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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

Following a hurricane, the risk of exposure to infectious disease increases due, in part, to the presence of floodwater and debris. Hurricanes may contribute to population displacement and overcrowding—further heightening risk factors for respiratory diseases—as well as cause damage to healthcare facilities. In this post, see how jurisdictions respond to the biggest post-hurricane threats, from water-borne diseases to severe disruptions in the healthcare system.

The Public Health Response to Hantavirus: Key Actions, Perspectives, and Takeaways Public Health Response to Hantavirus: Key Takeaways Ericka McGowan, Sidnie Christian, Margaret Nilz Learn about the hantavirus outbreak from the MV Hondius and the ongoing public health response — including the important work of state and local health departments. On May 2, the World Health Organization (WHO) received notification of an international hantavirus cluster linked to passengers aboard the MV Hondius cruise ship, following reports of severe acute respiratory illness. Subsequent laboratory testing confirmed infection with the Andes strain of hantavirus, a rare zoonotic virus associated with hantavirus pulmonary syndrome. The event drew international public health attention because of the distinct challenges posed by the cruise ship setting, the need for multi-country coordination as exposed passengers returned home, and the involvement of the Andes virus — which can be transmitted person to person unlike other strains of hantavirus. In response, WHO and U.S. health authorities initiated contact tracing and surveillance to monitor for additional cases. Despite international attention, the risk to the public is low at this time. However, it remains crucial for state and territorial health officials to stay up to date on this developing threat, which serves as an important reminder that public health preparedness is more critical than ever. What Is Hantavirus? Hantaviruses belong to the family Hantaviridae within the order Bunyavirales and are primarily spread through contact with infected rodents (i.e., via exposure to their urine, droppings, saliva, or contaminated surfaces). Various strains exist globally, including the Sin Nombre virus, predominant in North America, and the Andes virus, predominant in South America. In humans, clinical signs are non-specific, including fever, fatigue, muscle aches, headache, and gastrointestinal symptoms. In severe cases, infection may progress to hantavirus pulmonary syndrome, with rapid onset of cough, shortness of breath, and fluid accumulation in the lungs. The recent cases raised concerns as the cruise ship setting likely facilitated exposure among passengers and crew. Additionally, the expedition's international nature meant potential exposure across multiple countries, with passengers disembarking before confirmation that illnesses on board were due to Andes virus — thus requiring coordinated surveillance, contact tracing, and risk communication among national health agencies. The particularly long incubation period of the Andes virus, 4-42 days after exposure, further complicates monitoring. MV Hondius Hantavirus Outbreak: Key Insights Timeline In early April, the MV Hondius ship departed Argentina. On April 11, the first case died on board, and a close contact died shortly after. On April 28, a passenger experienced onset of symptoms, later presenting with pneumonia, and died on May 2. On May 2, the United Kingdom reported a cluster of passengers with severe respiratory illness to WHO. At the time of reporting, 147 passengers and crew were on board while 34 passengers had disembarked. On May 2, PCR testing confirmed hantavirus infection of a probable case. On May 10, the MV Hondius was permitted to dock and let passengers disembark in the Canary Islands off the coast of Spain. Passengers were then transported to their home countries via non-commercial means. On May 11, U.S. passengers arrived at the National Quarantine Unit (NQU) in Nebraska for evaluation and monitoring. WHO and CDC continue to provide updates as the situation evolves. Risk to the Public While the risk to the public remains low, it is important for public health authorities to assess and monitor contacts closely during the 42-day period for symptoms, as deterioration can occur quickly. Monitoring and assessment are collaborative efforts supported by CDC and led by state and local health departments. CDC released interim risk assessment guidance to support health departments in managing people with potential exposure related to the MV Hondius. It provides definitions of high- and low-risk contacts, recommended care, monitoring, and guidance to reduce the risk of transmission and exposure. A Coordinated Public Health Response This outbreak punctuates the importance of international and federal agencies, state and local health departments, laboratories, health care systems, and specialized treatment centers working together to manage emerging threats. Shared guidance and regulations were necessary to help standardize monitoring and response efforts. WHO coordinated with 10 countries to ensure timely information sharing, response, repatriation, and contact tracing. Domestically, the U.S. Department of State, Health and Human Services Administration of Strategic Preparedness and Response (ASPR), and CDC coordinated to form the domestic hantavirus