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The COVID-19 pandemic has negatively impacted youth mental health, particularly as a result of school closures, social isolation, family economic hardship, fear of family loss or illness, and reduced access to healthcare. However, states have many strategies to choose from to improve youth mental health and reduce suicide.

Spanish language version of "Embedded: Puerto Rico’s Public Health Emergency Preparedness Academy" blog post.

In the late fall of 2021, ASTHO leadership visited select jurisdictions in the Pacific and the Atlantic for the first time since COVID-19 curtailed travel to these regions. It was a fantastic to reconnect with our leadership and dedicated staff. Unsurprisingly, we heard about the jurisdictions’ challenges, including chronic ones related to funding and infrastructure, as well as new challenges resulting from the global pandemic.

Each year, ASTHO tracks and analyzes key legislation that impacts public health, and highlights the emerging trends for our members. While the bulk of the tracked legislation arises in state legislatures, ASTHO also follows legislation from the territories and Freely Associated States, jurisdictions collectively referred to as the insular areas. The insular areas often face different challenges than the states, while also sharing many common concerns. This post contains a brief look at some of the public health related legislation introduced in the insular areas during their current legislative sessions.

This report shares Puerto Rico’s strategy and recommendations for developing a social determinants of health dashboard.

This blog describes public health legislation introduced during the Island Areas’ 2024 legislative sessions.

To address the youth tobacco epidemic, jurisdictions filed lawsuits against JUUL to end their marketing practices aimed at youth and to obtain compensation from the financial toll experienced by communities.

Learn how public health agencies are improving their financial management strategies and systems.

