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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.

Anticipating a rapid deployment of COVID-19 vaccines as they are authorized, the CDC developed COVID-19 Vaccination Program Operational Guidance in collaboration with state and local jurisdictions to outline how each jurisdiction will make an authorized vaccine widely available. In addition to the operational plans, there is a legal framework of federal and state laws supporting the distribution and administration of the FDA-authorized vaccines.

As a truly historic year comes to an end, many public health policy issues received a considerable amount of attention in 2020. Subjects such as the pandemic that will live on in infamy, racial health disparities, and the future of the Affordable Care Act, are just a few of the major health issues that took center stage on Capitol Hill this year.

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 report shares results and key takeaways from interviews on topics including the overall structure of Legionnaires’ disease programs, diagnosis and clinical testing protocols, and risk communication.

State Health Officials Commend Public Health Emergency Declaration to Address Opioid Epidemic ARLINGTON, VA—Members of the Association of State and Territorial Health Officials (ASTHO) joined President Donald Trump and First Lady Melania Trump today at the White House for a meeting declaring the nation’s opioid crisis a public health emergency.  “While emergency declarations are normally reserved for natural disasters or infectious disease outbreaks, the President’s announcement recognizes the work that states and territories are already undertaking to address the crisis and will allow for increased collaboration and coordination of regional and federal assets across the country for an even more effective response,” says John Wiesman, ASTHO president and secretary of health at the Washington State Department of Health. “We hope the public health emergency declaration, combined with future additional federal investments in substance abuse treatment and prevention, will lead to fewer deaths and better health for all Americans.” State and territorial health officials have been at the frontlines of this crisis working to address the many facets of the epidemic. Six states have already declared emergencies in their jurisdictions: Alaska Arizona, Florida, Maryland, Massachusetts, and Virginia. “While federal leadership has been working hard in partnership with states to address this crisis, many states have taken executive and legislative action to address the epidemic including implementing new laws and regulations around prescribing and providing additional funding for treatment services and evidence-based public health interventions to prevent substance misuse in the first place,” says Michael Fraser, ASTHO’s executive director. “The federal emergency adds to the work that states and territories have been doing in many different ways across the country.” Treating and preventing substance use disorders and addiction is very complex. “Opioid addiction is challenging because many people first become addicted when receiving the medications through the healthcare system. Addiction is not a moral failing on the part of the individual; it is a health condition we must address in healthcare and across all sectors as a society at the national, state, and community levels,” says Jay Butler, ASTHO’s immediate past president and chief medical officer for the Alaska Department of Health and Social Services. “Addiction is treatable and, more importantly, preventable with appropriate evidence-based interventions. The declaration today will help us respond even more effectively to the loss of life and devastating impact of substance misuse and addiction.” ASTHO, in partnership with the National Association of State Alcohol and Drug Abuse Directors (NASADAD), recently released a framework on public health responses to the opioid crisis that was developed to assist health officials in combating the epidemic. As federal agencies and Congress look to implement their response to this public health emergency, ASTHO urges national leaders to provide additional resources focusing on both treatment and prevention of addiction. “This is a crisis we ultimately are not going to arrest—or treat—our way out of; instead, we have to prevent our way out of this,” adds Fraser. “Like any public health emergency, addressing this problem calls for important steps to prevent the disease in the first place. We hope that the President and First Lady’s attention to the opioid epidemic will help us focus on both treatment and prevention. That is the work of public health, and states and territories are committed to mustering all resources available to end this epidemic.” ASTHO Press Release Boilerplate website yes

During the COVID-19 pandemic, public health authority has been used to require the use of face masks and encourage social distancing, and other measures. In several states these legal authorities have been challenged and, in many jurisdictions, limited or eliminated by the legislature. Maintaining the legal authority to prevent and control the spread of infectious disease is crucial to preparing for and addressing disease outbreaks.

There are a number of court cases playing out across the country that could affect the options state and territorial health officials have to limit the spread of disease and promote health and well-being.

