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State and territorial health officials gathered on Capitol Hill to meet with lawmakers and discuss public health priorities—learn more about Hill Day in this blog post.

Cases of sepsis and septic shock can be prevented with strong health policies as shown in New York. Several states have taken action to enact mandatory early detection and treatment protocols.

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

Learn how developing effective partnerships can help health agencies and tuberculosis programs address drug shortages.

Defining Disease Forecasting and Modeling Disease forecasting, generated by disease models, helps the public health workforce understand potential future outbreaks. Learn more about disease forecasts and models. Disease forecasting is important in describing potential future outbreaks that will affect the population and demand for health services in a given geographic area. Forecasts pull input from various sources (e.g., disease models, demographic, mobility, and intervention impact data). Individual forecasts can also be part of an ensemble forecast to improve accuracy. Forecasts can cover any length of time, but most target a window of several weeks to a few months. A subset of forecasts, known as nowcasts, seek to estimate present conditions, or those expected to occur imminently. Disease models are mathematical tools that are foundational components of disease forecasts. They estimate quantifiable factors that are impossible or impractical to directly measure, (e.g., future hospitalizations from a given disease, or its infection count in a population). Although models can be useful for specific questions, they do not give as complete a picture as a forecast. There are four major disease model types: Mechanistic. Attempts to simulate biological and/or social processes of transmission based on assumptions from prior or experimental data. Statistical. Relies on past data (such as infections or death) to predict future trends and can incorporate some assumptions about intervention application and uptake. Quality and quantity of past data can be a major limitation, and some models may suggest biological improbabilities. Agent. Simulates individual risks and behaviors in a population. These are highly complex, computationally very expensive to develop and run and require vast amounts of data and strong assumptions. Ensemble. Like their forecasting counterparts, they compile models and outputs, mitigating the risk of relying on one data point. While raising the overall confidence in output, they require coordination of many models to be built and simulated, which can be complex and costly unless the models already exist (such as for COVID-19 case counts). Forecasts and Models Work Together While disease forecasts and models are often conflated, they are discrete concepts. Forecasts offer a general prediction, whereas models are the mathematical pieces forecasters use to create them. Weather forecasts are commonplace, and their weekly predictions are often reasonably accurate. In contrast, predicting a big storm’s individual factors (e.g., rainfall, wind speed, lightning strikes) fall to the job of models. Together, those models help meteorologists better understand the weather and generate a forecast. In a public health context, disease forecasting informs public health officials, health care providers, and policymakers about potential risks and guide decision-making regarding preventive measures, resource allocation, and response strategies. Meanwhile, disease models aim to simulate the behavior of infectious diseases under different scenarios, allowing researchers to explore and evaluate various factors that influence disease transmission. Considerations for Decision-Making Decision-makers should consider scope and limitations of forecasts and models. They may consider adding inputs—such as projections for economic and long-term impacts. Examples include economic impacts of school closures, costs of more staffing ahead of an outbreak, and supply chain shortage forecasts for personal protective equipment (PPE). Decision-makers at all levels should consider using modeling to answer more specific, practical questions rather than predicting overall trends. Forecasts can cover different geographic scales. Public health leaders will need granular, local data to most effectively inform decision-making and communications. Novel conditions and pathogens may not have readily available data to inform models or forecasts, which will affect their predictive ability. Health officials must effectively communicate these limitations to decision-makers and the public. Examples of Forecasts and Models CDC’s COVID-19 Forecast for Hospitalizations (ensemble forecast) shows the number of daily COVID-19 hospitalizations reported in the United States from the prior two months and projected daily COVID-19 hospitalizations over the coming four weeks. Information sources are independent teams meeting submission and data quality requirements. CDC’s FluSight (ensemble forecast) has many contributing teams and models that predicts the upcoming weekly laboratory confirmed influenza hospital admissions both nationally and by state. Johns Hopkins University’s Center for Systems Science and Engineering county-level risk model for COVID-19 in the United States. This model leverages epidemiological data, mobile phone data, demographic and socioeconomic information, and behavioral metrics. The Global Epidemic and Mobility Framework simulates the global spread of infectious diseases by mathematically representing infection dynamics, population geographies, and population mobility patterns. Additional Resources Disease modeling for public health: added value, challenges, and institutional constraints Predictive Models for Forecasting Public Health Scenarios: Practical Experiences Applied during the First Wave of the COVID-19 Pandemic Applying infectious disease forecasting to public health: a path forward using influenza forecasting examples Technology to advance infectious disease forecasting for outbreak management CDC-RFA-OT18-1802 2018-2024 article yes

