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Public health agencies are working to reduce dementia risk and to optimize the health and well-being of people living with dementia and their caregivers.

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.

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.

Good news and bad news on tobacco use: smoking rates are down but e-cigarette use continuing rapid rise among youth. Read how states are combating the problem.

State and Federal Actions to Reduce Per- and Polyfluoroalkyl Substances’ Impact on Public Health safe drinking water act, per and polyfluoroalkyl substances, water supplies, contaminated groundwater, chemical companies, pfas contamination, forever chemicals, synthetic chemicals, maximum contaminant levels, industrial pretreatment program, polyfluoroalkyl substances pfas, chemical sales, chemical industry, bottled water, safe drinking water act sdwa, unregulated contaminants, companies in the world, united states, consumer products, 1996 amendments, national primary drinking water, surface water, water system, largest chemical companies, pfas strategic roadmap, primary drinking water regulations, pfas chemicals, pfoa and pfos, drinking water, testing for pfas, astho, association of state and territorial health officials Maggie Davis, Beth Giambrone State and Federal Actions to Reduce PFAS Impact on Public Health Since 2018, when the city of Stuart, Florida filed its lawsuit, communities across the United States have filed lawsuits against manufacturers that produce Per- and polyfluoroalkyl substances (PFAS), alleging that they contaminated groundwater and exposed residents to these harmful chemicals. In June 2023, manufacturer 3M agreed to pay at least $10.3 billion to settle the Stuart lawsuit and others across the country with public drinking water systems. Similarly, chemical companies DuPont, Chemours, and Corteva reached $1.18 billion settlement with local communities that have detected PFAS in their water supplies. PFAS are synthetic chemicals used in products like nonstick cookware and firefighting foam, which can migrate to soil, water, and air during production and use. Most of these chemicals remain in the environment without breaking down—hence the nickname “forever chemicals”—and can cause harmful health effects (e.g., higher risks of kidney or testicular cancer, and pre-eclampsia or high blood pressure among pregnant people) and are prevalent across the nation. Evidence shows the widespread nature of exposure to the chemicals and the economic costs of exposure. For example, a 2023 USGS study estimated that at least 45% of tap water nationwide could have one or more PFAS, while recent research estimates the annual cost of the disease burden attributable to long-chain (i.e., six or more carbon) PFAS exposure to be at least $5 billion. As communities seek restitution for PFAS contamination, federal and state policymakers are working to eliminate PFAS from ground water and drinking water and to mitigate exposure to these forever chemicals. Eliminating PFAS in Drinking Water Under the Safe Drinking Water Act, EPA has the authority to regulate the public drinking water supply in the United States. These regulations establish legally enforceable Maximum Contaminant Levels (MCLs) or Treatment Techniques and non-enforceable Maximum Contaminant Level Goals (MCLGs) for public water systems. EPA’s recently proposed PFAS National Primary Drinking Water Regulation could potentially add six different PFAS compounds to the list of regulated contaminants. Within the PFAS chemical family, PFOA and PFOS are proposed to each have MCLs of 4.0 parts per trillion (ppt), while PFNA, PFHxS, PFBS, and GenX would be regulated collectively as a mixture using EPA's Hazard Index approach. The proposed rule also could require public water systems to monitor and notify the public of PFAS levels and reduce the levels in drinking water if they exceed proposed standards. According to a survey conducted by the Environmental Council of the States, state guidelines vary; at least eleven states have established statewide MCLs for PFAS in drinking water. Some states prohibit their agencies from setting standards more stringent than federal ones and, in the absence of a federal standard, state agencies may hesitate to establish one that could easily be invalidated. In other cases, a lack of resources inhibits the agency’s capacity to set and enforce a PFAS standard. When a federal standard is established by EPA’s final rule, expected by the end of 2023, state primacy agencies will need to enforce the federal standard and adopt standards aligned with the federal standard or stronger within two years. Additional State Efforts to Reduce PFAS Exposure Even without MCLs, states are finding ways to mitigate the public’s exposure to PFAS. In 2023, states enacted legislation on banning PFAS in consumer products, increased requirements for testing and reporting of PFAS, and PFAS mitigation. Banning PFAS in Products Indiana enacted HB 1341 prohibiting fire departments from purchasing gear unless it contains a permanent label indicating whether it does or does not contain PFAS as of June 30, 2024. Minnesota’s HF 2310 prohibits selling or distributing products containing intentionally added PFAS beginning January 1, 2026. An exception may be made if the manufacturer submits information to the commissioner of the Pollution Control Agency such as the product, the amount of PFAS used, and the amount of PFAS in the product. The Oregon legislature enacted SB 543, which prohibits the selling or using polystyrene foam containers for prepared food, food containers containing intentionally added PFAS, and polystyrene packaging peanuts. Washington enacted HB 1047, which prohibits manufacturing, distributing, and selling cosmetic products with PFAS and other chemicals or chemical classes as of January 1, 2025. Testing/Reporting Indiana enacted HB 1219, establishing a pilot program that collects blood samples of previous or current firefighters, analyzes the samples for serum PFAS levels, and determines whether there are corresponding health implications associated with elevated serum PFAS levels. Maine’s LD 1248 requires bottlers who extract water from the state to sell as bottled water to test, regularly monitor, and report the presence of PFAS to the Department of Health and Human Services and post the results on a public-facing website. Sales of bottled water are prohibited if PFAS levels in the water source exceed the state or federal community water system standards, whichever is lower. Currently, Maine has an interim MCL standard of 20 ppt. Virginia’s HB 2189 directs the State Water Control Board to adopt regulations requiring industrial users of publicly owned treatment works to test waste streams for PFAS before and after cleaning, repairing, refurbishing, or processing items the user knows or reasonably should know uses PFAS chemicals. West Virginia’s HB 3189 requires its Department of Environmental Protection to identify and address sources of PFAS in raw sources of public drinking water systems. It also requires facilities to report the use of PFAS if they discharge to surface waters under a National Pollutant Discharge Elimination System (NPDES) permit or to a Publicly Owned Treatment Works under an industrial pretreatment program. Mitigation Connecticut enacted SB 100 establishing a PFAS testing account, which provides municipalities with grants or reimbursements for testing and remediating PFAS in drinking water. Maine enacted LD 289, which requires the state to purchase the real estate of a commercial farm found to be contaminated by PFAS before January 1, 2023 at the assessed fair market value but at no less than $20,000 per acre, and provides that the fair market value assessment cannot take PFAS contamination into consideration. Two enacted bills in Rhode Island (SB 724 and HB 5861) amend current law to add that if PFAS in drinking water exceed the state’s interim standard of 20 ppt, the state and the public water supply will enter into an agreement that requires dates for submittal of water treatment plans that will reduce the PFAS levels to or below the interim level. As more information emerges about the health effects of PFAS, states will be sure to continue their work to combat, mitigate, and report on their presence in the environment. ASTHO will continue to monitor and report on all legislative and regulatory activity around this issue. Special Thanks-Blog - State and Federal Actions to Reduce PFAS Impact on Public Health website yes

A mid-session legislative update on five of ASTHO's top 10 public health state policy issues to watch in 2023: data privacy and modernization, reproductive health, health equity, strengthening public health agencies, and immunization.

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.

Recent legislation at both the state and federal levels has significantly affected the ability of health care providers to serve patients virtually and across state lines.

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.

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

Learn how states are regulating kratom, a plant-derived substance growing in popularity, in this Health Policy Update.