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Health Agencies Keeping Cottage Foods Safe Heather Tomlinson Rows of homemade jams at the local farmer’s market and a neighbor’s birthday cake on social media have something in common: they are both cottage (or homestead) food products. Cottage foods are home-based, home-made food products prepared outside of a commercial kitchen and sold to the public. Cottage food producers operate on a small scale, often from a home kitchen, selling goods locally. Although cottage foods provide opportunities to small, locally owned businesses, they also create complexity in selling food products to the public that are not inspected and may not meet basic food safety standards. And while home kitchens are not considered food establishments in the FDA Food Code, states are able to define “food establishments” by amending provisions in their food code adoption process or enacting legislation or regulations. In addition to regulating, state health agencies can play a role in keeping cottage foods safe through education, training, and other mechanisms. Cottage Food Regulation Currently, all 50 states and Washington, D.C. allow the sale of cottage food products directly to consumers. Several foodborne illnesses have been linked to products improperly prepared at home, such as botulism outbreaks in home-canned products and E.coli contamination of jerky. Many foodborne illnesses can be prevented by safely preparing, processing, and storing foods, processes often outlined by health regulations. Health agencies use a variety of tools to regulate cottage food production. Types of Foods: The types of foods permitted can vary across jurisdictions with some allowing only non-time/temperature controlled for safety (TCS) foods (e.g., baked goods, jams, candies), while others allow a wide range of products including TCS foods and items that require specialized processes (e.g., pickled vegetables). Some jurisdictions may use an exhaustive or illustrative list outlining permitted foods, while others limit specific food production processes but allow all other food items. Licensing and Inspection: Cottage food producers must follow a variety of rules in the form of permits, licenses, and registration. Although cottage foods are exempt from many inspection requirements, at least fifteen states require an initial inspection of home kitchens before they can sell items. All states allow the investigation of foodborne illness complaints; some states require annual licensure. Food Safety Training: States can require a food safety course to ensure that all cottage food producers understand the basic food safety requirements. Sales Caps: Gross sales caps limit the scale of operations allowed without full food safety precautions. After a cottage food operation exceeds their gross sales cap, they would be required to register as a food establishment and permitting rules would take effect. Sales Venues: States typically only allow direct-to-consumer sale of cottage foods (e.g., farmers’ markets) but some states permit online sales. Federal food safety regulations, which prohibit cottage foods, apply when food products are sold across state lines. Cottage food sales, whether in-person or online, should remain within the state they were created to avoid violating federal regulations. Labeling: All states have a labeling requirement for cottage foods. These labels can vary but typically include the food producer’s name and address, the product name, an ingredients list, allergens, product weight, date of production, and a disclaimer identifying that the product was prepared in a home kitchen that is not inspected. Recent Cottage Foods Legislation in the States Legislators often face tension in weighing the balance between maintaining food safety regulations and supporting small cottage food businesses by reducing the entry barriers (e.g., leasing commercial kitchen space). In recent years, there has been an increase in legislation expanding cottage food parameters ranging from product and preparation inclusions to modifying the gross sales cap. The Arizona House of Representatives passed and the Senate is currently considering HB 2864, which would expand the state’s cottage food item list to include precut and processed freeze-dried fruits and vegetables. Arizona enacted HB 2042, which expands the definition of cottage foods to include foods that require time and temperature control if they're exempt under federal regulations. The Hawaii legislature passed HB 2144 which is now awaiting action from the Governor, which would expand the definition of cottage foods to include pickled products and non-hazardous products that do not contain dried meat or seafood, permit the sale of products in retail stores, and allow for customer delivery via third party vendors or shipping. Several states have introduced legislation to increase the gross sales cap for those who qualify as a cottage food producer. Mississippi (MS SB 2638) and Washington (WA SB 5107) introduced bills that proposed to increase the annual gross sales cap, but both failed in session. There has also been legislation surrounding cottage food preemption. Massachusetts is considering S 2761, which would establish a cottage food regulatory framework and prohibit local health agencies from being able to establish their own cottage food regulations. Microenterprise Home Kitchens In expanding cottage food production, there has been increased legislation on microenterprise home kitchens. Microenterprises typically allow the production of more types of foods, including fully prepared hot meals, but also require stricter regulations (such as preparing and selling the food on the same day). Minnesota (MN SF 4501) and Hawaii (HI HB 1591) have introduced legislation that would allow microenterprise home kitchens and establish a regulatory framework for licensing and safety standards. Raw Milk Considerations Raw milk is an animal milk that has not gone through pasteurization (process of heating milk to a specific temperature for a set period of time) to kill harmful bacteria. Raw milk can carry dangerous bacteria that can cause food poisoning and has recently been shown to test positive for the recent highly pathogenic avian influenza (HPAI) virus. As of March 2024, 30 states allow the interstate sale of raw milk. This session, West Virginia passed legislation (WV HB 4911) and at least six states, Michigan (MI HB 5603), Hawaii (HI HB 1989), Missouri (MO HB 1711), Massachusetts (MA S 43), Louisiana (LA HB 467), and New Jersey (NJ A 1086), considered legislation that would allow unpasteurized, raw milk to be sold to consumers. How State Health Agencies Can Keep Cottage Foods Safe Health agencies consider cottage food inclusions based on food production risks. For instance, many agencies will allow baked goods but do not permit pickling due to the botulism risk associated with pickling. Health agencies evaluate food science to educate their legislatures on the considerations of cottage foods and where they would recommend public health regulations. Health agencies also ensure cottage food guidance is easily accessible and written in plain language, so producers have the needed information to follow regulations. Relevant information may include the permitted products, how to become a cottage food producer, and food safety considerations when preparing home-made foods. For example, the Illinois Department of Health, in collaboration with a diverse collection of stakeholders, created a robust cottage food guide to help producers and regulators understand state requirements and cottage food safety standards. Author card spacing 4 State policy surrounding cottage foods is constantly evolving. ASTHO will continue monitoring these changes and provide relevant updates. website yes

