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This toolkit details structure and outcomes of ASTHO’s Vaccine Equity Project to help jurisdictions in their pursuit of vaccine equity.

Forming Partnerships to Increase Rural Immunization Rates ASTHO, Association of State and Territorial Health Officials, national immunization awareness month, farmworker communities, vaccine equity project, increase rural immunization, immunization rates, healthcare access, community action agencies, barriers to vaccine uptake, community partnerships, underlying medical conditions, back-to-school vaccinations, national community action partnership, vaccination strategies, vaccination importance, farmworker communities, challenges to healthcare access, vaccination rates, national center for farmworker health, rural immunization, preventable disease Shalini Nair, Heather Tomlinson ASTHO | Learn how public health partners with community organizations to bring vaccines to rural communities that otherwise would have difficulty accessing care in this blog. Rural communities face many challenges in accessing health care, like limited provider availability, gaps in insurance coverage, transportation issues, language barriers, and limited internet access. Additionally, rural populations are more likely to have underlying medical conditions, less likely to have insurance, and live farther from medical facilities. During the COVID-19 pandemic, overall routine vaccination coverage remained stable; however, there was a notable 4–5% drop in vaccination rates among young children living below the federal poverty level and in rural areas. In response, CDC developed the Let’s Rise initiative and a back-to-school campaign to provide actionable strategies and resources for getting Americans back on schedule with their routine vaccines. This month is National Immunization Awareness Month, highlighting the importance of vaccination for people of all ages. Boosting vaccine access and confidence is crucial to limit the spread of vaccine-preventable diseases. Barriers to Vaccine Uptake While they only account for 14% of Americans, rural communities represent nearly two-thirds of primary health care shortage areas. Due to the lack of providers, rural Americans often live over 10 miles from their closest health care facility and do not always have access to reliable transportation. Additionally, rural communities also have a larger proportion of people who are uninsured and underinsured. Studies have shown that primary care visits and strong provider recommendations can greatly enhance utilization of preventative health measures, such as vaccination, while limited access to these aspects can reduce health outcomes. The COVID-19 pandemic exacerbated this disparity as many rural hospitals closed and the country faced national workforce shortages. Rural communities were significantly impacted, with 76% of rural adults knowing someone who had COVID-19 and 38% contracting COVID-19 themselves. Despite this impact, the majority of those polled reported this did not change their intent to get vaccinated. Furthermore, the gap in COVID-19 vaccination coverage between urban and rural areas more than doubled between April 2021 and January 2022, despite rural communities having disproportionately higher COVID-19 disease incidence and mortality. The digital divide also limits access to accurate information on the safety and efficacy of vaccines. States and community groups have taken various actions to address these barriers. Successful Strategies to Address Low Vaccination Rates in Rural Communities With support from CDC, ASTHO is working with the National Community Action Partnership and five community action agencies (CAAs) on the Partnering for Vaccine Equity project. A recent blog showcases some of the work the CAAs have implemented to improve vaccine acceptance and uptake and to customize evidence-based strategies to their own communities and neighborhoods. Two project partners, Pickens County Community Action and Enrichment Services Program, are working to build trust and increase vaccine uptake in rural Alabama by leveraging existing networks and taking a whole-health approach to outreach efforts. In Russell County, Enrichment Services deployed a highly successful paper- and social media-based messaging campaign centered around messages that emphasized three points: Vaccines are Safe, Vaccines Save Lives, and Vaccines Save Money. By reaching out to local churches, Enrichment Services was able to greatly expand the reach of their health promotion messages. In