Given the emergence of mosquito-borne viruses such as dengue, chikungunya, and Zika in the United States and U.S. territories, this, the second edition of this report, provides guidance to assist local, state, and territorial mosquito control programs in developing and maintaining an effective mosquito control infrastructure to meet the ongoing challenges surrounding vector-borne diseases.

With many of the state and territorial legislatures reconvening over the next few weeks, we can look forward to new (and not-so-new) legislation start to crop up that will impact public health. To help navigate the new legislative sessions, ASTHO’s "2021 Legislative Prospectus" series highlights eight priority policy areas jurisdictions will address during this year. Each prospectus in the series provides a brief overview of the issue, the issue’s impact on health, and recent legislative trends aimed at addressing the issue. This year, ASTHO developed prospectuses on COVID-19, e-cigarettes, HIV, influenza, maternal mortality and morbidity, neonatal abstinence syndrome (NAS), polyfluoroalkyl substances (PFAS), and rural health.

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.

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.

States and territories have broad powers to protect public health and safety, including powers to prevent and control the spread of communicable disease typically exercised by state and territorial health departments. This authority is an essential tool in the fight to keep the public safe and healthy.

Vaccines are one of the greatest public health achievements of the last century, as well as some of the most powerful and cost-effective tools to prevent disease, disparities, disability, and death among children and adults. The COVID-19 pandemic and the unprecedented development and distribution of the vaccines against the novel coronavirus have generated much focus on state laws related to vaccinations. As state and territorial legislatures prepare to convene in the coming weeks, we can already identify several topics within vaccine law that policymakers across the country will consider.

Reconciling the tension between public health and civil liberties is one of the most significant challenges of public health law and ethics. The Supreme Court of the United States historically upheld state authority to enact and enforce public health laws that temporarily limit a person’s civil liberties, such as quarantine and isolation powers that restrict a person’s freedom of assembly in order to prevent the spread of contagious disease. There have been many legal challenges to the public health orders issued to slow the spread of COVID-19—many of the claims asserting violations of First Amendment rights of assembly, association, and expression—but they’ve largely been rejected by the courts. However, courts have treated claims asserting violations of the free exercise of religion more favorably, which may indicate an impending shift in how courts analyze the impact state and territorial actions may have on religious organizations.

