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Strengthening Leadership, Risk Communications, and Preparedness in the Islands Strengthening Public Health Preparedness in the Islands Sidnie Christian, Alyssa Boyea Key strategies in on leadership, risk communications, and preparedness, can help island jurisdictions prepare for and respond to emerging public health threats. ASTHO convened a two-day, in-person workshop in Honolulu from June 25 – 26, bringing together public health preparedness staff from American Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, Guam, Hawaiʻi, the Republic of the Marshall Islands (RMI), and Palau, as well as federal partners from CDC, the Department of Homeland Security, and the Administration for Strategic Preparedness and Response. The workshop focused on leadership and workforce development, risk communications, administrative preparedness, and more to support island areas as they prepare for and respond to natural disasters and other emerging public health threats, of which emerged key learnings that can benefit all island jurisdictions. Leadership and Workforce Development Leading through change requires transparency, trust, and collaboration. Planned change involves assessing readiness for change, identifying resources needed, securing buy-in, and determining a path forward. However, sometimes change can leave little to no time for preparation. Island jurisdictions have encountered challenges in the face of change, with many workshop participants sharing firsthand challenges around retaining institutional knowledge, infrastructure, and receiving assistance from the mainland United States in a timely fashion. As such, change readiness, succession planning, and effective change management practices are of utmost importance in the islands. Key recommendations and takeaways include: Utilizing a reputable framework, such as Kotter 8-Step Change Model, is pivotal for improving change readiness and change management. Change management frameworks and methods can assist with different types of change including structural change, strategic operational change, people-centric change, etc. Trust is hard to build, but easy to lose. Participants spoke about characteristics of high trust relationships including open communication, consistency, good judgement or expertise, and cultural sensitivity, while low trust relationships characteristics include lack of communication, inconsistency, and lack of teamwork. Succession planning is important to ensure institutional knowledge and capabilities remain in the wake of staff turnover or retirement. Identifying the necessary expertise, skills, and capabilities for each role is vital in the case of unplanned changes in staffing. Promising practices include annual review of critical positions, conducting talent calibration sessions, defining action plans, and obtaining buy-in from leadership and relevant partners. Risk Communications The island jurisdictions face emergencies that require creative response efforts. Both Hawaiʻi and RMI demonstrated innovative approaches in risk communications during COVID-19, finding success in forming critical partnerships, utilizing trusted voices within the community, and bridging communication gaps: Hawaiʻi utilized social media to showcase individuals such as doctors, pastors, social media influencers, and even local sports teams getting vaccinated, and utilized trusted voices to deliver messages. Additionally, they translated their materials into three languages (Marshallese, Samoan, and Hawaiʻian), modeling that no one gets forgotten, the true meaning of “ohana.” RMI created a working group with a mix of partners that curated press releases, educational materials, and sitreps, and served as a liaison between RMI Ministry of Health and Human Services and the community. It also partnered with several media outlets (e.g., radio stations, local papers, and other private sectors) and utilized mass text messaging to spread information quickly. The latter proved to resonate with most island jurisdictions who struggle with staying connected to hard-to-reach populations, namely those in more rural and disconnected communities. RMI was able to connect with these populations through WhatsApp to keep them updated throughout the COVID-19 response. Administrative Preparedness Improving administrative preparedness plans and processes ensure timely and efficient access to needed resources for a public health response. Most workshop participants are currently in the process of updating existing administrative preparedness plans, while some are working with other departments to create and implement new plans. Attendees discussed key partnerships for collaboration including other departments, Medical Reserve Corps, and other volunteer organizations. One common key challenge that emerged was around staffing (e.g., finding qualified people to fill vacancies, hiring process issues, making sure positions are competitive, etc.). To address this issue, island jurisdictions can work closely with other departments or jurisdictional agencies to streamline current processes, establish memorandums of understanding with different partners/facilities to assist with emergency procurement, and ensuring staffing vacancies are competitive and match public health classifications. Disease Forecasting A survey on state and territorial expertise and needs for infectious disease forecasts, models, and other outbreak analytic techniques—implemented by ASTHO with support from CDC’s Center for Forecasting and Outbreak Analytics—revealed that respondents from island jurisdictions experienced several barriers that led to limited use of infectious disease forecasts to inform communication and decision making. Challenges noted include limited software access, limited disease modeling capacity or skills, and lack of uniform reporting systems. Through a discussion-based exercise, workshop participants shared their challenges and considerations for ASTHO and CDC to assist with disease forecasting in the island jurisdictions moving forward. Challenges include but are not limited to: Delays with sending samples to labs and receiving results in a timely manner. Without timely results, it is challenging to take swift action. Lack of staff / staff wearing many hats with limited capacity. In most cases, there is no specific communication plan for disease forecasting within the departments. Communication can be challenging without clear processes and channels. Participants noted the desire for additional disease forecasting training and opportunities for collaboration. They suggested an integrated training session with island epidemiologists and other relevant staff to enhance disease forecasting knowledge and communication, as well as strengthen collaboration. Preparing for and Responding to Climate Events From hurricanes to typhoons to volcanic eruptions, the island jurisdictions are no strangers to the effects of changing climate. Willliam “Brandon” Aydlett, science and operations officer at the National Weather Service, and Shelbi Davis, Senior Analyst on the Environmental Health team at ASTHO, offer the following recommendations to island jurisdictions for preparing and responding to unprecedented climate events, as discussed with workshop participants: Create or update standard operating procedures for various climate related responses unique to the island. Always prepare for a category higher storm than is expected. Consider conducting regular vulnerability assessments to better understand areas where the island or its people may be most susceptible to adverse health impacts from climate events. Jurisdictions can learn from one another and find a sense of camaraderie in their preparedness efforts, much like the workshop participants. For example, one island jurisdiction noted that they currently do not have a warehouse to store equipment but are working on a plan to secure one; another jurisdiction, having recently revamped their warehouse, noted that they could assist their island neighbor in this endeavor and provide lessons learned as well as strategies to help secure a warehouse that will fit their needs. Looking Toward the Future Sharing lessons learned with one another and reflecting on how to apply those learnings in respective communities is crucial. Workshop participants shared their intent to share and utilize resources and information shared throughout the workshop with their leadership and team to begin implementing in their jurisdictions, as well as using strategies and skills learned to enhance partnerships. To all the participants and our Hawaiʻian hosts, we say mahalo. Related Resources Modernizing Infrastructure and Facilities for Readiness and Response | ASTHO PH-HERO Workforce Resource Center | ASTHO ASTHO STAR Center | ASTHO Evidence-Based Strategies to Enhance Public Health Emergency Preparedness and Response | JPHMP article yes