addition, to increase the number of available access points for vaccination, Enrichment Services co-located outreach at schools and engaged local EMT representatives from the National Association of Emergency Medical Technicians for their first-hand knowledge of the community. Sample graphics from Enrichment Services' vaccine equity messaging campaign. In Pickens County, Pickens Community Action relied on existing partnerships with over 30 community organizations to kickstart their vaccine equity efforts. To address access-related barriers, Pickens sponsored rides to and from their vaccine clinics and partnered with local physicians to provide personalized counseling to individuals receiving vaccinations. Notably, they established both a faith-based and a disability services advisory committee to further assist their outreach efforts. Some of their existing partners in the community include the local National Association for the Advancement of Colored People (NAACP), the Black Belt Community Foundation, Whatley Health System, Hill Hospital of Sumter County, The University of Alabama, and elected officials. Left: A food table being set up for Pickens’ Community Health Fair at the Tom Bevill Lock and Dam in Pickensville, AL. Right: A mobile outreach van from partner the University of Alabama rolls in to assist at Pickens’ Community Health Fair. For both agencies, offering services that address the social determinants of health greatly increased engagement. Both sites found success in offering incentives—such as food or gas gift cards and free food giveaways—but their greatest success has been from co-locating vaccine events with service offerings that address essential needs such as housing, utility assistance, or education. This model has proven highly successful not only for COVID-19 vaccines, but also as a sustainable strategy for general vaccine outreach. Increasing Vaccination Rates in Farmworker Communities Numerous successful strategies have been implemented in rural communities largely comprised of immigrants—with a special focus on migrant farmworkers, who labored throughout the pandemic due to the critical nature of their work. In addition to facing barriers related to transportation, health insurance, and language access, many farmworkers are not able to visit a clinic or pharmacy due to their long working hours. The National Center for Farmworker Health, in collaboration with CDC and over 40 different organizations, worked to diffuse funding, trainings, and tools for building capacity to act during the public health emergency. This network generated over 1.3 million COVID-19 related educational interactions with farmworkers and supported the distribution of over 108,000 COVID-19 vaccine doses during 2020 and 2021. The network also documented effective practices undertaken by community-based organizations and agricultural employers to distribute vaccines, dispel myths, and build vaccine confidence. Photos courtesy of the Guatemalan-Maya Center (left) and National Center for Farmworker Health (right). State Considerations for Implementation Collaboration with trusted community groups can amplify state efforts to vaccinate communities, particularly in those with low vaccination rates. Working with CAAs and organizations that understand their communities and utilize innovative outreach strategies can help states expand the reach of their messaging. Communications should be tailored to include multilingual messaging and images that resonate with targeted communities. The National Governors Association developed a guide that provides valuable strategies for states to increase vaccine uptake in their rural communities. To help address the digital divide in their communities, several states have made investments in their digital infrastructure. Partnering with local pharmacies, federally qualified health centers, and emergency medical services to offer alternative vaccination sites in communities has been integral in improving awareness and access. Holding mobile vaccine clinics with after-hours availability or offering transportation to and from vaccine clinics can help address transportation issues and make vaccines accessible in communities with limited health care facilities. Addressing immunizationinequities in rural communities requires understanding the community and implementing innovative strategies tailored to these populations. Partnering with community-based organizations can help states reach critical audiences and ensure that vaccine efforts are addressing relevant barriers. article yes

