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Vaccines are one of the greatest public health achievements of the last century, as well as some of the most powerful and cost-effective tools to prevent disease, disparities, disability, and death among children and adults. The COVID-19 pandemic and the unprecedented development and distribution of the vaccines against the novel coronavirus have generated much focus on state laws related to vaccinations. As state and territorial legislatures prepare to convene in the coming weeks, we can already identify several topics within vaccine law that policymakers across the country will consider.

The COVID-19 pandemic has negatively impacted youth mental health, particularly as a result of school closures, social isolation, family economic hardship, fear of family loss or illness, and reduced access to healthcare. However, states have many strategies to choose from to improve youth mental health and reduce suicide.

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.

More than 100 rural hospitals have closed since 2010, and an additional 25% are at high risk of closure, and COVID-19 has magnified the existing stressors on rural healthcare. As a result, states are using a variety of measures to address and prevent more rural hospital closures.

ASTHO’s 2024 Legislative Session Update: Part One legislative session, state policy, data collection, domestic violence, health information exchange, data privacy, substance misuse, overdose prevention, sexually transmitted infections, reproductive health, contraceptive care, climate change, public health, protect data, user data, personal data, centers for disease control, disease control and prevention, social media, data management, primary care, health organizations, higher risk, family planning, data sources, astho, association of state and territorial health officials Lillian Colasurdo, Maggie Davis, Lana McKinney, JoAnne McClure This past December, ASTHO announced the top 10 public health state policy issues to watch for during the 2024 state and territorial legislative sessions. With at least 30 states concluding their regularly scheduled 2024 sessions, here is a brief update on five of the topics to watch. Data Collection and Exchange As expected, there was an increase in proposed legislation that specifically advances electronic health data access, encourages interoperability, and safeguards identifiable patient health records; this was particularly true for vital records. Hundreds of bills have been introduced this session addressing state vital records systems. The state of Illinois alone has already passed several bills, including HB 2856, which requires veteran status to be designated on death certificates, and HB 2841, which prohibits the assessment of fees to victims of domestic violence who are seeking a certified vital record (birth or death certificate) from the state. Other states such as Arizona (SB 1252) considered legislation that would require the Department of Health to provide vital records information on deceased individuals to the qualifying health information exchange (HIE). Arizona is one of eight jurisdictions (AZ, FL, IA, IL, NH, NJ, OK, and WV) that have proposed legislation addressing HIEs this session. Most of these bills increase requirements to connect to HIEs, but New Hampshire HB 1663 and Oklahoma HB 3556 would allow patients and health care providers to opt out of HIEs. As many states look to address health data privacy concerns, New Hampshire recently passed a constitutional amendment granting the explicit right to privacy and has introduced HB 1663, which would update many of the state’s privacy laws regarding medical records to conform with the constitutional requirements. Just next door, Maine considered legislation (LD 1902) that would strengthen privacy requirements for reproductive and gender-affirming patient health information. Finally, the launch of the new federal Trusted Exchange Framework and Common Agreement (TEFCA) led to the Florida legislature proposing SB 668, which, had it passed, would have required hospitals to make patient records available through a nationally recognized trusted exchange framework. It would also have required the Agency for Health Care Administration to adopt relevant rules. Substance Misuse and Overdose Prevention Measures to prevent substance misuse and reduce overdoses, namely increasing access to opioid antagonists, such as naloxone and regulating substances with the potential for misuse, are priorities this legislative season. ASTHO anticipated that states would consider legislation to reduce fatal overdoses including decriminalizing drug checking equipment, expanding naloxone access and distribution, establishing overdose prevention centers, and establishing state regulatory frameworks for commercial substances with the potential for misuse, including kratom and Delta-8. Current legislative priorities to expand access to naloxone include public spaces, such as libraries, schools, workplaces. Island jurisdictions along with at least four states—Colorado (HB 24-1003), Tennessee (SB 2141), Virginia (HB 732), and Wisconsin (AB 223)—passed legislation to provide greater access to and/or proper storage of naloxone in school settings. Additionally, Virginia passed HB 342 that requires naloxone access in state agency buildings. These legislative actions, along with the approval last year by the FDA of two non-prescription naloxone spray products for over-the-counter use, are collectively powerful policy shifts to expand access to naloxone. In an attempt to regulate substances with the potential for abuse or misuse, specifically kratom, eight states have considered legislation that would restrict the sale to people under the age of 18. Similarly, twelve states have considered legislation that would restrict the sale of kratom to those under the age of 21. At least 22 states have considered legislation that would compel specific labeling requirements for kratom. Of those, California (AB 2365) and New Jersey (A 1188) would require kratom products to be registered with the state health department annually and require lab testing of the product to meet certain qualifications. Preventing Sexually Transmitted Infections ASTHO has spotlighted the growing concerns of rising rates of sexually transmitted infections and state actions reducing