Six questions with Scott Becker, CEO of the Association of Public Health Laboratories. Becker is active in national and international public health initiatives. He chairs the Governance Working Group for the Global Laboratory Leadership Program, a collaboration with the World Health Organization, CDC, and others to develop a competency-based curriculum for laboratory leaders. Additionally, Becker is a member of the Affiliate Council of ASTHO, which he formerly chaired.

Pharmacies have long been instrumental partners in providing lifesaving vaccines nationwide. As state and territorial health officials evaluate their COVID-19 response, planners must include input from the pharmacy community when identifying areas for improvement, as well as best vaccination practices in advance of future public health emergencies.

In addition to the countless hours worked during the COVID-19 pandemic, many public health workers are also grappling with how to repay outstanding federal loans. In response, the U.S. Department of Education (DOE) recently announced temporary relief to current and future Public Service Loan Forgiveness (PSLF) program participants as a result of the COVID-19 pandemic.

If there is any word to describe 2020 it is “unprecedented,” with the work of health agencies front and center since COVID-19 emerged in the U.S. But as we approach Public Health Thank You Day and the Thanksgiving season, ASTHO wants to send a special appreciation to our entire state and territorial public health workforce. We have been so impressed by your tireless work to address COVID-19 in your jurisdictions and you have wowed us all with your dedication and commitment to the work of health protection and improvement. Thank you all for all you do to keep your communities healthy!

An ASTHO brief on the importance of understanding moral injury and burnout, with recommendations on areas of organizational focus.

