Long COVID (or post-COVID conditions) refers to symptoms or health conditions that persist or occur ≥4 weeks after SARS-CoV-2 infection. 1 Centers for Disease Control and Prevention. COVID-19: Long COVID or Post-COVID Conditions. Available at: https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html. Accessed June 6, 2023. Google Scholar Symptoms such as brain fog, fatigue, pain, dyspnea, depression, and a wide range of other manifestations can occur and may be debilitating. The mechanism(s) of these outcomes are poorly understood, creating challenges to prevention and treatment. The study of Long COVID is rapidly evolving and approaches to describe its burden vary. However, prevalence estimates of activity- or work-limiting Long COVID among U.S. adults in the 3-5 million range have been reported. 2 Tenforde MW Devine OJ Reese HE Silk BJ Iuliano AD Threlkel R Vu QM Plumb ID Cadwell BL Rose C Steele MK Briggs-Hagen M Ayoubkhani D Pawelek P Nafilyan V Saydah SH Bertolli J. Point Prevalence Estimates of Activity-Limiting Long-term Symptoms Among United States Adults ≥1 Month After Reported Severe Acute Respiratory Syndrome Coronavirus 2 Infection. J Infect Dis. 2023; 227 (1 November 2021) (Apr 12PMID: 35776165; PMCID: PMC9278232): 855-863https://doi.org/10.1093/infdis/jiac281 Crossref Scopus (7) Google Scholar ,3 Brookings Institution. Is ‘Long COVID’ Worsening the Labor Shortage? January 11, 2022. Available at https://www.brookings.edu/articles/is-long-covid-worsening-the-labor-shortage/. Accessed August 3, 2023. Google Scholar The vast number of individuals at risk of, or with symptoms of Long COVID underscores the urgency of addressing this complex public health issue.

Multisector community partnerships (MCPs) are a key element of the public health approach to addressing social determinants of health (SDOH). The Improving SDOH-Getting Further Faster (GFF) retrospective evaluation of MCP-driven SDOH interventions was designed to generate practice-based evidence that can help guide partnerships' efforts to improve chronic disease outcomes and advance health equity by addressing SDOH. This article shares Year 2 GFF findings related to sustainability strategies for partnerships focused on SDOH and their interventions. GFF partnerships' reported sustainability strategies, including establishing shared goals and increasing partners' capacity for SDOH work through training, align well with the rich coalition building evidence base. Findings also indicate some evolution of sustainability strategies, such as adopting team-based, decentralized leadership models to help guard against partner or staff turnover. Organizations looking to form, fund, or provide technical assistance to MCPs that address SDOH can use the practice-based insights shared in this research brief to plan ahead for sustainability.

Multisector community partnerships (MCPs) are key component of the public health strategy for addressing social determinants of health (SDOH) and promoting health equity. Governmental public health agencies are often members or leaders of MCPs, but few studies have examined the role of health departments in supporting MCPs' SDOH initiatives. We engaged 42 established MCPs in a rapid retrospective evaluation to better understand how MCPs' SDOH initiatives contribute to community changes that promote healthy living and improved health outcomes. As part of this work, we gained insights into how health departments support MCPs' SDOH initiatives, as well as opportunities for enhanced collaboration. Results indicate that health departments can support MCPs' SDOH initiatives through the provision of funding and technical assistance, data sharing, and connecting community organizations with shared missions, for example. Findings can be used to inform the development of funding opportunities and technical assistance for MCPs and health department partners.

Purpose: To better understand and inform how multisector community partnerships (MCPs) perform meaningful work to prevent chronic disease and advance health equity by addressing social determinants of health (SDOH).Methods: We conducted a rapid retrospective evaluation of SDOH initiatives implemented within the past three years by 42 established MCPs across the United States. The mixed methods evaluation included document review and coding of available outcomes data, virtual discussions, and Prevention Impacts Simulation Model (PRISM) analysis.Results: All 42 MCPs built community capacity for addressing SDOH through new or strengthened data systems, leveraged resources, or engaged residents, for example. Most MCPs (N = 38, 90%) reported contributions to community changes that promote healthy living. More than half of the MCPs (N = 22) reported health outcomes data for their SDOH initiatives, including improved health behaviors and clinical outcomes. Based on reach data provided by 27 MCPs, PRISM analysis results suggest that sustained initiatives could save over $633 million in productivity and medical costs cumulatively through 20 years.Conclusions: With sufficient technical assistance and funding resources, MCPs are a key component of the public health strategy to address SDOH.