Disease Forecasting and Modeling Data for Public Health Action Disease Forecasting Benefits Public Health Planning Disease forecasting and modeling help prepare public health departments for future infectious disease outbreaks and epidemics. Disease forecasting and modeling data can be powerful tools for state and local health agencies (S/THAs) that respond to outbreaks, develop appropriate policies, and ensure interventions have maximum impact. Actions for which decision-makers can leverage such data include: Surveillance. Forecasts and modeling help public health agencies anticipate the spread of disease or outbreaks. This advance warning allows public health officials to inform public health recommendations, preparation, and response. Communication. Disease forecasts help relate the risk of disease outbreaks to various audiences accurately and quickly, which, in turn, can inform messages on important preventive measures and encourages compliance with recommended interventions. Resource allocation. Modeling data can help decision-makers better allocate resources by predicting where and when disease outbreaks are likely to intensify and create the greatest need. Evaluation. Forecasts and modeling can help make evaluating the effectiveness of public health policies and interventions more efficient by comparing predicted outcomes with observed data and adjusting as needed. Considerations Informed by S/THA Forecasting Jurisdictions with forecasting experience identified key indicators to monitor as part of outbreak forecasting, which fall into three main categories: Epidemic spread indicators (e.g., symptom monitoring, morbidity and mortality data, percent positivity, regional pictures of transmission). Health care system capacity (e.g., essential and/or surge personnel, available beds, ventilator usage, and supply of personal protective equipment. Public health capacity for testing capacity and contact tracing. Further considerations for S/THAs: Know your strengths. Identify the unique skillsets among partners in public health, academia, and the private sector and consider how they foster reciprocal relationships. Recognize capacity/expertise gaps. Consider leveraging partnerships for specific types of analytics expertise while exploring internal capacity building opportunities (e.g., job shadowing and resource-sharing programs on workflows and methodologies). Engage legal and compliance teams. Ensure policy and practice are aligned among partners. Explore data access/sharing pipelines. Connect public, private, academic partners, and their audiences. Start small. Identify discrete forecasting and modeling projects to demonstrate success. Identify decision-makers’ needs. Provide quick access to analyses, metrics, dashboards. Michigan Used Models and Forecasting for Hep C Cases In response to Hepatitis C virus (HCV) in young adults from 2010-2018, the Michigan Department of Health and Human Services (MDHHS) simulated how HCV treatment could significantly reduce HCV prevalence among young people who inject drugs, especially for those both previously or currently injecting drugs. MDHHS used several novel predictors to paint a local picture of probable HCV diagnoses among residents up to age 40. These predictors included measures related to a variety of population characteristics (e.g., access to transportation, college education, presence of non-family households) and public health indicators (e.g., heroin treatment admissions, newborns with neonatal abstinence syndrome, and sexually-transmitted infections). MDHHS also leveraged county-level assessments of HCV vulnerability to identify locations for new syringe services programs in the state. MDHHS has recognized several modeling and analytics use cases that benefitted their work during responses to HCV and COVID-19: Short-term forecasts (i.e., weeks) helped predict likely transmission patterns and potential ranges of projections. Longer-term forecasts (i.e., months) explored scenarios based on new recommendations and policy changes. Retrospective counterfactuals evaluated the impact of policies or other changes by examining “what-if” situations. MDHHS is considering using forecasts and models for COVID-19, influenza epidemics, tuberculosis vulnerability, and C. auris spread. Resource constraints require decision-makers and public health practitioners to consider how they are using available resources for the highest return on investment. Models generated momentum to respond to threats and evaluate whether interventions were successful. CDC-RFA-OT18-1802 2018-2024 article yes

According to the federal government, a homebased individual is someone who requires the help of another person or supportive device to leave the home, someone who is advised against leaving the home by a physician, and/or someone for whom it is extremely taxing to leave the home. Compared to non-homebased adults, homebased people are more likely to be older, have lower income, and belong to racial minority groups—as well as live with disabilities, chronic health conditions, and comorbidities. Individuals who are homebased therefore tend to be at increased risk for COVID-19 morbidity and mortality.

