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Learn about public health strategies for preventing chronic disease that intersect with themes in MAHA report including nutrition and physical activity.

Learn how state and territorial legislatures can bolster or restrict public health legal authority, with examples from early COVID-19 as well as 2024.

From the Chief Medical Officer: Key Takeaways from ASTHO’s HPAI Scientific Symposium hpai scientific symposium, highly pathogenic avian influenza, one health, public health, state and local public health officials, wild birds, human health, infectious diseases, disease control and prevention, centers for disease control, infected with avian influenza, symptoms of illness, domestic animals, working closely, united states, health department, food safety, public health practice, domestic poultry, contact with infected, health official, health risks, infect humans, dairy cattle, exposure to infected Marcus Plescia, Jessica Baggett, Meredith Allen A recap of ASTHO's Scientific Symposium on Highly Pathogenic Avian Influenza While only one human case of Highly Pathogenic Avian Influenza (HPAI) has been reported in the United States this year, the discovery of transmission of HPAI in cattle has led to an increase in the need for federal, state, and local public health agencies to enter a heightened phase of readiness. The risk to the general population remains low but this change signals the need for an increase in collaboration, research, and communication. Last week, ASTHO hosted a virtual symposium in partnership with the Infectious Diseases Society of America and the Council for State and Territorial Epidemiologists that featured public health leaders and scientists driving the U.S. government’s response to HPAI. Experts outlined potential actions for managing further spread and identified areas requiring additional investigation and guidance. Using a One Health Approach is Critical One Health recognizes that the health of people is closely connected to the health of animals and our shared environment. This is not a new concept but has become more important in recent years. The disciplines of public health and agriculture are inextricably linked. The symposium emphasized the importance of building and maintaining partnerships between CDC, USDA, FDA, ASPR, NIAID, and state and local public health departments. Recognizing the interconnectedness of these domains is essential for effective disease prevention and control. Public Health Recommendations will Evolve with the Science A key insight from the symposium was the dynamic nature of the situation. While we know a great deal about pandemic flu response, spread through dairy cattle is new. More in-depth epidemiologic studies will call out changes in transmission between cattle, people and cattle, and the potential for person-to-person spread. Collaboration between public health, agriculture, and farm owners will allow public health to gather epidemiologic data that can be translated into clear and data-supported recommendations to prevent continued transmission. As scientific understanding evolves and new evidence emerges, so must our public health response. As always, the public health community will commit to continuous learning, flexibility, and readiness to adjust strategies accordingly to ensure that interventions remain evidence-based and effective. Assessing the Current State of Readiness The supporting federal government response to HPAI appears to be well positioned; our federal partners don’t anticipate challenges with the commercial supply chain for personal protective equipment (PPE), vaccine, or therapeutics. The commercial system continues to be the primary source for PPE, but there are federal stockpiles available from ASPR, and the Food Safety and Inspection Service (FSIS) national veterinary stockpile. There is no indication of viral resistance to existing antiviral treatments and, in addition to commercial supplies, "tens of millions of courses" of Tamiflu area available through the strategic national stockpile should they be needed. CDC is providing ongoing surveillance of emerging flu strains and anticipates rapid availability of vaccine should infection begin to occur in workers in high-risk settings. State and Local Public Health Officials are Increasing Planning and Coordination The interface between public health agencies and state or local agriculture departments is critical. A public health response includes rapid situational awareness, laboratory testing, implementing public health recommendations around screening/isolation, and providing appropriate care (medications). Questions and planning scenarios specific to health officials may include the following: How will your team determine whether people are exposed and, importantly, symptomatic? Who will you dispatch to the farm to obtain testing for those symptomatic individuals? What is your approach to case investigations? How will you engage in symptom monitoring in this population? On the laboratory side, how will specimens be transported to the public health lab? Are your laboratories ready to receive/run those specimens, even if they are, for example, conjunctival? If positive, how will that specimen be sent to CDC for confirmatory testing? If positive, how will you communicate the result to the individual and counsel them on isolation? How will Tamiflu be provided (if indicated)? From what cache? What is your communications plan if positive? ASTHO will continue to work closely with our partners to monitor this situation and provide updates as they become available. website yes

Leading Through a Pandemic: Teamwork and Crisis Communication Hear former and current State Health Officers and their Public Information Officers reflect on working together during the COVID-19 pandemic. 1/4 bottom Speakers Lee A. Norman, MD, MHS, MBA: Alum-KS John Wiesman, DrPH, MPH: Alum-WA Jessica Baggett, MPH: Former Public Information Officer (WA) Ashley Jones-Wisner: Former Public Information Officer (KS) Arundi Venkayya: Current Public Information Officer (OH) website yes

Sustained Management of COVID-19: Doing More of What Works to Control Future Surges article yes

An issue brief by ASTHO and the Duke University Margolis Center for Health Policy that highlights considerations for state health officials as they look to maximize the benefits of COVID-19 therapeutics.