While communities transition from emergency response to long-term monitoring and recovery, the federal government and states are taking legislative action to improve emergency preparedness capabilities.

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.

The ASTHO State Health Policy team provides brief updates on 5 of the ten state health policy issues to watch in 2022: mental and behavioral health, rural health, e-cigarettes and flavored tobacco products, HIV and PFAS.

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.

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.

ASTHO Legislative Prospectus | Prevention 2025 state legislative action on infectious disease control and prevention.

Navigating Public Health Planning with Precision and Purpose Discover examples and best practices for developing strategic plans that enhance community health outcomes. Embarking on the journey of public health planning demands more than good intentions. It requires a meticulous blueprint that encompasses budgetary considerations and strategic timelines, and effectively leverages external support. Across a landscape in which every decision has the potential to uplift entire communities, there are a world of opportunities and details to explore. Included among them are the critical components of crafting a robust plan, the value of engaging contractors, and strategies for optimizing resources. Mining Existing Plans for Insight and Inspiration Organizational strategic plans, Community Health Assessments (CHAs), and Community Health Improvement Plans (CHIPs) can supply guidance and inspiration for comprehensive public health planning. These documents offer both valuable insights into public health initiatives and tangible examples of effective planning frameworks. There are multiple examples of existing plans within health agencies across jurisdictions; when seeking them out, consider various criteria (e.g., population characteristics, geographic location, and specific health priorities). By examining plans tailored to communities with similar demographics or facing comparable health challenges, planners can apply approaches that resonate in their own context. Additionally, understanding the distinctions between strategic plans, CHAs, and CHIPs is essential, particularly for agencies aspiring towards PHAB Pathways Recognition Program or PHAB Accreditation. These plans are separate entities within the PHAB framework, each playing a vital role in shaping public health strategies and fostering community well-being. Strategic Plans Strategic plans outline organizational goals, plans to achieve them, and how to measure success. They drive resource allocation, decision-making, and other priorities organization wide. Examples U.S. Virgin Islands Hawaii Forest County Potawatomi* El Paso County, CO* San Joaquin County, CA* Community Health Assessments Community health assessments offer a complete view of risks, resources, and factors influencing outcomes. Supported by diverse environmental and socio-economic data, CHAs inform health policy, staff protocols, partnerships, program development, funding, resource allocation, and health improvement planning. Examples U.S. Virgin Islands Oneida Nation* Forest County Potawatomi* El Paso County, CO* San Joaquin County, CA* Pierce County, WA* Community Health Improvement Plans Community Health Improvement Plans are strategic, collaborative roadmaps derived from CHAs. They outline how health agencies, partners, and communities will unite to enhance overall health. They guide priorities, resource allocation, and steer project, program, and policy implementation. Examples U.S. Virgin Islands Hawaii Oneida Nation* Forest County Potawatomi* El Paso County, CO* San Joaquin County, CA* Pierce County, WA* *PHAB Accredited Health Department Plan Components, Timeline, and Budget Agencies considering planning processes and examples from other jurisdictions should recognize the diversity in approaches across different agencies and jurisdictions. There truly isn’t a singular “right” way to undertake public health planning. Instead, it’s about tailoring the process to suit the jurisdiction’s unique needs and circumstances. Examples to Guide Plan Development The Kansas Institute of Health’s Strategic Planning in the Public Health Sector Handbook offers a comprehensive breakdown of planning elements and timeframes based on a six-month plan development calendar. Explore Minnesota Department of Health’s