Initial estimates from 2020 suggest that annual drug overdose deaths in the United States reached a record high of 93,000. Fortunately EMS strategies are being put in place to combat this nation-wide issue.

Explore this report to learn about radiation readiness capacity in the public health workforce.

Implementing Health in All Policies in the Climate Space ASTHO, Association of State and Territorial Health Officials, HiAP lens, Health in all policies, climate change, climate space, flooding and rain, extreme weather, extreme heat, wildfire damage, seven strategies, Texas workgroup, national disaster operational workgroup, Washington state department of health, emergency preparedness and response, hiap implementation, Wisconsin department of health services, new mexico taskforce, interagency climate change taskforce, climate action teams, Climate and Health Capacity Survey, HiAP Task Force; Climate Change Commission, Resilience Initiative Kerry Wyss, Ali Aslam ASTHO | A Health in All Policies approach can help public health agencies better address the impact of climate change on population health and well-being. Each year, we face hurricanes, floods, extreme heat events, destructive wildfires, as well as other natural disasters and homeland security threats that test the resiliency of state, territorial, and freely associated state agencies and the communities they serve. To address the health threats posed by natural disasters and by climate change, more health agencies are integrating a Health in All Policies (HiAP) approach. This cross-sector approach can make these climate efforts more effective and impactful, and help promote health equity and optimal health. This report outlines strategies for health agencies to apply the HiAP lens and utilize cross-sector collaboration to optimize their climate and health responses. Get the Report (PDF) website yes

Investing in Indiana’s Public Health Infrastructure Through Community-Driven Policy Change public health infrastructure, community driven policy, indiana state health commissioner, public health system, indiana department of health, outpatient facilities, technical assistance, data and information integration, emergency preparedness, child and adolescent health, legislative action, state and local elected officials, health problems, health care, health system, health departments, federal agencies, essential public health services, centers for disease control, state and local levels, health outcomes, health organization, covid-19 pandemic, health infrastructure, promoting health, public health organizations, states public health, federal funding, astho, association of state and territorial health officials Maggie Davis, Keith Coleman Indiana enacts historic public health funding through community engagement and legislative support. In April 2023, Indiana passed bill SB 4, which was a historic investment in the state's public health funding and restructuring its public health system. This case study shares how the Governor's Public Health Commission and the Indiana Department of Health approached community listening sessions, formulated recommendations, and successfully built legislative support to reform the public health system in the state. Get the Report (PDF) website yes

Read a detailed summary of the FY26 Senate Appropriations Bill, which was released on July 31.

The experts on today’s episode make the case for how a robust public health workforce could have changed the trajectory of the pandemic response, but also explain why we can reimagine what a strong public health workforce requires as we enter into pandemic recovery.