Understanding Current U.S. Measles Outbreaks and Elimination Status Current U.S. Measles Outbreaks and Elimination Status Jessica Baggett, Susan Kansagra, Meredith Allen, Kimberly Martin Understand current U.S. measles outbreaks and the country's elimination status, following recent outbreaks and the highest case counts in decades. In 2016, the Pan American Health Organization (PAHO) declared the elimination of measles in the Region of the Americas, marking a monumental public health achievement. But in 2025, that progress came under threat and remains at risk at the top of 2026 — as recent measles outbreaks have driven the highest case counts in decades, prompting health agencies to reassess elimination status. Current Outbreaks Jan. 21 marks one year since the first U.S. measles outbreak of 2025 was reported. The United States went on to experience its worst year for measles in over three decades, with 2,144 confirmed cases. According to CDC, there were 49 outbreaks in 2025 and 88% of confirmed cases (1,884 of 2,144) were outbreak-associated. For comparison, 16 outbreaks were reported during 2024 and 69% of cases (198 of 285) were outbreak-associated. Most 2025 cases occurred in unvaccinated (93%) or under-vaccinated (3%) individuals, and three deaths were confirmed. Measles Elimination These outbreaks put the United States at risk of losing elimination status if transmission of the same strain continues for 12 months uninterrupted. In public health terms, “elimination” means that a disease’s continuous (endemic) spread within a region has ceased for at least 12 months. While it doesn’t necessarily mean zero cases, it does mean that local chains of transmission have been interrupted. The United States achieved elimination status in 2000 due to high coverage with the measles, mumps, and rubella (MMR) vaccine, strong disease surveillance, and public health response to isolated cases. Other countries in the Americas followed similar paths. As a result, PAHO verified the region as measles-free for years. Why Elimination Status Matters Elimination is more than a label. It reflects protective immunity within a population and the capacity of the public health system to prevent sustained outbreaks. When elimination status holds: Transmission is less likely, preventing widespread illness and death. Health care systems avoid unnecessary strain from preventable care utilization. Public health systems circumvent the toll of managing large outbreaks. Vulnerable groups (i.e., infants too young for vaccination, immunocompromised people) are better protected. Public confidence in immunization programs remains strong. What Happens if Elimination Is Lost? In November 2025, PAHO announced that the Region of the Americas — including the United States and Canada — lost measles elimination status after endemic transmission persisted, especially in Canada, for more than 12 months. This means that measles is once again circulating continuously within the region rather than only in isolated imported cases and quickly contained outbreaks. CDC is currently working with state and local health officials to analyze data and determine individual U.S. status, assessing if the various outbreaks are linked, which would signify ongoing transmission rather than individual introductions of disease. In November 2025, Canada officially declared their lost elimination status following prolonged transmission in 2024-2025. Ongoing outbreaks in Mexico and other parts of the Americas further contributed to the rise in regional case counts. Finally, PAHO invited both the United States and Mexico to a virtual meeting on April 13 to review their current measles elimination status. Endemic transmission makes outbreaks larger and more frequent, and increases the number of people who become ill, particularly those not protected by vaccination. Ongoing measles transmission also requires additional public health resources including expanded surveillance, outbreak response, and efforts to raise vaccination coverage, especially in communities with low immunization rates. This adds strain to health departments which often have fixed resources, with one study estimating the average cost per measles case at nearly $60k when including the public health perspective. Measles transmission in the United States has disproportionately impacted communities with lower vaccination rates. Therefore, the loss of elimination status could necessitate greater attention to vaccination recommendations for international travelers coming to the United States, particularly for infants. For example, similar to U.S. recommendations for those traveling internationally, Australia suggests that infants 6-11 months traveling to areas where measles is endemic or having an outbreak can get assessed for an earlier dose of the measles vaccine. Response Strategies for Public Health Departments While the United States works to determine its official status, there are many activities state and territorial public health departments continue to implement to prevent the spread of measles: Vaccination Campaigns The MMR vaccine is highly effective in preventing measles, with CDC reporting 93% protection after one dose and 97% after two doses. Herd immunity is a critical preventive measure that interrupts transmission and requires approximately 95% of the population to be vaccinated. Despite this strong science, falling vaccination rates driven by hesitancy, misinformation, and gaps in access have left pockets of the population vulnerable. Boosting vaccination is the most effective way to stop outbreaks, protect children and adults (particularly those who can’t get vaccinated), and prevent hospitalizations and deaths. Examples of vaccination campaigns include New York’s “Immunization Is Protection” and Minnesota’s reminders about immunization importance. Analyzing Local Data to Identify High Risk Sub-Populations Public health departments are evaluating local Immunization Information System data to identify sub-populations with lower measles vaccination rates, areas with high exemption rates, and settings with persistent under-immunization. Examples include Illinois’ Vaccination Coverage Dashboards, Washington’s Immunization Measures by County Dashboard, and American Immunization Registry Association’s Small Area Analysis. Understanding which populations are at higher risk can inform education and outreach activities. Establishing Relationships with Trusted Community Messengers Identifying under-vaccinated sub-populations is only beneficial when health departments build trust and authentic engagement within communities. They must work with trusted messengers such as faith leaders, community health workers, and local organizations to co-develop and amplify messages about measles risks and the importance of MMR vaccination. In addition, it is important to tailor communication materials to reflect community languages, values, and concerns. Communities are more likely to accept and act on respectful, relevant messaging. Examples of successful community partnerships include the Palmetto Community Action Partnership, the Enrichment Services Program, and the Community Action Program for Central Arkansas. Read ASTHO’s “Championing Change” Toolkit for more information and examples. Supporting Health Care Systems and Providers Clinicians remain highly trusted voices within communities. Health departments equip providers with up-to-date information and resources to ensure they are prepared to recognize, test, report, and manage measles cases effectively. Examples of these resources include CDC’s Be Ready for Measles Toolkit, Arizona’s Measles Surveillance Toolkit, South Carolina’s Measles Clinical Assessment Guide, and North Carolina’s Measles (Rubeola) Resources for Health Care Providers. article yes

