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Environmental health and public health preparedness staff work closely together to respond to natural disasters and climate change—learn how in this report.

Breastfeeding is considered the gold standard in postnatal care for both birthing persons and infants. Yet racial disparities in breastfeeding initiation and duration rates continue to persist. Effective intervention strategies require a multi-level approach that includes comprehensive legal, policy, and programmatic efforts.

Reconciling the tension between public health and civil liberties is one of the most significant challenges of public health law and ethics. The Supreme Court of the United States historically upheld state authority to enact and enforce public health laws that temporarily limit a person’s civil liberties, such as quarantine and isolation powers that restrict a person’s freedom of assembly in order to prevent the spread of contagious disease. There have been many legal challenges to the public health orders issued to slow the spread of COVID-19—many of the claims asserting violations of First Amendment rights of assembly, association, and expression—but they’ve largely been rejected by the courts. However, courts have treated claims asserting violations of the free exercise of religion more favorably, which may indicate an impending shift in how courts analyze the impact state and territorial actions may have on religious organizations.

May is Mental Health Awareness Month and the importance of continued mental health promotion and suicide prevention efforts during the COVID-19 pandemic. As we address the physical effects of COVID-19 through social distancing, mask wearing, and vaccination, we still need to prioritize mental health and well-being during and after the pandemic. A recent Morbidity and Mortality Weekly Report found increases in adults reporting symptoms of anxiety or depression (36.4% to 41.5%) and unmet mental health care need (9.2% to 11.7%) between Aug. 2020 to Feb. 2021.

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.

As many state legislatures seek to expand vaccine exemptions, it’s important to understand the fundamental differences in exemption type and their impact on a community.

In an effort to help meet demand, some states and territories have joined interjurisdictional licensing compacts that allow a mental health care provider licensed in one state to provide care in another state—without needing to gain licensure in multiple states. These agreements also offer guidance on patient privacy for services rendered remotely or from out-of-state.