Public Health Organizations Unite in Call to Restore State and Local Emergency Funding and Approve Emergency Supplemental for Zika ARLINGTON, VA—As the weather warms and the threat of Zika virus intensifies, state and local health agencies are faced with the dilemma of a significant funding cut, as documented in two new reports released by the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials (NACCHO), the Association of Public Health Laboratories (APHL), and the Council of State and Territorial Epidemiologists (CSTE). Absent dedicated funding from Congress to prepare and respond to the threat of Zika virus, the Centers for Disease Control and Prevention (CDC) last month announced it will need to reprogram $44.25 million from the Public Health Emergency Preparedness (PHEP) fund to help combat Zika. State and local health agencies depend on PHEP funding to prepare and respond to health emergencies, everything from natural disasters to terrorist or mass casualty events. Preparing for and responding to emerging infectious disease is also a primary use of PHEP funding, meaning state and local health agencies will have less capability to find, control, and mitigate localized outbreaks of Zika as a result of the reallocation. ASTHO, in cooperation with CSTE, APHL, and NACCHO, asked their members what the consequences of the PHEP reprogramming would be, should the cuts take effect on July 1. The results raise significant concern showing that state and local emergency response will be compromised. Major findings from the surveys include the following. Community Preparedness Will Suffer the Most Both state (77%) and local (75%) respondents listed “Community Preparedness” as the area that will be most negatively affected. Scenario planning and training exercises will be curtailed or eliminated. Volunteer recruitment and training will slow or cease. Community partnerships and contracts with specialized vendors will be compromised. Laboratory Testing and Surveillance Capacity Will Diminish More than 70 percent (72%) of state respondents said they expect that functional preparedness programs, including disease surveillance, epidemiology, lab services, and mosquito control, would be negatively affected. Labs would be forced to delay or eliminate new equipment purchases or scheduled equipment maintenance. Public Health Staff Cuts State and local agencies suffered significant job losses—up to 20 percent—during and after the Great Recession that started in late 2007, and they have not come close to adding that number back since. Both state and local survey respondents report likely staffing cuts as a result of the PHEP reprogramming. Almost two-thirds (64%) of local health agencies responding to the survey said they expect to lose at least one health preparedness staff person. There is significant fear that this could worsen significantly if the reprogramming continues in future years as the threat of Zika is not expected to abate in the short term. Zika Response at State and Local Level Will Be Compromised as a Result of the Reallocation State and local health agency leaders are unified in saying the reduction of PHEP funding will harm their ability to respond to and control Zika once it establishes itself in the U.S. Our capacity to identify localized outbreaks and our capability to control and eliminate virus transmission will be slower. Local agency responders cited the following concerns: A decrease in staffing, Medical Reserve Corps (MRC) unit, or volunteer sustainability. A reduction in opportunities to provide staff trainings as well as plan and conduct exercises. An inability to conduct surveillance or epidemiologic investigations. At the state level, 61 percent of respondents say decreased PHEP funding in their state will significantly harm their ability to prepare for and respond to Zika. One respondent wrote: “The PHEP funding in [our state] is the resource we have for providing a response to Zika, and any other novel communicable disease. By reducing this funding you are reducing our ability to respond to a Zika event in [our state].” All public health sectors—federal, state, and local—have worked hard to build and sustain an all-hazards preparedness infrastructure that can deliver on their mission to protect and enhance the health and well-being of their constituents. However, large-scale emergencies, such as the 2009 influenza pandemic, Ebola, and Zika, require sufficient and reliable core funding to maintain a solid and ready public health infrastructure and additional emergency funds to provide the enhanced protections and services those living in the United States deserve and expect. Robbing the fund that sustains the all-hazards infrastructure to pay for large, widespread emergencies, no matter how necessary, ensures that infrastructure will deteriorate. Dedicated emergency funding that will enable all public health sectors to prepare for and respond to Zika is essential. ASTHO Press Release Boilerplate NACCHO Boilerplate APHL Boilerplate CSTE Boilerplate website yes

One of tools presidents have to implement and drive their strategy are executive actions. Executive orders and presidential memoranda carry the force of law and allow presidents to move quickly, deliver a clear message, organize the functioning of the executive branch, and spotlight critical issues with declarations of commemorative observances.

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

To ensure that establishments were abiding by food safety rules during the COVID-19 pandemic and to protect the health of professionals who inspect these facilities, multiple state health agencies implemented virtual inspection protocols.

Fortunately, looking at the ASTHO Directors of Public Health Preparedness (DPHP) peer group and seeing the great work of public health emergency preparedness and response programs across the nation, we recognize that there is much to be celebrated this month—but also much more work that needs to be done.

ASTHO's mission is to support, equip, and advocate for state and territorial health officials in their work of advancing the public's health and well-being. To that end, here are the 12 most popular resources our members, partners, and email subscribers accessed in 2021.

In recognition of Rural Health Day, which falls on Nov. 18, we spoke with Ayne Amjad (SHO-WV) and Maggie Cook-Shimanek (SHO-MT) about the importance of public health in rural areas.

The impact of the COVID-19 response on the public health workforce has been profoundly felt by employees and the agencies they serve. Across the country, unplanned leadership transitions, early retirements, and personnel scale-ups have all impacted who the workforce is and what they do day-to-day. Many of those who have remained are feeling depleted and battered. In order to support and build the public health system the country needs, we need data specific to governmental public health.