Outcomes and Implications of ACIP’s Vote on the Hepatitis B Vaccine for Newborns Implications of ACIP Vote on Hepatitis B Vaccine for Newborns Susan Kansagra, Andy Baker-White, Kim Martin, Jessica Baggett Learn about the outcomes and implications of the December 2025 ACIP vote on the hepatitis B vaccine for newborns. On Dec. 4 and 5, the Advisory Committee on Immunization Practices (ACIP) held a long-anticipated meeting featuring two major topics of discussion: the hepatitis B birth dose and the pediatric vaccine schedule. The committee voted on two questions related to the pediatric hepatitis B vaccine schedule, both of which passed. To briefly summarize the outcome of the meeting, ACIP shifted from recommending a universal birth dose of the hepatitis B vaccine for all newborns to individualized decision-making for newborns born to HBsAg-negative mothers. There was no change to the recommendation for infants born to HBsAg-positive mothers or whose HBsAg status is unknown. CDC has not yet adopted these changes. In the meantime, many states are taking actions to provide clarity to providers and promote public confidence in the vaccine. How States Are Taking Action In response to (and in some cases before) the new ACIP recommendations, several states issued recommendations, guidelines, standing orders, executive directives, and health alerts for providers to provide clarity. States Recommending or Encouraging the Full Vaccine Series Some states are issuing their own guidance and recommendations for the hepatitis B vaccine series or encouraging providers to adhere to the series as is it was before the new ACIP recommendations: The Northeast Public Health Collaborative released a consensus statement before the ACIP meeting recommending the hepatitis B vaccine birth dose and a schedule that aligns with clinical recommendations. Collaborative members also issued statements reaffirming their adherence to established hepatitis B vaccine recommendations, including Connecticut, Maine, Maryland, Massachusetts, New Jersey, New York, Pennsylvania, and Rhode Island. Maryland also released guidance for parents and caregivers about its childhood immunization recommendations. States in the West Coast Health Alliance issued statements supporting the universal birth dose of the hepatitis B vaccine. These states include California, Hawaii, Oregon, and Washington. Many individual states also issued statements affirming the recommendation for the continued use of the hepatitis B vaccine birth dose, including Arizona, Colorado, Illinois, Michigan, New Mexico, and Vermont. States Issuing Standing Orders and Executive Directives At least two states issued a standing order or executive directive related to the hepatitis B vaccine: The Maryland Department of Health issued a standing order to ensure hepatitis B vaccine access for infants and children in the state. The standing order authorizes qualified health care providers to administer the hepatitis B vaccine and outlines the policies and procedures for administering the vaccine. In New Jersey, the acting health commissioner issued an executive directive recommending the hepatitis B vaccine birth dose and full series. States Issuing Public Health Alerts and Advisories Well before the recent ACIP meeting, the Maine CDC issued a health advisory to providers recommending the hepatitis B vaccine birth dose and full series. Since the ACIP meeting, at least two other states have released provider advisories. Maryland issued a letter to providers laying out the state’s hepatitis B vaccine recommendations, and New Hampshire issued a health alert with a continued recommendation for the full hepatitis B vaccine series and birth dose. In addition, Vermont sent a guidance letter to the providers in the state’s vaccine program. States Reexamine State Statutes and Agency Rules Linking to ACIP Recommendations Over the last several months, many states have proposed and