States Stay Prepared by Supporting the Public Health Workforce Margaret Nilz, Christina Severin Learn how states use policy to support emergency preparedness and bolster the public health workforce. Public health — particularly public health preparedness — continues to experience workforce shortages, driven by longstanding systemic challenges such as chronic underfunding, high turnover, limited recruitment, and an aging workforce. While some jurisdictions report increased capacity to hire and train public health staff in recent years, they often rely on short-term or temporary funding streams, which limit long-term sustainability. State, local, tribal, and territorial health agencies have varying capacities to respond to public health emergencies, particularly in rural and underserved communities. Because a limited workforce can inhibit emergency preparedness efforts, jurisdictions recognize the importance of cultivating a resilient public health preparedness workforce to respond to future emergencies. In recent years, jurisdictions have pursued several policy interventions to bolster the public health preparedness workforce such as legislation supporting front-line clinical staff and first responders, and rulemaking and other executive powers to provide structural and financial support to critical personnel. Legislative Efforts Legislative efforts to increase benefits and support for health care and public health workers can help address the root causes of workforce challenges and lay the groundwork for sustainable, long-term investment in public health preparedness. Laws that establish standards and expectations for the preparedness workforce, including expansions of benefits or additional training, support workforce growth and retention. Since 2024, several jurisdictions expanded mental health benefits and related support for first responders and other preparedness personnel. Both Alaska (SB 103) and California (AB 2859) enacted legislation that allows peer support programs for emergency service personnel. In Alaska, the bill creates programs for entities such as law enforcement agencies, firefighters, and emergency dispatchers, while California’s bill creates programs to serve a variety of health care providers involved in emergency medical care, including physicians, nurses, paramedics, and emergency medical technicians (EMTs). Utah enacted HB 378, which requires the Department of Public Safety to annually distribute information about its critical incident stress management program to first responder agencies. The bill also requires first responder agencies to annually notify employees about the availability of mental health resources, including periodic screenings for employees and continued support for retired or separated first responders and their spouses. On a broader scale, Hawaii SB 3279 recently established a well-being project tasked with mental health trainings and support for several community organizations, including first responders, hospitals, and medical staff. In Washington, HB 2311 directs the state’s Criminal Justice Training Commission to develop resources for first responder wellness, including a peer support network for active and retired first responders and their families. States have also enacted legislation expanding traditional employment-related benefits, including Colorado (HB 24-1219), which expanded certain health benefits for firefighters to include part-time and volunteer firefighters, and Idaho HB 55, which allows retired public employees to volunteer with public employers without it being considered reemployment. In addition, Georgia HB 451 requires state and local entities to provide disability benefits for first responders who experience occupational or volunteer-related post-traumatic stress disorder. Finally, several jurisdictions enacted legislation to support education and training for their public health and health care workforce. For example, Kentucky HB 484 established an emergency medical service education grant program that provides tuition support for students pursuing paramedic certification, wage reimbursement to ambulance providers whose employees pursue certification, and funding for institutions planning to offer EMT, advanced EMT, and paramedic programs. Oklahoma HB 1696 expands eligibility for the Oklahoma Medical Loan Repayment program to include certified nurse practitioners. Two new laws in Puerto Rico require police officers with the Puerto Rico Police Bureau to be certified in first aid or immediate rescue (PC 0859) and adds seminars on sign language, suicide prevention, and conflict mediation to the Bureau’s continuing education training (PC 0543). Other Policy Levers: Beyond the Legislature Jurisdictions can also use non-legislative policy tools to enhance workforce capacity in public health preparedness. This includes rulemaking, where executive agencies use existing legal authority to adopt or amend regulations. Regulations have the force of law and can help support the public health workforce by establishing licensure standards, training requirements, and operational protocols. Wisconsin, following the enactment of AB 576 in 2024, is developing rules to establish a program for peer support and critical stress management teams in the state. And Utah recently adopted rules for its first responder mental health services grant, which helps these professionals pursue a degree or certification as a mental health provider. Government agencies can also leverage grants and contracts to fund and otherwise direct workforce development initiatives, support training programs, and expand capacity in targeted areas. Jurisdictions can strategically direct funds to address skill gaps and assist local, state, tribal, and territorial agencies build a more resilient workforce. One example of this is in Michigan, where in 2024 the state health agency issued a request for grant proposals to award up to $9 million in EMS workforce grants, building on similar awards to address EMS shortages in 2023. Executive orders are another policy option for jurisdictions to consider as they explore different pathways to workforce sustainability. Executive orders are issued by a jurisdiction’s chief executive (often the governor) and direct certain policy actions or activities. Generally, the power to issue an executive order comes from existing law or a jurisdiction’s constitution and, in most cases, does not require legislative approval or review. Several states have leveraged executive orders to advance the public health workforce and support preparedness activities more specifically. For example, Vermont and New Jersey have recently used executive orders to create or extend advisory councils on issues pertinent to public health preparedness. In 2024, Virginia’s governor issued an executive order formalizing the Office of First Responder Wellness, which provides training, counseling, and other resources to first responders in Virginia. In 2023, the governor of Maryland issued an executive order establishing a State of Preparedness directive if there is a risk of public emergency, and the actions state agencies must undertake to promote improved coordination and hazard planning. Key Takeaways Addressing public health emergency preparedness workforce challenges demands strategic, long-term policy solutions, but several implementation options are available. Health agencies can pursue a variety of policy interventions to support and prepare their public health workforce for future emergencies. ASTHO will continue to monitor this important issue and provide updates as appropriate. article yes

In this infographic, ASTHO highlights some of the biggest takeaways, successes, and data collected from the Breastfeeding Learning Community.

Assessment of Foundational Capabilities Assessment of Foundational Capabilities in Public Health Grace Gorenflo, Brian Lentes, Melissa Touma, Anna Bradley Learn how state health departments are implementing the Foundational Public Health Services model to bolster their public health work in this report. The Foundational Public Health Services model serves as the core framework for defining cross-cutting capabilities essential for public health departments to deliver a minimum standard of service. This report compiles examples and assessments from 25 states to illustrate the implementation and progress of these foundational capabilities. Highlighting the importance of public health infrastructure, the report also includes a summary of state activities, showcases models and strategies for modernization and transformation, and reference tools such as cost assessments, legislation, and funding mechanisms used to strengthen public health systems nationwide. Dive into the full report to access these resources. Download the Report (PDF) article yes

16 recommendations for states as they set up mobile and drive-through COVID-19 test sites.

This week might have marked the beginning of summer, but many policymakers and health officials have their eye on the upcoming school year and what that might mean in terms of getting students vaccinated against COVID-19. According to a recent MMWR, COVID-19 related hospitalizations among adolescents increased in March and April 2021, potentially related to increased circulation of new COVID-19 variants, changes in physical distancing, and a larger number of children returning to school or other in-person indoor activities. This increase indicates an urgent need for vaccination against COVID-19, which is currently authorized for use in youth as young as 12.

A training to help clinicians report and recognize the signs and symptoms of a cyanobacterial bloom-associated illnesses.

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

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

As leaders of their state agency, state and territorial health officials can be named parties in lawsuits alleging that an action taken by a public health agency was unlawful. These officials are typically sued in their “official capacity,” meaning the lawsuit is brought against them as the representative of the agency and not as an individual. This post contains three examples of state health officials who have found themselves named in lawsuits.