Community Health Assessment and Planning Toolkit, a rich resource for navigating the CHA-CHIP process and timeline. Their template includes a detailed approach that considers capacity to accomplish each step within a desired timeline. Given the variation in the depth and breadth of jurisdiction planning processes, it is challenging to pinpoint a specific dollar amount to cover a planning endeavor. NACCHO’s MAPP Budget Template (part of their downloadable MAPP 2.0 process) can help systematically think through the resources necessary for planning processes. Outsourcing Key Support External support—in the form of facilitators, contractors, or other specialized professionals—can play a pivotal role in enhancing public health planning by offering fresh insights, innovative strategies, and diverse perspectives. Such support also allows for full, active organizational participation in the planning process. Moreover, they can provide valuable technical assistance, helping to navigate complex challenges and identify best practices from other contexts. By harnessing external support, organizations can optimize their decision-making processes, foster collaboration, and enhance the delivery of services to communities, thereby promoting better health outcomes for all. Conducting a SWOT Analysis: Contractors can assist in facilitating a thorough analysis of the organization's strengths, weaknesses, opportunities, and threats (SWOT). This structured assessment helps identify internal factors that impact the organization's ability to achieve its objectives and external factors that may affect its operations. Proposing Strategic Priorities: Based on the SWOT analysis and input from stakeholders, contractors can help planning teams crystallize priorities aligned with the organization's mission and vision. These priorities serve as the foundation for developing the plan. Facilitating Steering Committee Meetings: Steering committee meetings are crucial for decision-making and guiding the strategic planning process. External facilitators can lead these meetings, ensuring productive discussions, consensus-building, and alignment with organizational goals. Developing Components of the Strategic Plan: Contractors can support in drafting or reviewing various components of the plan, including vision and mission statements, goals, objectives, and action plans. They may ensure these components are clear, concise, and aligned with the overarching strategic direction. Developing a Draft Implementation Plan: An implementation plan outlines how to achieve strategic goals, including timelines, responsible parties, and resource allocation. Contractors can support an organization to develop a draft implementation plan that outlines actionable steps to translate the strategic plan into reality. Developing Quality Improvement Metrics: Contractors can assist in guiding the development of metrics to measure the effectiveness of the strategic plan. These metrics should be specific, measurable, achievable, relevant, and time-bound (SMART), providing a framework for monitoring progress and making data-driven decisions. Conducting Training Among Organization Staff: To ensure buy-in and understanding of the strategic plan and process itself, contractors can help develop and co-facilitate training sessions for staff members. These sessions may cover strategic objectives, action plans, and their roles in achieving organizational goals. Developing a Communication Plan: Effective communication is an essential key for keeping any strategic plan off the shelf. Contractors can support an organization in developing a comprehensive communication plan that outlines key messages, target audiences, communication channels, and timelines to ensure consistent and transparent communication throughout the organization and with partners. Developing Process Logs, Templates, and Meeting Notes: Contractors can create documentation tools such as process logs, templates for strategic planning documents, and detailed meeting notes. These resources streamline the planning process, capture important discussions and decisions, and serve as valuable references when considering sustainability. In summary, external support brings valuable expertise and resources to public health planning processes, enabling organizations to navigate complexities, engage partners effectively, and develop actionable strategic plans that drive positive health outcomes for communities. OE22-2203 PHIG website yes

