Recommended Strategies to Prioritize Evidence-Based Public Health Authority

State and territorial health agencies are responsible for keeping the public healthy and safe. To meet this responsibility, public health must have effective legal tools to prevent, identify, and contain the spread of disease.1 Years of underinvestment in core public health services2 and recent legislative limitations3 on public health authority has hindered4 some public health agencies, at times leaving them unable to direct and guide the public on how to remain safe during a crisis. Ensuring state and territorial health agencies have effective legal powers and a strong public health workforce is necessary for allowing agencies to fulfill their responsibility of protecting and improving the well-being of their communities unable to direct and guide the public on how to remain safe during a crisis. Ensuring state and territorial health agencies have effective legal powers and a strong public health workforce is necessary for allowing agencies to fulfill their responsibility of protecting and improving the well-being of their communities. Public Health Authority Technical Package We bundle these interventions into a "technical package," a set of recommendations to the field to guide future public health responses. ASTHO technical packages are based on evidence-based interventions, promising practices, subject matter expert recommendations, and – where available – consensus from the field. Technical packages are not intended to be comprehensive but instead help prioritize efforts toward what works to address a particular problem and establish a focused and proactive approach to technical assistance. ASTHO's technical package to support public health authority comprises three major categories with additional details outlined in Table 1. Retain isolation and quarantine authority among local and state public health officials. Example: In early 2023, a local health department5 in Washington went to court after identifying a woman with Tuberculosis in civil contempt for refusing to comply with the local health officer order to take her medication or be isolated (ie, separated from other people to prevent the transmission of disease). Retain the ability for public health officials to identify and investigate disease outbreaks. Example: In October 2023, the U.S. Food and Drug Administration and the North Carolina Department of Health and Human Services6 released an advisory for consumers not to buy or feed certain cinnamon fruit puree pouches to toddlers and young children because the product may contain elevated levels of lead. Include public health expertise in development of vaccination policy. Example: California enacted CA AB 659,7 which requires schools to notify parents of students enrolled in sixth grade to be advised to have their child immunized against human papillomavirus (HPV) in accordance with CDC guidelines. HPV infections are associated with cervical cancers, with HPV vaccination associated with as much as an 83% decline in HPV infections8 among females 13 to 19 years old. TABLE 1 - ASTHO Technical Package on Public Health Authority Objective Aligned Policies Considerations for Implementation Potential Indicators Retain isolation and quarantine authority among local and state public health officials. State/territorial laws that clearly define who can issue an isolation or quarantine order.State/territorial laws provide governmental public health the authority to quarantine individuals exposed, or suspected of being exposed, to an infectious disease or agent.State/territorial laws provide governmental public health the authority to isolate persons diagnosed with an infectious or communicable disease, or who display symptoms of a known or unknown pathogen. Identify current barriers, gaps, and/or opportunities under current state law. Legislative changes to public health officer powers. Retain the ability for public health officials to identify and investigate disease outbreaks. Ensure ability to collect information on new and emerging pathogens.Support data modernization efforts to streamline data collection and sharing. Identify barriers, gaps, and/or opportunities under current state law.Review existing authorities to require reporting of new or emerging pathogens.Review existing authorities to share public health data with other state and federal public health authorities. Legislative action to expand or limit public health data collection and sharing.Legislative action to delegate authority to health agencies to add novel or emerging pathogens to the reportable disease list.State agency rulemaking authorizing the reporting of novel pathogens and known pathogens during an outbreak. Include public health expertise in development of vaccination policy. State/territorial laws establishing requirements for routine vaccinations to prevent disease based on input from jurisdictional public health leaders (eg, state health official, board of health).Incorporate administration and dosing schedules established by ACIP and AAP to childhood and school immunization requirements. Identify current barriers, gaps, and/or opportunities under current state law. Legislative action altering the decision-making authority for childcare, school, and employer vaccination requirements.State agency rulemaking incorporating ACIP and AAP recommendations. Conclusion Following the COVID-19 pandemic, legislatures reassessed the role of executive branch officials, including some state and territorial health officials, in responding to emergency events. While this reassessment was not unexpected, legislative changes to longstanding public health authorities can adversely alter the tools available to public health leaders to prevent, identify, and respond to infectious and communicable disease outbreaks. As public health leaders, state and territorial health officials should prioritize building a strong relationship with their legislature and educating lawmakers on the need for these powers and how they are used in their jurisdiction to protect the public's health. ASTHO supports public health leaders in retaining these core public health authorities by working with public health law groups, such as the Act for Public Health, and facilitating peer sharing through ASTHO's legislative liaison and public health attorneys peer networks. Similar to entities that have been created for tobacco control and HIV, public health could benefit from a legal defense program to promote and protect state and local infectious disease authority. To operationalize some of these priorities, ASTHO developed a public health authority toolkit9 to support state and territorial health agencies.