Outreach, including patient navigation, has been shown to increase the uptake of colorectal cancer (CRC) screening in underserved populations. This analysis evaluates the cost-effectiveness of triennial multi-target stool DNA (mt-sDNA) versus outreach, with or without a mailed annual fecal immunochemical test (FIT), in a Medicaid population. A microsimulation model estimated the incremental cost-effectiveness ratio using quality-adjusted life years (QALY), direct costs, and clinical outcomes in a cohort of Medicaid beneficiaries aged 50–64 years, over a lifetime time horizon. The base case model explored scenarios of either 100% adherence or real-world reported adherence (51.3% for mt-sDNA, 21.1% for outreach with FIT and 12.3% for outreach without FIT) with or without real-world adherence for follow-up colonoscopy (66.7% for all). Costs and outcomes were discounted at 3.0%. At 100% adherence to both screening tests and follow-up colonoscopy, mt-sDNA costed more and was less effective compared with outreach with or without FIT. When real-world adherence rates were considered for screening strategies (with 100% adherence for follow-up colonoscopy), mt-sDNA resulted in the greatest reduction in incidence and mortality from CRC (41.5% and 45.8%, respectively) compared with outreach with or without FIT; mt-sDNA also was cost-effective versus outreach with and without FIT ($32,150/QALY and $22,707/QALY, respectively). mt-sDNA remained cost-effective versus FIT, with or without outreach, under real-world adherence rates for follow-up colonoscopy. Outreach or navigation interventions, with associated real-world adherence rates to screening tests, should be considered when evaluating the cost-effectiveness of CRC screening strategies in underserved populations.

The COVID-19 vaccine has highlighted adult vaccination and vaccine hesitancy, particularly in communities of color. Prior to the COVID-19 pandemic, influenza, pneumonia, shingles, and hepatitis A and B vaccination rates were well below federal goals, with participation even lower across racial and ethnic groups.1,2 Key drivers of these rates include barriers to health care access, limited trust in the government and the medical establishment, as well as a lack of sufficient data to better understand racial and ethnic disparities. As we work to maximize COVID-19 vaccination and increase participation in routine adult vaccinations, we must be both strategic and cautious. In this column, we outline a summary of our adult immunization technical package of interventions for state and territorial health agencies (S/THA) to strengthen data management and improve adult vaccination. ASTHO reviewed data on effective vaccination interventions that included an internal literature review of evidence-based approaches compiled by the Guide to Community Preventive Services, the US Preventive Services Task Force, and the Centers for Disease Control and Prevention. These evidence-based approaches were divided into 4 categories: community interventions, health care systems, data-driven strategies, and policy and regulatory approaches. On the basis of recent experience with the COVID-19 vaccination efforts, we prioritized 2 approaches ASTHO is well positioned to advocate for and assist or advise S/THA leaders with adult vaccination efforts: Increasing vaccination efforts in community-based health care settings; and Enhancing immunization information systems data sharing and reporting capacity. Strengthen Partnerships With Community-Based Health Care Settings Health care systems and medical providers are our traditional vaccination partners and are effective in addressing vaccine hesitancy on an individual level. Early in the COVID-19 vaccination effort, states channeled vaccine administration through high-volume community sites (ie, mass vaccination events). As demand for COVID-19 vaccine has decreased, many jurisdictions transitioned to increase vaccine administration in health care settings to better address vaccine hesitancy. Community-based health care settings, such as Federally Qualified Health Centers (FQHCs), can help states understand barriers to vaccine uptake and implement focused and tailored strategies that address concerns and foster trust in communities of color. FQHCs receive most of their funding from designated federal grants and state Medicaid programs.3 They provide care to around 30 million medically underserved patients each year, with 63% of those patients belonging to a racial or ethnic minority group.4 During the pandemic, people of color made up the majority (64%) of