State Policy Advances in Extreme Weather Preparedness Margaret Nilz Learn about recent policies that aim to improve extreme weather preparedness, boost community resilience, and ultimately protect public health. Extreme weather events are increasing in both frequency and severity — challenging public health systems, straining infrastructure, and risking lives. As states face rising temperatures, more intense wildfires, historic flooding, and stronger hurricanes, state legislatures are adopting forward-looking policies to improve preparedness. These policies aim to boost community resilience, protect public health, and modernize emergency responses across the country. They reflect a move toward proactive planning and investment, grounded in innovation and cross-sector collaboration. Strengthening Critical Infrastructure A growing area of legislative focus is pre-disaster planning and infrastructure resilience, with jurisdictions considering policies that proactively strengthen critical systems (e.g., infrastructure, energy, and communications). For example, in Maine, LD 1 creates the Office of Resilience, tasked with coordinating and implementing state policies to improve resistance to extreme weather events. It also increases homeowners’ access to home resiliency grants, establishes a revolving loan fund for county, municipal, and tribal hazard mitigation infrastructure projects, and invests in floodplain mapping improvements. Texas SB 75 establishes a Grid Security Commission, directs an evaluation of hazards to the state’s electric grid, and makes recommendations that ensure municipalities have energy, power, and fuel supplies in the event of a catastrophic power outage. Jurisdictions are also considering legislation that would: Amend procedures for cities and counties to finance post-disaster infrastructure repair and long-term climate adaptation projects (California SB 782). Require biennial emergency preparedness exercises as well as conduct disaster preparedness training in vulnerable areas (California AB 1200). Create a real-time, interoperable emergency communication platform to improve coordination across agencies during disasters (Texas HB 147). Addressing Wildfire Risk and Air Quality Jurisdictions are also paying close attention to growing wildfire threats and subsequent poor air quality. They’re moving beyond emergency response, ensuring systems/personnel are in place before a crisis unfolds and advancing wildfire mitigation strategies. Systems and Personnel Hawaii recently enacted HB 1064, establishing an Office of the State Fire Marshal. The office is tasked with increasing the state’s readiness for wildfires, including exploring opportunities to reduce wildfire risk and developing a statewide map that displays wildfire hazard zones. California is considering AB 1003, which would require the Department of Public Health to complete a plan that includes recommendations for counties during a significant air quality event by June 30, 2026. California is considering AB 1003, which would require the Department of Public Health to complete a plan that includes recommendations for counties during a significant air quality event by June 30, 2026. It would also require these plans to incorporate county-specific outreach, stakeholder communication, and implementation. These measures build critical infrastructure for training, staffing, and coordinated response. Mitigation Strategies California (SB 326) introduced policies that accelerate the implementation of ember-resistant zones, enhance risk modeling, and support local governments through grant funding for fire reduction efforts. New legislation (CA SB 629) also updates the state’s fire hazard severity maps and sets new criteria for safety zones, including annual defensible space inspections to help residents manage fuel loads around their homes. In Colorado, recently enacted laws support increased use of prescribed burns to improve forest health (SB 7) and empower local fire protection jurisdictions to mandate vegetation removal from private properties (HB 1009). Oregon enacted SB 85, which requires the State Fire Marshal to develop recommendations for community-based wildfire mitigation and submit them to the legislature by February 2, 2026. Two bills being considered in California would: Require the creation of a framework for wildfire mitigation and a wildfire risk forecast (SB 326). Update the state’s fire hazard severity maps and set new criteria for safety zones, including annual defensible space inspections to help residents manage fuel loads around their homes (SB 629). Together, these policies signal a shift from reactive firefighting to community-level risk reduction and long-term adaptation. Improving Flooding and Hurricane Preparedness Flooding, hurricanes, and coastal erosion remain central concerns for many states, particularly those already experiencing repeat disaster declarations. As flooding and coastal threats intensify, states are taking multi-pronged approaches to preparedness — investing in early warning systems, expanding access to mitigation funding, and examining the readiness of critical facilities. These policies can assist states in both major non-hurricane flood events and hurricane preparedness and response. Several states are working to improve community-level preparedness and emergency alert systems. Vermont recently enacted H 397, which expands the Governor’s authority in the anticipation of a flood event, increases municipal access to weather alert systems, and expands access to disaster recovery grants. Texas recently introduced HB 108, which requires the Division of Emergency Management to develop a flood preparedness guide for local organizations that includes structured guidance around training, communication, and post-disaster recovery. Alongside these efforts, states are strengthening long-term mitigation strategies through grant and buyout programs. Massachusetts (H 980) and New Jersey (A 5226) are considering legislation that would establish funding programs for municipalities to address flooding (i.e., through risk assessments and mitigation measures). In Virginia, recently enacted HB 2077 expands eligibility for the Virginia Community Flood Preparedness Fund to include federally and state-recognized tribes. Employing Innovation and Research Innovation continues to shape the next frontier of preparedness policy as jurisdictions pilot emerging technologies, promote cross-sector collaboration, and rethink how they can adapt infrastructure for a changing climate. In California, legislators are considering three bills that merge cutting-edge science with emergency responses: AB 270 directs the Department of Forestry and Fire Protection to assess whether autonomous firefighting helicopters could be transitioned to operational use in the state. SB 599 proposes improvements to atmospheric river forecasting, a key strategy in flood management. SB 223 would establish a centralized wildfire smoke and health data platform within the Department of Public Health to better inform public health decisions during smoke events. Additionally, jurisdictions are addressing the resilience of the built environment, balancing traditional engineering with nature-based approaches. Mississippi enacted HB 959, extending a program focused on wind hazard mitigation and grants to retrofit homes to July 2028. Additionally, Puerto Rico introduced PS 579 (en español), which establishes the use of natural mitigation structures (e.g., sand deposits and coral planting) as the first alternative to protect infrastructure affected by coastal erosion, flooding, or other events. In Conclusion The scale of today’s public health challenges requires long-term planning, robust infrastructure, and coordination across different sectors and levels of government. Investments in real-time data systems, interoperable communication, and resilient financing tools will be essential. This Preparedness Month, the increasing momentum behind jurisdiction-level policy action shows a clear understanding: Preparedness is public health. And by focusing on resilience, jurisdictions are not only preparing for the next emergency — they are actively creating a healthier, safer, and more climate-resilient future. ASTHO will continue to monitor and provide updates on extreme weather preparedness legislation. article yes