State Policy Trends in Cybersecurity and Public Health Preparedness Maggie Nilz Learn how states are including cybersecurity in their emergency preparedness work in this Health Policy Update. Cybersecurity is an increasingly important component of public health preparedness as state cybersecurity policy intersects with public health agency responsibilities. Public health agencies rely on interconnected digital systems and critical infrastructure for disease surveillance, laboratory reporting, emergency communications, and health data management, making cybersecurity critical to maintaining these functions. Beyond compromising sensitive data and potentially harming patients, cyber incidents can disrupt essential public health services, including emergency response operations. Health care data breaches have steadily increased over the last 15 years, highlighting growing risks for government and health systems. A recent report showed that more than 7,000 health care data breaches were reported to the Department of Health and Human Services since 2009, and reported HIPAA data breaches in 2023 were nearly double the number recorded in 2018. Meanwhile, preparedness capacity has lagged: as of 2022, only 13% of local health departments reported being prepared for cyber-related disruptions, and recent scans show cybersecurity is rarely included in emergency preparedness planning. In response at the federal level, HHS recently announced it is undoing a 2024 reorganization by returning department-wide technology responsibilities to the Office of the Chief Information Officer while refocusing the Office of the National Coordinator for Health Information Technology on improving nationwide health IT interoperability and data sharing. In recent years, state and territorial legislatures have begun to address these gaps by incorporating cybersecurity into preparedness, health care oversight, and statewide governance structures. These legislative trends signal a need to integrate cybersecurity into emergency operations plans, strengthen cross-sector coordination, and safeguard the continuity of public health services. Some of the most recent policies considered and enacted by legislatures treat cyber incidents as emergencies, expand reporting requirements, and strengthen cyber governance. Cyber Incidents Are Being Built into Emergency Preparedness Frameworks In response to these growing threats, jurisdictions have begun incorporating cyber response into emergency plans and strategies, reinforcing cybersecurity as essential to preparedness. These developments highlight growing awareness that cyber incidents can disrupt critical services, much like natural disasters. In 2025, New York enacted S 7672, which requires municipal entities and public authorities report cybersecurity incidents and demands for ransom to the state Division of Homeland Security and Emergency Services. In addition, it directs the Director of the Office of Information Services to establish cybersecurity training and protection standards for state systems as well as require cybersecurity training for state and local government employees. Virginia is currently considering HB 83, which would establish a volunteer Cyber Civilian Corps within the state IT agency to provide rapid assistance during cybersecurity incidents affecting municipalities, nonprofits, education, and critical infrastructure. Preparedness efforts also extend beyond legislation to executive action. In February 2026, Minnesota Governor Tim Walz authorized $1.2 million in state disaster assistance to support response efforts and restore critical systems in response to a cyber incident that disrupted digital services in Saint Paul on July 29, 2025. Additionally, the National Governors Association has included cybersecurity as a primary consideration for planning and preparedness in their latest edition of the Public Health Emergency Playbook. Health care and Public Health Critical Sectors Are Facing New Cyber Requirements Beyond emergency response frameworks, jurisdictions are also adopting cybersecurity reporting and planning requirements for health care and public health organizations. Companion bills in Tennessee (HB 511/SB 555) would require health care providers and facilities to notify their contracted health insurers of cybersecurity incidents. In Maine, LD 2103 would require hospitals to adopt cybersecurity plans to protect patient data and maintain operations, and must include cybersecurity training for employees and board members. New Jersey is looking to adopt and implement a more comprehensive cybersecurity plan across all sectors. This session, legislators have introduced at least two cyber security bills: A 3231 would require “sensitive businesses” (defined as those engaged in financial, essential infrastructure, or health care industries) to report cybersecurity incidents to the New Jersey Cybersecurity and Communications Integration Cell (NJCCIC) when they are aware of their occurrence and would require NJCCIC to conduct a cybersecurity audit within 30 days of notification. A 3283 would require the same “sensitive businesses” to implement cybersecurity programs in accordance with standards adopted by NJCCIC and certify compliance annually. As states expand reporting and cybersecurity requirements, these obligations may intersect with public health reporting and continuity planning. States Are Strengthening Government Cyber Governance and Coordination In addition to sector-specific requirements, jurisdictions are also strengthening the governance structures responsible for coordinating cybersecurity, improving their ability to respond to large-scale incidents affecting public systems. Legislation enacted recently in Texas and California aim to improve coordination among state government by establishing a state agency centralizing cybersecurity incident prevention and response (Texas HB 150) and mandating the development of a cybersecurity playbook to strengthen information sharing (California AB 979). A 2024 bill enacted in Puerto Rico (PC 1530) requires commonwealth agencies to develop and implement a cybersecurity program, which must include a yearly risk assessment as well as vulnerability assessment. At least three jurisdictions are currently considering bills strengthening established cybersecurity programs, with two states recently passing legislation. Utah recently enacted a bill authorizing the Utah Cyber Center to conduct voluntary cybersecurity risk assessments for critical infrastructure and coordinate with government entities on infrastructure safety (HB 165). Utah also enacted legislation creating a specific funding stream for the Center to use for various activities, including implementing a statewide cybersecurity plan and conducting assessments for governmental entities (SB 123). Kansas enacted HB 2574, which would require chief information security officers for the executive, legislative, and judicial branches to adopt cybersecurity programs based on a nationally recognized standard for governmental entities. Finally, Florida recently passed SB 7024, which would expand the state’s public record exemption to include risk assessments, information related to cybersecurity breaches, and information related to data protection, ensuring the confidentiality of sensitive cybersecurity information held by state agencies; the bill is with the governor for final consideration. Key Takeaways for Preparedness Leaders Cybersecurity is critical for preparedness across multiple policy areas, and requires new planning, coordination, and oversight responsibilities. By including cyber incidents into disaster frameworks, standards for health care organizations, and governance, preparedness leaders may find themselves more directly engaged in integrating cybersecurity into emergency operations, exercises, and cross-sector partnerships. For state and territorial health agencies beginning to incorporate cybersecurity into their preparedness plans, agencies such as the Cybersecurity and Infrastructure Security Agency provide jurisdictional support and resources to guide this work. article yes