Learn about three key efforts informed by frontline staff that can help improve infection prevention in dialysis settings.

Learn about the importance of immunization information systems to public health in this Health Policy Update.

States Reassessing Vaccine Policy and Public Health Powers Shalini Nair, Andy Baker-White Review of state policies to weaken vaccine requirements and reduce public health powers. Immunization is a key pillar of public health, crucial for protecting communities and preventing infectious diseases from spreading. State and territorial health officials and their departments play critical roles in setting and implementing immunization requirements, managing disease surveillance and outbreak response, and ensuring access to vaccines. In recent years, however, the immunization landscape has evolved as legislative changes alter public health authority and access to vaccines. As these challenges persist, public health officials must be informed and prepared to navigate the dynamic policy environment to ensure immunization programs’ continued effectiveness at protecting public health. The True Cost of Vaccine Skepticism and Misinformation In the years since the pandemic, rates of routine vaccinations among U.S. children have steadily declined; there has simultaneously been an increase in non-medical exemptions. While reasoning behind personal decisions about vaccination are not always clear, increasing prominence of vaccine-related myths is a significant contributor to this phenomenon. Perhaps the most glaring consequence of this decrease is best illustrated by the 2025 measles outbreak and the first measles-associated deaths in more than a decade. Previously considered to have been eliminated, measles is now under threat of resurgence as vaccine rates fall below the thresholds to uphold herd immunity. Health officials are also seeing declines in coverage for several other vaccine preventable diseases like pertussis, mumps, hepatitis, and even polio. Legislation Restricts Innovation and Sows Doubt About Vaccine Components The use of mRNA technology expanded in 2020 following its breakthrough success in COVID-19 vaccines. These mRNA vaccines prevented more than 120 million additional COVID-19 infections and 3.2 million additional deaths. Researchers are currently assessing mRNA technology to address pandemic influenza, HIV, Zika, and even cancer. During 2025 sessions, at least seven states introduced legislation to ban or limit using mRNA vaccines. Iowa’s SF 360 sought to prohibit any “gene-based vaccines” (i.e., those developed using mRNA or DNA technology); the bill was based on a widely debunked myth that mRNA vaccines can interact with and alter human DNA (they can’t). New York’s A 4798 would prevent administering COVID-19 mRNA vaccines until the department of health conducts a risk-benefit analysis. Several states have introduced legislation to prohibit selling — or require labeling foods that contain — vaccine or vaccine material. This bill is based on another common internet rumor that mRNA vaccines are being introduced into the food supply via livestock and produce (they aren’t). Nonetheless, Utah enacted a bill (HB 84) requiring that food intended for human consumption that contains a vaccine or vaccine material be designated as a drug. Similar bills were introduced in Florida (HB 525), Alabama (HB 316), and Tennessee (SB 616, HB 1100). Vaccine Authority’s Shifting Landscape While the federal government plays an important role in putting forth policy recommendations, the ultimate power to impose or revoke vaccine requirements and determine exemptions outside of health emergencies rests with states. In many jurisdictions, state health agency expertise determines the vaccines required for school enrollment. These decisions, while ultimately at the feet of state health officials, rely heavily on input from experienced, knowledgeable, and skilled agency staff. Recent legislative actions in several states seek to shift authority for determining school-based immunization requirements solely to the legislature. Idaho’s new law (H 290) removes the state board of health’s authority to determine which immunizations are required for daycare and school enrollment, as well as the manner and frequency of their administration. The bill also repeals a former law establishing the Idaho Childhood Immunization Policy Commission, created in 2010 to issue recommendations to the legislature and board of health. A similar effort in Maine (LD 727) would remove health department authority to determine school vaccine requirements as part of a larger repeal effort responding to the 2019 law disallowing vaccine exemptions based on religious or philosophical grounds. In New Hampshire, existing statutes define required immunizations for school attendance and allow the state health official to add to this list via the rulemaking process. Recently, lawmakers introduced a bill (HB 357) that would remove this add-on ability. If passed, existing commissioner-led requirements for vaccines such as varicella, hepatitis B, and Hib would expire in June 2026 and no future amendments could occur under this authority. Several other bills introduced in Texas (HB 468, HB 3304, SB 94, SB 117, HB 3852), West Virginia (SB 108, HB 2203), and North Carolina (HB 89) target shifting authority and/or modifying vaccine requirements for certain school types. Evidence-Based Policy as the Path Forward State and territorial health agencies are foundational to preventing the spread of infectious diseases through vaccine education and administration. ASTHO has identified public health expertise in developing vaccination policy as one of three recommended strategies that prioritize evidence-based public health authority and support agencies to protect and improve health. As this landscape further evolves, ASTHO will continue tracking legislative and executive action on this important public health issue. article yes

Under the Tenth Amendment, states have the power to protect the health and welfare of their populations, including the authority to implement isolation and quarantine orders to limit the spread of disease. This post is an examination of state public health authority for isolation and quarantine.