As schools work to stay open for in-person learning, it is essential to understand key recommendations related to COVID-19 prevention in K-12 schools. CDC recommends that health department staff work closely with K-12 schools to effectively prevent and respond to COVID-19 infections. Health department staff may look to school officials to understand the unique context of each school setting, while school officials may look to health department staff to better understand federal, state, and local guidance. This document compiles CDC guidance for COVID-19 prevention strategies in K-12 schools and should supplement state or territorial and local policies. Schools and health departments should layer the COVID-19 prevention strategies listed in this ASTHOBrief.

Learn how to best prioritize emerging infectious disease cases and contacts for follow-up, with this five-step framework.

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Discover how lessons learned from tuberculosis outbreaks can improve public health preparedness for other infectious diseases.

Learn how health agencies can improve access to critical medications by preparing for drug shortages and working with a diverse set of partners.

Strengthen your knowledge of wastewater surveillance ethics, with firsthand insights on key challenges and considerations from state health agencies and partners.

Learn how health departments can focus their infectious disease prevention efforts in this brief.

On Aug. 23, 2021, the FDA announced full approval of Pfizer and BioNTech’s mRNA vaccine for COVID-19. ASTHO has answers to five key questions about the approval and what it means for state and territorial health officials: What does the FDA’s approval approve; what did we learn from the FDA’s safety and efficacy review; How long did the approval process take, and when could we see more FDA-approved vaccines; What does FDA approval mean for vaccine confidence; What does FDA approval mean for employer and university vaccine mandates.

Supporting Health Department Decision Makers with Disease Forecasting and Outbreak Analytics Disease Forecasting and Outbreak Analytics Amelia Poulin, Chris Taylor ASTHO and CDC surveyed states and territories about disease forecasting and outbreak analytics—learn more about the results. ASTHO, with support from CDC Center for Forecasting and Outbreak Analytics, conducted a survey to assess state and territorial health agencies' expertise and needs in using infectious disease forecasts and analytic techniques. Senior deputies from 28 jurisdictions submitted responses, which will help to inform health agency communications and decision-making efforts. The information in this report, fielded from March – May 2023, provides a comprehensive overview of the needs assessment results as well as key takeaways. Get the Report article yes

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

Health Officials Intensify Zika Prevention Efforts ARLINGTON, VA—State and territorial health officials are redoubling prevention efforts to address the serious public health threats associated with Zika virus and to protect the health of mothers and babies. Yesterday, CDC published an analysis of nearly 1,300 pregnant women with evidence of Zika infection, per data reported by 44 states to the U.S. Zika Pregnancy Registry in 2016. About 1 in 10 pregnant women with confirmed Zika had a fetus or baby with birth defects. In light of these findings, the Association of State and Territorial Health Officials (ASTHO) calls for continued resources to support an aggressive, long-term governmental public health response to Zika, including laboratory, epidemiological, and surveillance capacity, vector control, and public awareness and education campaigns. With most of the women in the study acquiring Zika infection during travel to an area where Zika was present, all jurisdictions within the United States must remain on alert and prepared due to travel-related cases and sexual transmission. Also, with warmer weather and mosquito season approaching, CDC’s new Vital Signs report highlights the need for ongoing vigilance and sustained measures to prevent and manage cases of Zika, diagnose patients, increase lab capacity and vector control, and coordinate Zika-related birth defects surveillance activities, especially in parts of the United States where local transmission through the bite from the specific mosquito capable of carrying the Zika virus is possible. “Public health has a long history of combatting and eradicating mosquito-borne diseases, but ensuring robust epidemiological and laboratory infrastructure across the governmental public health system is critical to stay ahead of the spread of Zika virus,” says Brenda Fitzgerald, ASTHO president-elect and commissioner and state health officer of the Georgia Department of Public Health. “In Georgia, for example, we have limited geographic mosquito surveillance and vector control capabilities. That causes particular concern about the 63 counties at higher risk of Zika transmission due to their dense populations, high rates of poverty, and large numbers of females of reproductive age.” State, territorial, and local health departments play an active role in determining the risk of ongoing local transmission through enhanced surveillance and vector control activities. Health departments, together with healthcare professionals, laboratory experts, and disease control specialists, are working nonstop to protect Americans from Zika and other emerging health threats. Strong collaboration among state and local partners is critical to protecting pregnant women against Zika and connecting affected families with medical, social, and community resources. ASTHO urges sustained investments in public health funding to give state, local, tribal, and territorial health departments the resources needed to pursue a broad range of strategies to prevent Zika virus. ASTHO Press Release Boilerplate website 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.

Public health officials from all levels of government are working to respond to the existing outbreak of monkeypox, while preparing for the potential of more widespread transmission.