In 2020 and early 2021, state policymakers took action to raise awareness of the impacts of racism on health outcomes, to reverse the damage of racist polices, and to implement policy changes to ensure that future policies are enacted with a racial equity lens. In the past two years, many states introduced and adopted resolutions declaring racism a public health crisis. In the early weeks of 2022, there is notably less legislation that has been introduced as compared to the same time last year.

An ASTHO blog article on leave policies to support better work/life balance.

ASTHO staff identified a range of evidence-supported policies considered by state legislatures that could prevent ACEs. This report synthesizes these research and policy proposals and is intended for public health practitioners and policymakers who are considering adopting similar policies.

ASTHO's 2024 Legislative Session Update: Part Two Beth Giambrone, Maggie Davis, Christina Severin ASTHO's Public Health Legislative Update on Tobacco, Mental Health, Environmental Health, Workforce, and Containing Infectious Disease By the end of April, at least 36 states will have concluded their regularly scheduled 2024 sessions, with several states passing laws on important public health issues. Earlier this month, ASTHO provided a brief update on five of the top 10 public health state policy issues to watch during the 2024 state and territorial legislative sessions; this update examines the remaining five. Containing the Spread of Infectious Disease Public health agencies have a responsibility to keep their communities safe and healthy by maintaining foundational public health services including identifying, containing, and preventing the spread of communicable disease. ASTHO supports maintaining and guaranteeing robust public health legal authorities allowing public health leaders to meet their responsibilities for containing the spread of infectious disease. Following the COVID-19 pandemic, state and territorial legislatures considered many bills to change public health agency’s legal authorities to meet their responsibility, a trend that ASTHO anticipated continuing into 2024. So far, at least 28 states have considered, and at least two legislatures passed, bills relating to public health authority to address the spread of infectious disease in 2024. For example, the Hawaii legislature passed SB 3122, expanding public health authority by providing the state health official broad authority to issue standing orders for people 18 years and older to receive evidence-based services recommended by the U.S. Preventative Services Task Force. In March, however, Utah enacted HB 405, which limits local public health official’s authority to issue an isolation or quarantine order to specific conditions unless the local legislative body agrees that a new, drug resistant, or reemerging pathogen likely to cause high mortality or morbidity needs containment. Environmental Health Under the Safe Drinking Water Act, the EPA has the authority to set national standards for public drinking water. These standards establish legally enforceable Maximum Contaminant Levels (MCLs) and non-enforceable Maximum Contaminant Level Goals for public water systems. In April 2024, EPA released a final rule establishing legally enforceable MCLs for six PFAS compounds that occur in drinking water. Public water systems have until 2027 to complete initial monitoring and inform residents of the levels of PFAS in their water, and until 2029 to act if their drinking water levels exceed the MCLs. To date in 2024, at least four states have enacted or are considering legislation that would aid in monitoring and remediating PFAS in drinking water. Virginia recently enacted HB 1085/SB 243, which requires that the Department of Health notify the Department of Environmental Quality (DEQ) of any results from their monitoring of public water systems that show MCL exceedances, at which time requires DEQ to implement a plan to prioritize and conduct assessments of the public water system's raw water source(s). The Rhode Island House of Representatives passed H 7439, which would require the Department of Environmental Management to determine the maximum number of PFAS detectable by standard laboratory methods, and specifies the types of water systems that will be required to monitor untreated drinking water for those PFAS by June 1, 2025. Massachusetts is considering H 853, which would require the Department of Environmental Protection to maintain a list of municipalities where PFAS levels exceed the MCL and provide vouchers to homes in those municipalities to purchase home water filtration equipment. Strengthening the Public Health Workforce With several successes in 2023, ASTHO anticipated legislatures to continue