New World Screwworm Insights and Action Steps Shalini Nair Learn about the recently confirmed human case of New World screwworm in the United States, plus action steps to stay prepared for this evolving threat. CDC, in coordination with the Maryland Department of Health, recently confirmed a human case of New World screwworm (NWS) in the United States associated with the ongoing outbreak in Central America. Prior to late 2023, NWS was present in South America and certain countries of the Caribbean, and a biological barrier in eastern Panama prevented the pest from spreading through Central America. Although the United States has experienced travel-associated cases from countries where NWS is endemic in the past, this is the first travel-associated case from a country affected in this outbreak. The parasite, most often seen in animals (especially livestock), was confirmed on Aug. 4 in a Maryland resident with recent travel to El Salvador — a country affected by the current outbreak. While the risk to public health in the United States remains low at this time, it is important for state and territorial health officials to stay informed and prepared for this evolving threat. What Is New World Screwworm? New World screwworm, or Cochliomyia hominivorax, is a parasitic fly whose larvae (maggots) feed on healthy tissue. NWS flies are attracted to and lay eggs on and inside of open wounds, which leads to myiasis, or a parasitic infestation in which fly larvae burrow into the flesh of the affected host. While NWS can affect various warm-blooded animals, most commonly livestock and wildlife, it does not spread between humans and animals. Further, the fly is not a carrier of vector-borne disease. Risk factors for contracting NWS myiasis include: An open wound (even wounds as small as a tick bite may attract the flies). A weakened immune system. A medical condition that contributes to bleeding or open sores. Spending extended amounts of time outdoors or near livestock in areas where NWS flies are present. NWS infestation can be very painful. In humans, symptoms may include unexplained skin wounds or lesions that worsen over a few days, bleeding from an open sore, the presence or feeling of maggots around or in open wounds, and a foul-smelling odor at the infestation site. Larvae can also be present in the nose, eyes, mouth, or ears. In animals, signs may include irritated behavior, head shaking, presence of larvae in wounds, and the smell of decay; animals may also stop eating and self-isolate. There is currently no drug-only cure for NWS but effective treatment consists of quick and thorough removal of larvae. The USDA also maintains a list of EPA-registered pesticides to use against NWS on pastures, agricultural buildings, livestock, and other animals. Framework for Outbreak Prevention NWS was formerly eradicated from the United States in the 1960s, following a large-scale, coordinated effort and the creation of a “barrier” zone between NWS-endemic South America and NWS-free Central and North America. While subsequent outbreaks have occurred since then, the last confirmed (and later eradicated) U.S. outbreak of NWS was in the Florida Keys in 2016, affecting wild Key deer. However, NWS has slowly migrated northward towards the southern U.S. border since the emergence of a new outbreak in Panama in 2023. In the 1950s, USDA developed a successful method for eradicating NWS, referred to as sterile insect technique (SIT). This method involves the mass-rearing and release of sterilized male flies into infested areas to mate with wild females, resulting in nonviable eggs and a vast reduction in the target fly population. It has been used in the United States and across North and Central Mexico and was successful in maintaining eradication until the outbreak in recent years. Addressing the Current Outbreak USDA and HHS have initiated proactive measures to address the current threat to the United States. This includes CDC collaborating with health care professionals, state and local health departments, and tribal organizations to prepare for the potential arrival of NWS in the United States and developing clinical guidance and other resources for health care and public health partners on how to identify and respond to NWS myiasis cases in humans. Additionally, USDA is taking comprehensive action in coordination with U.S. Government partners to protect the United States and prevent the further spread of NWS. In May, USDA suspended imports of cattle, horses, and bison from Mexico, following recent detections of NWS as close as 370 miles from the border. In June, USDA announced the construction of an $8.5 million sterile NWS fly production facility in South Texas, aimed at bolstering their ability to control and eliminate this pest. Also, the new NWS Domestic