based interventions that allow a person who uses drugs to test their supply for an adulterated substance. State drug paraphernalia laws historically prohibited drug checking equipment, limiting the possession, distribution and use of items like fentanyl test strips. To make fentanyl test strips more widely available to prevent overdose, legislatures rapidly changed their laws to either explicitly legalize fentanyl test strips or generally legalize drug checking equipment. As of July 5, 2023 more than 33 jurisdictions legally authorize the use of fentanyl test strips, 12 of which (Alaska, Colorado, Guam, Maine, Maryland, Nebraska, New York, the Commonwealth of the Northern Mariana Islands, Pennsylvania, South Carolina, Utah, and Vermont) generally authorize the possession and use of drug-checking equipment. Similar to fentanyl, people may not know whether they are exposed to xylazine when using other substances, increasing the risk for harm. New test strips can detect the presence of xylazine, however state drug paraphernalia laws that criminalize drug checking equipment may limit the accessibility of xylazine test strips to prevent overdose. In 2023, at least three states—Illinois (HB 3203), New Hampshire (HB 287), and Utah (SB 86)—enacted legislation to authorize or decriminalize use of drug-checking equipment for fentanyl and xylazine, ensuring that xylazine test strips are lawful and able to be distributed. Additionally, states that previously passed legislation to allow for fentanyl-specific drug checking are amending their statutes to include all drug checking to ensure the legal possession of xylazine test strips. For example, Delaware enacted (SB 189) that specifically legalized xylazine test strips. Two other states—Vermont (H 222) and New Jersey (SB 3957)—enacted laws expanding the authorization of fentanyl test strips to allow for all harm reduction supplies, including drug checking equipment, which would permit the use of xylazine test strips. The Question of Scheduling Drugs are scheduled based on their acceptable medical use and potential for misuse and severe psychological and/or physical dependence, with drugs in Schedule I being the most tightly regulated. Xylazine is not a controlled substance under the federal Controlled Substance Act so it is not DEA scheduled or controlled. Nevertheless, xylazine is subject to FDA regulation under the federal Food, Drug, and Cosmetic Act and state law. Prior to 2023, only two states directly or indirectly scheduled xylazine. Florida codified xylazine as a Schedule I substance in 2016, and xylazine could fall under Massachusetts’ Schedule VI designation, which applies to prescription drugs. As state and territorial leaders take steps to schedule xylazine, policymakers should consider whether scheduling or other criminal penalties will deter people from seeking care if they fear being arrested for unknowingly testing positive for exposure or xylazine use. Another consideration for leaders before scheduling xylazine is whether scheduling will also make possession of test strips illegal under the jurisdiction's drug paraphernalia law. In 2023 at least nine states–Delaware (SB 189), Illinois (HB 3873), Louisiana (HB 106), Michigan (HB 4913), New Jersey (A 5448), New York (A 5914), Oklahoma (SB 668), Rhode Island (HB 5922), and West Virginia (SB 546)—considered legislation to schedule xylazine as a controlled substance. Of those, Delaware, Rhode Island, and West Virginia enacted laws scheduling xylazine in 2023. In addition to legislative action, at least two governors (Ohio and Pennsylvania) took executive action to schedule xylazine. ASTHO’s overdose prevention and state health policy teams continue to monitor these important public health issues. website yes

As new diseases or emergencies arise, working alongside trusted committees can help health officials quickly respond and prevent undue burden on at-risk groups such as people with disabilities, pregnant people, and children.

This Health Policy Update is an overview of policy strategies that states have taken at the executive and legislative levels to increase the healthcare workforce to more effectively and efficiently respond to the COVID-19 pandemic.