taskforce. Together, the agencies have managed: U.S. passenger transport and repatriation. International coordination and communications. Access to health care and treatment structure. Quarantine and preparedness assets. Disease surveillance. Epidemiologic support. Risk assessment. Public communication. Coordination with state and local public health departments. This response highlights the expertise, logistics, and coordination required to manage high-consequence public health threats. Specialized Response Systems Responses to high-consequence infectious diseases (HCID) often require specialized infrastructure beyond routine health care. During events like this Hantavirus cluster, quarantine facilities, treatment centers, and coordinated health care networks help safely manage potentially exposed travelers while supporting health care system readiness. Together, these specialized preparedness systems help ensure that patients can be safely evaluated and treated while minimizing disruption to broader health care operations during HCID emergencies: The NQU at the University of Nebraska Medical Center and the Global Center for Health Security is a key component of this infrastructure. This unit is specifically designed to support quarantine and individuals exposed to HCIDs. U.S. passengers returning from the cruise ship were transported to Nebraska for assessment and monitoring, including one asymptomatic passenger who was admitted to the Medical Center’s Biocontainment Unit for further evaluation but has since been cleared to return back to the NQU. Regional Emerging Special Pathogen Treatment Centers (RESPTCs) serve as specialized hubs within the National Special Pathogen System. ASPR funds 13 RESPTCs in the United States to support management of care related to high consequence pathogens. The system is designed to distribute specialized care, offset operational burden, and maintain national surge capacity during complex infectious disease responses. ASPR’s Hospital Preparedness Program provided additional preparedness aid. This program supports health care coalitions and strengthens coordination among hospitals, emergency management agencies, public health departments, and health care partners. By advancing planning, training, exercises, and regional coordination, it helps health care systems maintain surge capacity and preparedness for complex emergencies. The Laboratory Response Network, which supports responses to biological threats, emerging infectious diseases, and other public health emergencies, plays a role in public health responses by supporting epidemiologic investigations and providing timely laboratory information to guide monitoring and response activities. In response to this Hantavirus cluster, the Association of Public Health Laboratories activated its Incident Command System to help support a coordinated laboratory response to the Andes virus. The Role of State and Local Health Departments State, territorial, and local public health agencies play a central role in infectious disease responses, especially when exposed travelers cross jurisdictional boundaries. For this response, agencies coordinated contact tracing, symptom monitoring, health care communication and preparation, laboratory coordination, and public risk communication. State and Territorial State and territorial health agencies serve as the primary lead for investigating and managing public health emergencies within their jurisdictions. In addition to coordinating with federal partners, health care systems, and laboratories, state and territorial health agencies may exercise legal authorities (i.e., isolation and quarantine) when necessary to help contain infectious disease threats. Their role helps translate national guidance into coordinated, jurisdiction-specific response activities. Local Local health departments also play a multifaceted role in outbreak response through community-level coordination, health care access, communication, and follow-up for potentially exposed individuals. In some states, local health departments also have the authority related to quarantine and isolation to prevent spread of public health threats. Local health departments help connect public health agencies, health care, emergency management partners, and community organizations to facilitate operational coordination and timely information sharing. Support from the Public Health Emergency Preparedness Cooperative Agreement Many of these preparedness and response capabilities are supported by the Public Health Emergency Preparedness cooperative agreement, which has helped health departments across the country strengthen their ability to respond to infectious disease outbreaks, natural disasters, and other public health emergencies since 2002. It supports surveillance capacity, emergency coordination, epidemiology staffing, and risk communication capabilities while helping jurisdictions build flexible and adaptable preparedness systems before emergencies occur. Events like this recent Hantavirus

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The COVID-19 pandemic has changed the landscape of we go about preparing and responding to public health threats. In collaboration with CDC, ASTHO embarked on an initiative to identify effective resources, policies, and model practices utilized by state and territorial health agencies throughout the pandemic response. In this blog, we highlight four areas of focus that are central to any successful preparedness effort.