Learn how Kentucky is integrating public health and health care emergency programs to improve their emergency readiness in this blog.

Learn how North Dakota leveraged cross-sector partnerships to create a stronger emergency response system.

Public Health Authority Toolkit public health emergency, disease outbreak, public health authority, infectious disease, environmental health, emergency response plans, executive emergency powers, disease spread, public health services, national emergencies act, federal government, local government, emergency authority, communicable disease, public health emergency declared, local health departments, centers for disease control, disease control and prevention, geographic area, executive order, reporting requirements, emergency situations, covid-19 pandemic, state and local governments, public health agency, astho, association of state and territorial health officials Public Health Authority Toolkit | ASTHO The authority to manage public health threats was built into the U.S. legal system as far back as the first boards of health at the turn of the 19th century. To date, state and territorial health officials have broad responsibilities to protect their communities from various health threats and, by virtue of the statutory authorities granted to their positions, can mitigate these threats through a variety of activities. These legal authorities support routine public health activities such as investigating a disease outbreak or abating a nuisance. When the outbreak exceeds a traditional response, becoming a public health emergency, health officials often have additional powers under an executive emergency declaration. Given the political response towards the exercise of public health authority during COVID-19 pandemic (e.g., isolation and quarantine, social distancing orders, contact tracing, etc.), rapid and substantial changes to public health authority have occurred in several jurisdictions. The efforts to limit the ability of public health officials to protect their communities vary significantly by jurisdiction and are shaped by a variety of political landscapes. As the leading voices in governmental public health, current and former health officials are uniquely qualified to inform the public and policymakers about the need to retain the foundational legal responsibilities to protect public health. ASTHO developed this toolkit to support governmental public health officials and ASTHO alumni, and to provide an understanding of state and territorial public health’s legal responsibility and authority in an acute or declared public health emergency. This toolkit includes evidence-based resources, examples of legislative testimony, and other resources to assist state and territorial health officials and educate the public and policymakers. On This Page Protecting Public Health Evidence Base and Rationale Support from ASTHO Alumni and Partner Organizations Responding to Challenges of Public Health Authority Additional Resources Padding Block - Medium(12) Divider - Gray Protecting Public Health What is public health authority? Public health agencies are responsible for protecting and promoting the health of the public within a specific jurisdiction. State and territorial health officials are granted legal authorities to prevent and mitigate the spread of infectious disease and other health threats. These mechanisms are available in day-to-day operations to prevent, detect, and contain health threats in the community, and in the event of a declared disaster or public health emergency. Public health authority is not a static concept and can vary by jurisdiction, change over time, and be utilized in both routine and emergency situations. Public health authority is typically governed by laws and regulations at different levels of government, including federal, state, tribal, local, and territorial. The specific powers and responsibilities granted to public health agencies can differ between jurisdictions and be shared. For example, under Maryland law, a Governor’s proclamation of a public health emergency can authorize the health official to require people to be tested or treated for disease whereas other states do not have a similar law specifying that power. Public health legal responsibility is not fixed and can evolve over time to address emerging health challenges, advancements in scientific knowledge, and societal changes. Public health laws and regulations may be updated or revised periodically to adapt to new threats or to improve public health outcomes. For instance, the COVID-19 pandemic highlighted the need for rapid policy changes, such as implementing mask mandates, travel restrictions, or vaccine distribution plans, which were enacted under existing or newly established public health authority. Public health officials exercise their legal authorities with great care, weighing the need to prevent or stop the spread of disease with individual rights and liberties. Additionally, state laws establish boundaries and safeguards to ensure that people’s rights and liberties are respected. Public health laws often define the scope of authority, specify procedures for enforcement, establish