Puerto Rico Program Supports Vulnerable Populations ASTHO Island Support Learn how Puerto Rico addresses social determinants of health and promotes equity among vulnerable populations. The Puerto Rico Department of Health’s Health Equity Program implemented an innovative initiative to support diverse institutions, with the goal of addressing social determinants of health and promoting health equity among vulnerable populations. This provided opportunities for a wide range of sectors including private non-profit organizations, universities, and hospitals. The project evolved throughout its duration, demonstrating the power of local funding and the importance of flexibility in program administration. Project Kickoff Grant Awarding and Training Process During the second request for proposal, 30 organizations expressed interest in submitting applications. However, given the detailed and rigorous rubric, six applied, of which four grants were awarded. The team scored the proposals based on the rubric, and allocated funds to support vulnerable populations such as individuals living in rural areas, people with disabilities, pregnant women, and older adults. Implementation and Best Practices Once the Health Equity Program awarded grants, they designed a detailed work plan, including key indicators for monitoring and tracking the progress of beneficiary organizations. They implemented a SharePoint-based system for the submission of reports and documentation. In addition, they held monthly meetings to ensure cohesion and effective communication among all stakeholders. This collaborative approach enabled efficient and transparent monitoring processes. “It was a collaborative process since the institutions know their populations best. We just wanted to ensure a systematic and consistent plan because these matters are crucial for project progress and monitoring.” — Miguel Cruz, PhD, Co-Principal Investigator Project Evolution The program initially funded one institution and due to its positive impact, additional opportunities emerged to provide funding for up to four additional institutions. The main topic revolved around health literacy as a strategy to reach health equity among people living in rural areas, older adults, people experiencing homelessness, individuals with functional diversity, and those experiencing a mental health challenge. These four new institutions covered the west, central, and other rural areas broadening coverage within traditionally underserved communities. Administrative Flexibility and Communication Strategies Administratively, the program had to be flexible during pre-award and award processes, ensuring compliance with state and federal regulations. This included revising announcements and creating plans. Additionally, the program created documentation, like templates, and provided technical assistance to clarify compliance guidelines to ensure transparency and proper use of funds. The program implemented effective communication strategies to inform institutions about funding opportunities, including announcements via mass media and the Department of Health’s official social media platforms. They also created an external technical committee as an official communication channel to evaluate proposals. For this purpose, the creation of a detailed rubric facilitated its proper, unbiased, and timely assessment. Technological Challenges and Solutions One key challenge throughout the project was the use of technology to receive, process, and manage documentation. To mitigate obstacles, a SharePoint webpage facilitated electronic documentation acquisition between each subgrantee and the program. Additionally, the program provided clear instructions and developed a Q&A guide based on the needs that various institutions identified. In case of new inquiries, the Health Equity Program also shared responses collectively to ensure all organizations received consistent information, enabling them to complete the process smoothly and with equal opportunity. Lessons Learned A final evaluation of the process revealed that anticipating challenges was key to the project’s success. However, there are still areas for improvement: One of these is the optimization of financial processes by the organizations. It is critical to submit evidence of fund use in a timely manner and ensure accuracy in reconciling invoices within the allocated period. Organizations should also align internal processes with the parameters set when they receive funds. Adhering to these parameters can streamline the process on the Department of Health's side. Although beneficiaries get an assigned accounting professional, the documentation must still go through the Fiscal Office for review. Another challenge faced by institutions was retaining participants in the training sessions provided as part of the grant. Therefore, mechanisms need to be in place to ensure active and continuous participation in future interventions. The Health Equity Program also identified the opportunity to standardize the evaluation processes for organizations. While each institution worked on diverse projects, evaluations were based on their respective work plans and progress reports. However, a standardized evaluation process could improve efficiency in future interventions. Sustainability and Recommendations Many institutions that received funds have used them as a starting point to develop larger initiatives while others have used them to develop internal resources (i.e., digital libraries, trainings). “Organizations used this funding as seed money for projects that are now receiving greater financial support. Others have developed internal resources that allow them to continue addressing key health issues. For instance, they have optimized the use of digital libraries, expanded training reach, and replicated projects funded by this grant in other municipalities.” — Miguel Cruz, PhD, Co-Principal Investigator For other agencies looking to implement similar programs, the recommendation is clear: Streamline efforts to maintain consistency and coherence. Additionally, explore other agency or office supports for fostering an organizational culture that prioritizes continuous monitoring and process improvement, emphasized Cruz, PhD. Conclusion Clear, transparent communication and flexible administration with a focus on health equity generate a positive impact on vulnerable populations — as evidenced by increased knowledge, improved participant skills, attitude changes, inclusion in services, greater technology use among older adults, and enhanced equity skills among workers. This project demonstrates how health departments can collaborate with other sectors to address social determinants and ensure equitable access to resources. article yes