Readiness and Response Policy Initiative outlines a five-pronged plan to mitigate the threat of NWS. In response to the travel-associated human case, USDA has initiated targeted surveillance for NWS in nearby areas of Washington, D.C., Maryland, and Virginia. As of September 5, no trap results have come back positive for NWS flies. Need-to-Know Information for Health Officials Veterinary Considerations Currently, the potential threat of NWS looms largest for livestock such as cattle, horses, and pigs — although no infestations in animals have been identified in the United States since the outbreak in Key Deer was eradicated in 2017. Coordination between public health agencies and the agricultural and animal health sectors is strongly encouraged as part of a One Health approach to strengthening disease surveillance. Veterinarians should report any suspicious cases in any animal species immediately to their state animal health official and to USDA-APHIS. HHS recently authorized FDA to issue emergency use authorizations for drugs to treat infestations in animals, should they be necessary. While no FDA-approved drugs currently exist for treating NWS infestation in animals in the United States, this may expedite the use of drugs approved for other purposes or those available in other countries to treat NWS-infested animals. Food Safety NWS is not transmitted through consuming appropriately cooked meat or poultry products. In addition, all livestock used for food production in the United States must pass inspection both before and after slaughter, and the presence of infestations or treatment residues that deem meat unsafe for human consumption will prevent the affected product from entering the food supply. Current Human Epidemiologic Situation Over the years, the United States has experienced occasional travel-associated cases of NWS in people traveling from endemic countries; however, the confirmation of a travel-associated case of NWS in Maryland marks the first human case of this parasitic infestation in the United States from the outbreak area. The patient has since recovered, and officials confirmed that there is no indication that the infestation spread to other humans or animals. At this time, there are no active human cases in the United States. The risk to public and traveler health in the United States remains low, and cases of NWS in humans remain much lower than animal cases in countries affected by the current outbreak in Mexico and Central America. Public health officials are encouraged to promote clinician awareness of NWS and consider developing coordinated public communications resources as necessary. Diagnosing and Reporting Suspected Human NWS Infestations Health care providers should remain aware of the risks in patients who have traveled to areas affected by the current outbreak, in addition to those where NWS is endemic. If a human case is suspected, providers should report it immediately to their local or state health department for further investigation. Any maggots found in suspected cases should be placed into a leak-proof container filled with 70% ethanol for proper disposal, and providers should contact CDC’s DPDx team for further specimen submission instructions. Proper disposal of suspected NWS larvae is critical to preventing the parasite from spreading to the environment. If a suspect case is identified, contact CDC (newworldscrewworm@cdc.gov) to obtain the case report form and case investigation guide. ASTHO will continue to monitor developments on this emerging public health issue. Supplemental Resources Overview of NWS – CDC About New World Screwworm Clinical Overview of New World Screwworm Acerca de la miasis por el gusano barrenador del Nuevo Mundo Información clínica sobre la miasis por el gusano barrenador del Nuevo Mundo Lab Identification of New World Screwworm (PDF) Local/State Public Health Departments Epi On Call by CSTE Clinical or Diagnostic Assistance – CDC Clinical inquiries and patient management related questions: parasites@cdc.gov or 404-718-4745. Direct after-hours inquiries to CDC’s Emergency Operations Center at 770-488-7100. Diagnostic assistance for suspected human cases: dpdx@cdc.gov. USDA New World Screwworm New World Screwworm: What You Need to Know PDF (English and Spanish) New World Screwworm Story Map Screwworm: An International Threat to Human and Animal Health (PDF) Veterinarians Report any suspicious cases immediately to your state animal health official and APHIS office. Insect Bite Prevention – CDC Preventing Mosquito Bites Preventing Mosquito Bites While Traveling About Permethrin-Treated Clothing and Gear How to Prevent Mosquito and Tick Bites Insect Repellents Repellents: Protection Against Mosquitoes, Ticks and Other Arthropods Reviewed by - Susan Kansagra article yes