those who received a COVID-19 vaccine in FQHCs.5 Working more closely with community-based health centers is an effective way for public health agencies to increase adult vaccination, particularly in underserved communities. During the pandemic, FQHCs received direct allocations of COVID-19 vaccines from the federal government.6 Many states augmented FQHC vaccine supply with state allocations and engaged them in community outreach efforts. Some states also developed or expanded Medicaid reimbursement systems for vaccine counseling and administration. In the future, public health agencies can build on this momentum by continuing to work with FQHCs and networks, state primary care associations, and state Medicaid programs to expand clinical capacity and engage providers in a wide range of evidence-based practices to improve vaccination participation in health care settings.7 ASTHO and other national associations can work at the federal level to expand existing immunization benchmarks for children to include standardized adult vaccination measures and reimbursement systems that are recognized by the Health Resources & Services Administration, the National Committee for Quality Assistance, and the Centers for Medicare & Medicaid Services. Enhancing Immunization Information Systems Data Reporting and Sharing Capacity Perhaps, the greatest emerging challenge to increasing effective and equitable adult vaccination efforts is our lack of complete, interoperable data. As states enhance their immunization information systems (IISs), it is important to provide leadership on issues such as data exchange with clinical practice and to address our long-standing need to capture accurate and comprehensive data on race and ethnicity. A number of states are now reporting more complete race and ethnicity data in their IISs. These improvements have required multiple strategies, including changes to existing laws barring the collection of federal reporting of race and ethnicity data; matching incomplete immunization data to electronic health records (EHRs), Health Information Exchange (HIE), and other data sets; state laws requiring providers to report race and ethnicity; incentives to encourage providers to improve collection and submission of these data; and widespread training of staff in both the public health and private health care workforce. Continued leadership on this issue as we implement data modernization efforts and expand the public health workforce could allow us to overcome a long-standing barrier to understanding and improving racial and ethnic health disparities for a wide range of public health issues beyond COVID-19. Ultimately, IIS interoperability needs to be ubiquitous with the many other systems engaged across the immunization ecosystem, including EHRs, pharmacy systems, and HIEs, as well as other IISs. Interstate access to immunization records has been a long-standing challenge. However, many states are now addressing laws that prohibit IIS data sharing across borders, with multiple states working closely with HIEs and participating in the Immunization Gateway to increase interstate access to immunization records.8 In addition, state IISs could be more interoperable with health care providers. Most EHRs now upload vaccinations directly into the IISs, while also querying for information back to the practice for patients who have received vaccination elsewhere; ideally, this near-real time bidirectional data exchange would be available in every setting where immunization information was needed. Universal implementation of immunization data exchange with IISs would allow every provider to have immunization status on hand so that the right immunization can be given at the right time at every patient encounter. In parallel, IISs could work with HIEs or with larger health care system patient rosters to update this information on a regular basis so that practices can target patient outreach efforts. Conclusion Public health leaders are tasked with addressing many areas of public health and oftentimes have a short tenure to make an impact on the health of their state. Many public health agencies focus on improving vaccination rates because of the significant and avoidable human burden and cost of infectious disease. ASTHO's adult immunization technical package represents an approach to technical assistance at ASTHO that is evidence based, policy oriented, and proactive. It will be used as a guide to prioritize our technical assistance efforts with S/THA to address adult vaccination and demonstrate tangible health outcomes.