enacted legislation to move away from sole reliance on ACIP recommendations. More recently, Massachusetts adopted H 4761, authorizing the health commissioner — in consultation with a newly established committee on immunization recommendations — to review and issue alternative standards to ACIP recommendations. States are also proposing changes to agency rules related to school and childcare immunization requirements. For example, Colorado’s health department has issued a proposed rule to modify the state’s standards for school and childcare immunization requirements and to align its rules with recent changes to state statute. Additional Considerations for States If CDC adopts the proposed ACIP recommendations, states can consider the following actions. Hepatitis B Screening States should continue to work with health care providers to close gaps in hepatitis B screening and follow-up for infants of HBsAg-positive mothers. Data show the most common cause of perinatal infection occurs when a mother with hepatitis B gives birth and the infant does not receive follow-up postexposure prophylaxis. Insurance Coverage While public and private insurance, including the Vaccines for Children program, are still required to cover the hepatitis B vaccine, such as any birth doses given to infants of HBsAg-negative mothers under shared clinical decision-making, states can consider creating additional coverage requirements. Some states have passed policies on insurance coverage, and other states have proposed legislation related to other vaccine coverage. Implementation of Shared Clinical Decision-Making While health care providers and parents have the flexibility to determine their approach for infants of HBsAg-negative mothers (i.e., continuing to recommend/give a birth dose), ACIP recommendations that rely on shared clinical decision-making have increased provider questions on how to have and document these conversations. States can work with medical associations, provider boards, and health care partners to ensure clinicians understand how to apply shared clinical decision-making recommendations. This includes educating staff in birthing hospitals, community clinics, and pediatric practices on how to counsel parents and document informed discussions. Jurisdictions can also develop or adapt educational materials and decision aids that clearly outline benefits, risks, timing, and follow-up options to support both providers and parents. More information on shared clinical decision-making is available from CDC and Common Health Coalition. States can also encourage providers and birthing institutions to examine workflows, Immunization Information System documentation, and follow-up to ensure scheduling of future doses. Implications for Vaccine Supply States can examine vaccine supply through the Vaccines for Children program to understand how the new recommendations impact supply of single antigen hepatitis B vaccines. If a significant percentage of the population receives vaccines on a different timetable, it could impact supply and timing for other vaccinations, given the reliance on combination vaccines for hepatitis B dose two and three, which can include DTaP, polio, and Hib vaccines. Supplemental Resources Common Health Coalition: Vaccine Resources December 2025 ACIP Meeting: Hepatitis B Updates for Health Leaders (PDF) Vaccine Integrity Project – Hepatitis B by Centers for Infectious Disease Research and Policy Understanding the Benefits of Vaccines: Common Questions by HealthyChildren.org Childhood Vaccinations (PDF) by Your Local Epidemiologist Hep B Birth Dose Media Toolkit by Hepatitis B Foundation Reframing the Conversation About Child and Adolescent Vaccinations by Frameworks Institute CDC: ACIP Shared Clinical Decision-Making Recommendations ACIP Meeting Materials for Public Posting: Hepatitis B Birth Dose Briefing Document (PDF) Hepatitis B Birth Dose Vaccination (PDF) article yes