accountability mechanisms, and outline avenues for judicial review or appeal. It is important to note that these authorities can be exercised in both routine and emergency situations. In routine circumstances, public health agencies use their authority to enforce regulations related to disease control, food safety, sanitation, immunizations, environmental health, and more. They carry out disease tracking, monitoring, and prevention efforts to safeguard public health on an ongoing basis. During emergencies, such as disease outbreaks, natural disasters, or bioterrorism events, public health authority can expand to address the unique challenges posed by the situation. This may involve activating emergency response plans, mobilizing additional resources, issuing emergency orders (e.g., citing orders to promote social distancing, gathering restrictions, closing a school to limit the spread of disease, etc.), coordinating with other agencies, and communicating critical information to the public. Emergency situations often provide public health agencies with additional powers and flexibility to protect the population rapidly. How are public health authorities different than executive emergency powers? Executive emergency powers are generally exercised through a Governor or through an Emergency or Executive Order. During COVID-19 pandemic many states used emergency powers to: Promote social distancing through gathering limits, closures of non-essential businesses. Require face coverings in certain situations. Expand staff capacity to conduct contact tracing,case investigations, and mass vaccination campaign. When can governmental public health entities exercise their legal powers to protect public health? Governmental public health entities have a range of legal responsibilities that are generally established in statute by the state or territorial legislature and ratified by the governor. The list below is not all encompassing but highlights the foundational capabilities that guide the actions public health officials may take to address a health threat. Communicable Disease Prevention and Control Although specific mechanisms vary between jurisdictions, common powers include the ability to order isolation or quarantine, to conduct contact tracing and disease investigations, to require vaccinations among certain groups and in specific situations, and to order other measures to mitigate and prevent the community spread of disease (e.g., cancelling events, venue closures, and face mask protocols). Isolation and Quarantine Some of the oldest tools available to governmental public health to limit disease spread are isolation and quarantine. All 50 states, Washington, D.C., and most territories provide the state and territorial health official (S/THO) with the legal authority to require an individual or group of people to remain in isolation or quarantine. In all cases, anyone subject to an isolation or quarantine order has rights to due process under the law and can petition a court to review the order and determine whether the isolation or quarantine should continue, be modified, or ended. Contact Tracing and Case Investigation Another core function of state and local public health is determining the spread of communicable diseases. To do so, public health personnel interview individuals infected with and exposed to a communicable disease to determine their close contacts and notify those contacts of recommended next steps to limit the spread of the communicable disease. Few states have codified this common public health practice in statute, although a few states have enacted statutes related to COVID-19 contact tracing over the past year. Vaccination Expanding vaccination efforts is a cornerstone function of public health. All 50 states, Washington, D.C., and most territories require vaccinations in some form. In some jurisdictions, the S/THO also has the power to limit the attendance of unvaccinated students during disease outbreaks. In many jurisdictions, state health agency expertise determines which vaccines are required for school enrollment. Community Mitigation Measures In some jurisdictions, the scope of the health official’s power extends to measures that can mitigate the community spread of a disease. This may include orders cancelling or altering the size of events or other gatherings, requiring the use of face coverings, gloves, or other personal protective equipment, altering the operation of businesses and other venues, or requiring health screenings or proof of vaccination. Studies of the community mitigation measures taken during the COVID-19 pandemic have shown that stay-at-home orders helped reduce activities associated with the coronavirus’ spread and that face mask protocols and venue closures helped to limit community transmission of the disease. Environmental Health Governmental public health entities routinely address environmental factors that contribute to disease transmission and poor health outcomes.

This report highlights lessons learned about how to remain resilient in the face of complex disasters and environmental events, following two listening sessions hosted by ASTHO and the Environmental Council of the States.