considering legislation to strengthen the public health and health care workforces that represent the communities they serve during the 2024 legislative sessions. One strategy is establishing career pathway programs that provide students training and support to pursue public health careers. At least six states have considered, and three have passed, bills creating or strengthening a career pathway program during the current legislative sessions. At least two states have enacted programs to address health care provider shortages in April. Maine’s legislature passed LD 2268, which would allow internationally trained physicians to receive a limited license to practice medicine and address provider shortages in rural areas of the state. Washington enacted SB 5582, directing community and technical colleges to develop a plan in consultation with local workforce development councils and health care employers to train more nurses over the next four years. In May, Hawaii’s legislature passed HB 1827 appropriating funds to support public high school health care workforce certificate programs to support graduates seeking entry-level positions in the health care industry. Supporting Mental Health Children and adolescents continue to experience mental health issues, with teen girls reporting significant challenges. Schools can play an important role in supporting the mental health of all students through direct services or policies that address prevention, education or coordination. In 2024, a number of jurisdictions considered legislation related to youth mental health, through training requirements for staff and students, and support for treatment flexibility in the school setting. At least six jurisdictions considered bills related to mental health education for students, including specific suicide and violence prevention content. Virigina enacted HB 603, which requires school health instruction to include information about common mental health challenges, helpful coping strategies, the importance of seeking help from a professional or other adult, and available school resources. Several jurisdictions, including Virginia (HB 224), Minnesota (HF 4363) and Missouri (HB 2471), also considered establishing or amending suicide prevention and related mental health training programs for teachers and other school staff. Finally, several jurisdictions considered legislation to explore or otherwise support using telehealth services in schools for mental health services. Minnesota is considering legislation that would create a pilot program to determine whether the availability of telehealth services in schools increases mental health access (SF 4236) as well as a requirement to provide space at secondary schools for students to receive telehealth mental health services (HF 3542). New York is currently considering S 8976, which would authorize telehealth services in schools to be delivered by licensed providers, while Maryland enacted HB 522 in April, which requires school districts to develop guidelines to allow telehealth appointments at schools starting in the 2025-26 school year. Tobacco and Nicotine Products According to the American Lung Association, 22 states do not have comprehensive smoke-free laws that help protect against the dangers of second-hand smoke in a variety of settings (e.g., multi-family homes, public spaces, restaurants), or reduce the number of people who start smoking. At least 16 states have introduced legislation aimed at creating, promoting, or expanding smoke-free environments. Connecticut recently enacted SB 132, which expands their clean indoor air act to prohibit vaping at dog race tracks. The Maryland legislature passed HB 238/SB 244, which would update their Clean Indoor Air Act to prohibit vaping in public indoor areas, indoor places of employment, and mass transportation. In addition, the Alabama Senate recently passed SB 37, which would prohibit vaping in public places. In addition, at least 14 states have introduced legislation to either prohibit or further restrict the sale of flavored tobacco products, including menthol products. For example, bills introduced in Hawaii (HB 2441/SB 3130), Minnesota (HF 2177/SF 2123), and New Jersey (S 1947) would prohibit the sale of flavored tobacco products, including menthol, within their jurisdiction. In addition, a bill in New York (A 699/S4477) would ban the sale of flavored smokeless tobacco products within five hundred feet of a public or private school. ASTHO’s state health policy team continues to monitor these important public health issues and will provide relevant updates. website yes

Earth Day is a natural time to examine current and future climate change policies that impact human health, including clean air, safe drinking water, access to food, and secure shelter.