Learn about the importance of exploring intermediaries that work alongside existing data platforms in addressing ongoing public health challenges.

This toolkit is designed to support public health leaders in leveraging the policy development process to achieve health equity in their jurisdiction.

This brief highlights four top takeaways from the experience of six public health agencies working to establish and strengthen their own performance management systems.

Strengthening Maternal and Infant Health Data in the U.S. Territories ASTHO, association of state and territorial health officials, maternal and infant health data, U.S. territories, public health, surveillance programs, pregnancy risk assessment monitoring system, improving the health, live births, health problems, reproductive health, federal government, toggle the centers for disease control and prevention cdc, risk assessment monitoring system, assessment monitoring system prams, pregnancy risk assessment monitoring, maternal and infant health, information collected, table of contents, population based, health status, supreme court, prams data, toggle the table, risk factors, prenatal care, collecting information Stephany Strahle The U.S. territories—Puerto Rico (PR), U.S. Virgin Islands (USVI), Guam, Commonwealth of the Northern Mariana Islands (CNMI), and American Samoa—are largely excluded from most statistical data systems in the United States. This gap leaves island health leaders, national partners, and federal agencies without the surveillance necessary to inform timely and robust public health programs and policies. This is also seen in critical maternal and child health surveillance programs like the Pregnancy Risk Assessment Monitoring System (PRAMS), Maternal Mortality Review Committees, and the Pregnancy Mortality Surveillance System, which either do not include or only recently included territories in their scope of coverage. This incomplete information creates challenges in identifying the aspects health systems need to address to reduce adverse maternal and infant health outcomes. Applying a life course perspective to maternal and infant health data reveals gaps in public health systems that impact outcomes before, during, and after birth. PRAMS provides vital insights into these lived experiences and pregnant people’s interactions with health care services. PRAMS data can also be linked to other administrative datasets, such as Medicaid, child welfare services, and Community Healthy Start programs, to provide a broader understanding of determinants of health across the life course for both the birthing parent and their child. With the breadth of contextual experiences that PRAMS captures in its data and the potential for data linkage projects to explore outcomes and their contributing factors, U.S. territories can leverage this wealth of information to assess the needs of their pregnant communities and their children. Despite its development in 1987, PRAMS has been implemented in only two territories, PR and CNMI, within the past decade. This brief highlights the work of these two islands and the potential to gain further insights into maternal and infant health outcomes using data linkage methods. Island Expansion of Maternal and Infant Health Surveillance Using PRAMS Since beginning PRAMS data collection in 2017, PR has made considerable strides in providing their communities with comprehensive reports on various topics. In 2021, one in eight live births was preterm in PR—the U.S. average is one in 10 live births. This outcome is one example of a potential research area in PR that could leverage PRAMS linkages to clinical administrative data sources to investigate contributing factors. In a special project conducted from 2016 to 2018, PRAMS served as an avenue for assessment of Zika awareness among pregnant people and their partners. Moreover, PRAMS informed numerous reports and educational materials on topics ranging from dental care to lactation and opioid use during pregnancy. Linking PRAMS to other administrative datasets could illuminate more information about health care utilization and access among pregnant people in PR. Although limited research exists on maternal and infant health outcomes in CNMI, available evidence reveals disparities in preterm birth among the territory’s indigenous Chamorro and Carolinian communities and Asian and Pacific Islander groups. Since CNMI started administering PRAMS in 2021, strong relationships with entities outside the territory (e.g., the Hawaii Department of Health) have facilitated PRAMS implementation by helping navigate Internal Review Board regulations and applications—both of which are necessary to conduct PRAMS collection and potential research using PRAMS data, like data linkage projects. Moreover, the CNMI PRAMS team’s deep familiarity with their communities could help identify local administrative data sources that, when linked to PRAMS, capture priority areas for improved health care and social service delivery. Considerations for Future Maternal and Infant Health Data Exploration With the existing gaps in surveillance data available for maternal and infant health, this recent implementation of PRAMS and the potential for data linkages to other data sources could provide enhanced insights for U.S. territories. The following considerations can inform best practices to optimize this data. Building Partnerships to Support a Linked Maternal and Infant Health Data Network To build capacity for further data exploration, building partnerships with other agencies and PRAMS jurisdictions can facilitate the information-sharing necessary to navigate data use agreements and other considerations before successfully linking data. Leveraging these connections can also supply more avenues to administer educational tools about PRAMS and perinatal services, linking their pregnant populations to the services they need. A robust web of partnerships can create a network of linked data capturing the life course perspective to inform high-quality programs for the ongoing care of pregnant people and their infants. Leveraging Community Input and Data on Social Determinants of Health Territories are uniquely positioned to leverage closer community ties to examine how data linkages can inform initiatives that improve experiences surrounding pregnancy and the life course after birth. As with PR, integrating the voices of pregnant people, their families, and the people providing their care into their advisory committees allows for better identification of what communities need. Active engagement ensures agencies can be efficient with their linkage efforts by tailoring their projects to high-priority maternal and infant health outcomes. Moreover, to foster community awareness about PRAMS and possible linked data sources, territories could create dashboards such as those created by Washington D.C.’s PRAMS program to provide a comprehensive and interactive view of the data. Data on social determinants of health collected through PRAMS—such as insurance coverage throughout pregnancy and postpartum as well as access to social support and a wide range of services—can also be leveraged for potential data linkage to identify inequities in health outcomes and the delivery of care. website yes