States Continue to Address PFAS in U.S. Food and Water Supply States Continue Addressing PFAS in Food and Water Supplies Heather Tomlinson, Beth Giambrone Read how federal and state actions aim to tighten regulations to reduce PFAS exposure in the U.S. food and water supply. Use of per- and polyfluoroalkyl substances (PFAS), manufactured chemicals that resist water and heat, has steadily increased since they were first developed in the 1940s. PFAS are present in a wide variety of consumer products. PFAS do not degrade easily and can result in increasing concentrations of contamination in water and soil. PFAS exposure has been linked to a variety of health impacts, causing state and federal governments to enact legislation and create policies that reduce their presence in consumer products. States are also working on ways to address and communicate about PFAS contamination and elimination. PFAS in Food and Food Packaging FDA has been evaluating potential dietary exposure by testing foods most commonly eaten by the U.S. public for PFAS through the Total Diet Study (TDS). The initial findings indicate that the vast majority do not — 97% of the 810 fresh and processed foods samples, to be precise. Nevertheless, some specific food subtypes have shown a higher prevalence, with over half of TDS seafood samples detecting at least one type of PFAS. As part of their technical assistance to states, FDA can test foods produced in areas with known environmental contamination to evaluate potential contamination of human and animal food. One recent example came from two dairy farms in New Mexico with known PFAS groundwater contamination; this sampling resulted in milk samples from one farm showing PFAS levels at a potential health concern threshold and lead to them being discarded prior to entering the food supply. Consumers can also be exposed to PFAS through food packaging. As of February 2024, FDA announced that grease-proofing materials containing PFAS are no longer sold for food packaging in the United States, eliminating the primary source of dietary exposure from food contact surfaces. At least 17 states have introduced legislation in their 2025 sessions to prohibit selling food packaging that contains PFAS, with bills in seven states seeing significant movement. In April 2025, New Mexico enacted HB 212, which prohibits selling food packaging and other products containing PFAS starting January 1, 2027. Bills in California SB 682, Illinois SB 1531, and New York S 187 that would prohibit manufacturing, distributing, and/or selling products containing PFAS (including food packaging) advanced in the first chamber. Regulating Drinking Water In April 2024, EPA used their authority under the Safe Drinking Water Act to establish Maximum Contaminant Levels (MCLs) for PFAS found in drinking water. This National Drinking Water Regulation (NPDWR) established individual MCLs for PFOA,PFOS, PFNA, PFHxS, and GenX and a Hazard Index MCL for mixtures of two or more PFAS (specifically PFHxS, PFNA, GenX Chemicals, and PFBS). Under the rule, public water systems must complete initial monitoring for PFAS by 2027 and continuously monitor thereafter. In addition, they must inform the public about PFAS levels in their drinking water and, beginning in 2029, any public water system that exceeds one or more of the MCLs must reduce the PFAS levels and notify the public of the violation. A recent announcement from EPA stated that while they intend to retain the current MCLs for PFOA and PFOS at four parts per trillion (ppt), they will “rescind the regulations and reconsider the regulatory determinations for PFHxS, PFNA, HFPO-DA (commonly known as GenX), and the Hazard Index mixture of these three plus PFBS.” The agency will also propose to give drinking water systems until 2031 to come into compliance with the PFAS rule. A proposed rule is planned for a fall release, with finalization in the spring of 2026. Finally, EPA plans to establish a framework for exemptions and provide assistance to drinking water systems through the PFAS OUTReach Initiative. EPA delegates responsibility for enforcing regulations for public water systems to states that meet certain requirements. Under the current federal rule, states have two years to establish regulations that are at least as stringent as current EPA standards. At least 20 states currently have regulatory standards for at least one PFAS in drinking water, and so far in the 2025 sessions, at least six states introduced legislation to establish new or updated MCLs: Indiana (HB 1366), North Carolina (SB 384), and West Virginia (HB 3475) introduced bills directing their health departments to establish MCLs for certain PFAS contaminants. North Carolina’s bill also requires the Commission on Public Health to consider adopting MCLs for PFAS contaminants not listed in their legislation if at least two other states have set MCLs or issued guidance. The New York state Senate recently passed S 3207, which would tighten MCLs for PFOS and PFOA from 10 ppt to 4 ppt, and establish MCLs of 10 ppt for PFNA, PFHxS, and HFPO-DA. The measure is currently in the Assembly for consideration. Pennsylvania HB 578 would establish MCLs for PFAS at 10 ppt, and would allow MCLs established by the Environmental Quality Board or executive order of the governor to supersede current MCLs. Vermont H 286 would establish MCLs for PFOS, PFOA, PFHxS, PFNA, perfluoroheptanoic acid (PFHPA), and perfluorodecanoic acid (PFDA) at zero ppt, and MCLs for any other testable PFAS at 20 ppt. Two states also introduced legislation modifying requirements for monitoring or reporting PFAS. Maine recently enacted LD 1326, which codifies the requirements to monitor and report PFAS compounds in accordance with EPA’s final rule and requires public notification of the type and level of PFAS in drinking water if they exceed the federal standard. Delaware SB 72 would require the Department of Health and Social Services to create a website where residents can access information related to the level(s) of PFAS in public drinking water systems, and require water utility companies to provide notice of excess PFAS levels to residents who receive water from that system. The measure passed the Senate in May and is currently in the House for consideration. PFAS is a cross-cutting issue, impacting health departments, agricultural agencies, environmental agencies, and the public. State and territorial health agencies can collaborate with community groups to create a broad coalition that can work together across their respective areas to address PFAS contamination. Many states have created internal cross-agency workgroups to evaluate and address PFAS exposures. ASTHO will continue to provide updates on PFAS elimination and MCL implementation. article yes

Polysubstance Use During Pregnancy and the Benefits of Universal Verbal Screening polysubstance use, universal verbal screening, health equity, polysubstance use during pregnancy, public health, substance use disorder, health problems, health care, health outcomes, prescription medications, increase the risk, risk of overdose, pregnant women, treatment programs, health service, illicit drugs, birth defects, increased risk, neonatal abstinence syndrome nas, fetal alcohol spectrum disorder, prescription drugs, multiple substances, risk factors, prescription opioids Shannon Vance Polysubstance Use During Pregnancy and the Benefits of Universal Verbal Screening Polysubstance use, the use of two or more substances, during pregnancy is common and can result in negative outcomes for both mothers and infants. This report explores the occurrence of polysubstance use in pregnancy, details the advantages of universal verbal screening in pregnancy, and emphasizes the importance of health equity in providing this care to patients. Get the Report (PDF) website yes

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.