congenital syphilis rates and expanding access to HIV prophylaxis (PrEP) and post-exposure prophylaxis (PEP). Rates of both syphilis and congenital syphilis continue to rise at an alarming rate, with more than 10 times as many babies being born with syphilis in 2022 than in 2012. Routine screening and timely and adequate treatment of pregnant people for syphilis, ideally more than 30 days before delivery, can effectively prevent this condition in newborns. Due to increasing cases, the American College of Obstetricians and Gynecologists recently updated their guidance for obstetrician–gynecologists and other obstetric care professionals advising serological screening for all pregnant individuals at the first prenatal visit and universal screening at the third trimester and at birth. During the 2024 legislative session at least two states—Missouri (SB 1260) and Maryland (HB 119)—are considering legislation that would require testing during pregnancy care at the third trimester for syphilis. Maryland’s legislature passed HB 119, which would require screening at the third trimester and at birth, as well as requiring the hospital to determine the syphilis status of the birthing parent before discharging the newborn. In 2023, New York enacted legislation (A 3007) that requires syphilis screening in the third trimester, and in the current legislative session they are considering S 2472, which would allow the state health department to provide education about congenital syphilis and screenings. At least six states have considered and passed legislation during the 2024 legislative session regarding expanded access for HIV prophylaxis (PrEP) and post-exposure prophylaxis (PEP). Of those considered, Georgia enacted HB 1028 to allow PEP to be issued by a standing order; Florida’s legislature passed HB 159 that would allow pharmacists to screen for HIV exposure, order, and dispense prevention drugs PEP and PrEP and sent it to the governor. Similarly, in Delaware the Senate chamber passed SB 194 that would permit pharmacists to provide PrEP and PEP pursuant to an approved protocol. Family and Reproductive Health Policymakers across all levels of government continued taking steps to make it easier for people to access contraceptives. In 2023, at least 14 states enacted laws in 2023 to facilitate expanding access to contraceptive care by either expanding the ability for pharmacists to dispense birth control without an individualized prescription and/or allowing pharmacists to dispense up to 12 months of contraceptives at once. So far in 2024, at least 13 jurisdictions considered legislation allowing pharmacists to dispense contraceptives without a prescription and at least 18 states considered legislation supporting access to 12 month supply of contraceptives. Following FDA’s July 2023 approval of Opill—the first over-the-counter (OTC) birth control pill—the drug is currently available in stores with several major pharmacies and health plans announcing that they will provide the medication at zero cost for many health plan sponsors. To further support access to Opill, at least two states (New Mexico and Wisconsin) issued standing orders for Opill to facilitate Medicaid coverage of the medication. Additionally, Maryland’s legislature passed SB 527 in March 2024, which requires community colleges to develop and implement a plan to provide students access to OTC contraception. In February 2024, New York enacted S 8096 allowing the commissioner of health to issue a standing order allowing a pharmacist to dispense self-administered hormonal contraceptives, effective retroactively to January 1, 2024. Under the new law, New York’s Commissioner of Health issued a standing order to allow pharmacists to dispense up to 12 months of self-administered hormonal contraceptives like birth control pills, vaginal rings, and contraceptive patches. Optimal Health for All ASTHO anticipates policymakers will take steps to improve collection of health disparities data, address inequities rural communities face in accessing care, and to support climate change adaptation planning efforts. So far in the 2024 legislative session, several states are considering bills to improve health care access and outcomes in rural areas. California is considering legislation (SB 945) that would build an integrated data dashboard to provide the public with information on the health impacts caused by wildfires and the effectiveness of forest health and wildfire mitigation on health outcomes. Additionally, California (AB 2342) is looking to ensure critical access hospitals on remote islands receive adequate funding through a dedicated annual supplement. New York is considering at least two bills that would promote rural health care access. First, New York S 8582 would create a pilot program to identify rural health zones and convene a rural health zone board

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 the number of COVID-19 vaccinations grows, some states are looking at their vaccination rates to determine when to loosen measures that mitigate the spread of COVID-19, such as venue capacity limits, business closure times, and masking requirements. As vaccinations allow businesses to reopen and customers to return, questions have arisen about whether venues or services—especially those that bring people in close contact for long periods of times—such as retail stores, concert venues, entertainment venues, air travel, cruise ships, etc., can require patrons or customers to verify that they received a COVID-19 vaccine. So far, state policy makers have had mixed views on the issue.

A pressing public health issue before the COVID-19 pandemic hit, the need for public health interventions to reduce tobacco use is heightened with a strong association between tobacco use, in all forms, with severe COVID-19 outcomes. Additionally, tobacco use remains the leading cause of preventable death in the U.S., claiming approximately 480,000 deaths each year. Evidence-based policies to reduce tobacco use like raising the age of sale to 21, increasing tobacco pricing, and prohibiting the sale of flavored tobacco products are common public health strategies enacted through state legislation. As anticipated in ASTHO’s 2021 Legislative Prospectus on E-Cigarettes, states are considering many of these evidenced-based tobacco reduction strategies during the 2021 legislative sessions.