The 2020 holiday season is coinciding with a nationwide surge of COVID-19 cases. With great concern that holiday travel to see loved ones may exacerbate community spread of the virus, many states are increasing public health measures before the winter holiday season. As of November 16, 2020, 13 states and D.C. had a quarantine requirement for out-of-state travelers. The U.S. territories also have instituted travel restrictions to limit the spread of COVID-19.

This blog explains ASTHO’s Islands Health Equity Framework, which outlines a culturally resonant approach to health equity in the island areas.

Collecting and sharing data are crucially important to improving health equity, because those datasets inform effective policymaking. Despite having some of the most challenging population health outcomes, the U.S. island areas are often absent within federal public health datasets.Federal, island, and nonprofit partners should prioritize efforts to increase their inclusion.

Learn how increasing the use of indirect cost rates in the territories and freely associated states can help improve public health financing in these jurisdictions.

This report aims to highlight the unique vector-borne disease challenges faced by Island Areas and to dive into the key components of a mosquito control program, that are relevant to these unique jurisdictions.

2020 has been a year of unprecedented events, and the past few months have already shown that they do not exist in a vacuum. While the country continues to respond and cope with the COVID-19 pandemic, many extreme weather events have already occurred, and are additional infectious disease challenges to consider. Responding to these events in the current conditions presents unique challenges to responders and communities.