ASTHO Helping Agencies and Providers Advance Vaccine Equity vaccine equity toolkit, community-based vaccine outreach, public health vaccine partnerships, increasing vaccine confidence, vaccine equity strategies, vaccination rates, improving vaccination, community based organizations, health equity, vaccination coverage, trusted messengers, health care, health and human services, disease control and prevention, vaccine preventable diseases, centers for disease control, increasing vaccine, covid-19 pandemic, vaccination program, immunization program, public health departments, build vaccine confidence, control and prevention cdc, united states, health systems, ASTHO, Association of State and Territorial Health Officials Shalini Nair ASTHO | Highlights of ASTHO toolkit that helps health agencies and providers advance equity in their communities. Over the past several years, views on vaccination have fluctuated, with periods of widespread demand followed by waves of declining sentiment due to the spread of mis- and disinformation—ultimately contributing to worsening health disparities. Addressing immunization equity is essential to mitigating the effects of vaccine-preventable diseases among vulnerable individuals and communities who may be at higher risk for adverse outcomes. The COVID-19 pandemic response provided many lessons to take forward for health equity initiatives, specifically in highlighting the importance of community-centered outreach in addressing the health care divide. Introducing: Vaccine Equity Toolkit ASTHO’s Championing Change: A Toolkit for Addressing Vaccine Equity Through Community Mobilization helps state and territorial health agencies, community leaders, and health care providers advance vaccine equity in their communities. For the past three years, ASTHO’s award-winning Partnering for Vaccine Equity initiative has supported boots-on-the-ground efforts to increase vaccine confidence, drive demand for vaccines, and facilitate vaccine uptake. Alongside the Community Action network and a diverse group of advisors, ASTHO and national and local partners have collated this comprehensive resource, which highlights the promising strategies, lessons learned, outcomes, and more from the novel collaborative. Lille Seels_ASTHO Helping Agencies and Providers Advance Vaccine Equity From the Field Snapshot The Championing Change toolkit highlights the work of five local community action agencies across Alabama, Arkansas, California, Georgia, and South Carolina, to increase uptake of vaccines in their jurisdictions. Each agency took a slightly different approach to implementation, emphasizing the importance of tailoring interventions to local community needs. The toolkit includes in-depth case studies on the standout strategies, including: Partnering with health care and public health: Palmetto Community Action Partnership engaged with their health department and a regional federally qualified health care center to help maximize the reach and impact of their services in rural South Carolina. Meeting people where they are with fact-based messaging: Enrichment Services Program leveraged the power of targeted messaging campaigns to address the underlying opinions and attitudes of community members, and cultivate discussion around vaccination across three counties in Georgia and Alabama. Leveraging existing programming and partnerships to expand reach: Community Action Program for Central Arkansas looked to their internal programmatic initiatives around early childhood education and outreach for individuals experiencing homelessness to help amplify their vaccine equity work. Since the project’s inception, ASTHO’s community action partners have held more than 450 events, engaged more than 1.5 million community members in their efforts, and administered at least 5,500 vaccinations including those for COVID-19, influenza, Tdap (tetanus, diphtheria, and pertussis), shingles, and more. Susan Bailey_ASTHO Helping Agencies and Providers Advance Vaccine Equity Using the Toolkit State and territorial health agencies work to promote, improve, and maintain health for all. However, their ability to fulfill these responsibilities sustainably depends largely on public trust in public health institutions. One of the most effective ways to build trust is by engaging the communities most affected and leveraging existing, trusted organizations to help address the issues. Every site participating in ASTHO’s Vaccine Equity Project cultivated partnerships with their state or local health department to aid in their outreach efforts, which can transcend into other areas and stages of public health interventions. Aurora GrantWingate_ASTHO Helping Agencies and Providers Advance Vaccine Equity In Conclusion Jurisdictions can learn more about the innovative structure and outcomes from this project and implement similar partnerships that further the pursuit of equity in their communities. Access the Championing Change toolkit now. Special Thanks-Blog - ASTHO Helping Agencies and Providers Advance Vaccine Equity Padding - small 1 NU21IP000598 website yes

During the the 2021-2022 legislative sessions, several states have enacted laws addressing flu prevention efforts.

In commemoration of National Influenza Vaccination Week ASTHO is highlighting work in Arkansas and South Carolina, where unique collaborations with health care and public health have allowed them to effectively promote flu vaccinations within their communities.

Equip your public health agency with strategies to maintain and expand services for HIV, viral hepatitis, sexually transmitted infections, and tuberculosis.

Learn how health agencies can pursue public health partnerships with Community Action partners to strengthen immunization infrastructure.

In the background of the COVID-19 pandemic, cases of viral hepatitis continue to rise at alarming rates across the United States. Data from CDC highlights a 133% rise in cases of acute hepatitis C infection from 2012-2019 and new case counts four times higher than those seen a decade ago. State and territorial health officials play a crucial role in the planning and implementation of viral hepatitis elimination activities.