Between Fall 2020 and Spring 2021, the Association of State and Territorial Health Officials conducted 2 rapid queries to collect information from the field regarding the status of COVID-19 case investigation and contact tracing (CI/CT) programs and practice. These short surveys were distributed to senior deputies in state and territorial health agencies, yielding a response rate of 45.8% (November 2020) and 40.7% (April 2021). Findings indicated that CI/CT staff roles and assigned functions varied across jurisdictions, as did staffing levels/capacity, approaches for linking individuals to social supports, and program changes that were planned or underway. Agency-reported staffing levels/capacity and programmatic challenges changed over time, highlighting the dynamic nature of CI/CT program practice and implementation. While findings from the surveys cannot be generalized to the national level, they provide critical insights from the field on CI/CT program implementation, challenges, and changes in response to the evolving COVID-19 epidemic in the United States.

Increasing COVID-19 infection rates and the prospect of a significant fall surge are concerning to state and territorial public health leaders. Health officers are charged with preparing for ongoing management of the pandemic while addressing pushback against public health mitigation efforts and public sentiment that the pandemic is “over.” While hospitalizations continue to remain manageable as of June 2022, now is the time for public health officials to prepare for responses to upcoming surges of COVID-19 in tandem with other seasonal respiratory viruses such as influenza and respiratory syncytial virus. Experts have learned a great deal about effective prevention, mitigation, and management of COVID-19 over the last 2 years to help guide future efforts. Planning for future response should draw upon evidence-based prevention efforts and what has worked in the past 2 years. A “Technical Package” of Effective Public Health Approaches to Managing COVID-19 This article summarizes approaches to preventing COVID-19 infection with an eye toward sustained management of COVID-19 in the fall of 2022 and beyond. We bundle these interventions into a “technical package,” a set of recommendations to the field to guide future public health responses to COVID-19. ASTHO technical packages are based on evidence-based interventions, promising practices, subject matter expert recommendations, and—where it exists—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, such as COVID-19, and establish a focused and proactive approach to technical assistance. The ASTHO technical package to support the sustained management of COVID-19 comprises 5 major categories, described as follows, with additional details outlined in the Table. Increase immunization rates and capacity: Vaccines, both the primary series and booster dose, are critical tools to prevent severe illness from COVID-19 infection. Engaging health care providers, who are often the trusted source of information for individuals who have questions about vaccines or who may be hesitant, is an established evidence-based practice for addressing vaccine hesitancy. Expanded availability of vaccine in health care settings will be particularly important in pediatric COVID-19 vaccination. National data already indicate a preference for pediatric COVID-19 vaccination in medical settings,1 and vaccination can serve as an important opportunity for families to reengage their children in well childcare following the pandemic shutdowns. States can identify and address financial, access, and administrative barriers to participation in the COVID-19 vaccination program. They can also work with their state Immunization Information Systems (IIS) to review immunization data use and exchange policies to identify potential barriers and leverage the IIS reminder and recall function so that medical practices can easily identify and outreach to patients who are not fully vaccinated. Identify and address COVID-19 health disparities: Population-based data are foundational to public health practice. Having the capability to identify disparities in case numbers, hospitalizations, death, vaccination status, and access to therapeutics by race, ethnicity, and urban/rural differences is essential to guide redistribution of interventions and services, target outreach, and inform public policy. Health equity cannot be realistically addressed without accurate and complete race and ethnicity data in all public health data sets. States can consider engaging health information exchanges in matching public health data sets with vital statistics and other data sources; incentivize medical providers and commercial laboratories to provide more complete race and ethnicity data; and expand the use of the social vulnerability index to identify vulnerable rural populations at a greatest risk of poor COVID-19 outcomes. Expand the capacity and scope of the public health workforce: Response to the COVID-19 pandemic should include health agency efforts to sustain their investments to support, expand, and increase the effectiveness of the public health workforce. Investment in community-based public health workers (eg, community health workers [CHWs], promotoras, peer recovery coaches) has been widely recognized as an evidence-based approach to improving individual and community health and addressing health disparities.2 Their ability to build trust and relationships in underserved communities is essential to successful public health work in the future. Community-based public health workers have a deep understanding of their communities through lived experience, which makes them uniquely qualified to address social and behavioral determinants of health. Early contact tracing needs led to widespread use of CHWs through contractual and temporary hiring. This capacity could be sustained and redirected to other aspects of public health by standardizing CHW job descriptions, salary ranges, and supervision structures in state/local human resources systems and by partnering with local and national community-based organizations. More broadly, states can conduct workforce surveys and update workforce policies, including sick leave policies. Prepare the public to make risk-based decisions: The availability of highly effective COVID-19 vaccinations has dramatically reduced the risk of severe disease and death, and effective therapeutic agents are widely available for individuals at high risk who can be quickly treated after confirmed infection. Home COVID-19 testing now provides an accessible and convenient mechanism for early diagnosis. The use of these important assets in the COVID-19 response must be communicated to the public through succinct messaging guided by audience testing. Variation in community transmission, and the risk associated with certain behaviors, should be made clear so that individuals can make their own decisions about avoiding gatherings, social distancing, or wearing masks. In addition, new social norms of staying home when sick or wearing a mask when exposed should be reinforced with expanded workforce sick leave benefits and periodic, localized use of testing, contact tracing, and mask wearing requirements during disease surges. Implement environmental interventions in schools, workplaces, and other congregate indoor settings: Infectious diseases such as COVID-19 can spread through the inhalation of airborne particles and aerosols. Environmental interventions to reduce COVID-19 spread in confined workplaces such as meat and poultry processing facilities were highly successful early in the pandemic.3 There is broad consensus that improving indoor air quality in school buildings can reduce the risk of COVID-19 spread among students and teachers.4 Many school systems are now working to upgrade their HVAC systems, and similar approaches could be considered in long-term care facilities. Wastewater surveillance is an emerging community surveillance system that could be particularly useful in self-contained water treatment system settings such as large international airports and correctional facilities. TABLE - ASTHO Technical Package on COVID-19 Sustained Management Strategies Objective Potential Indicators Mechanisms Levels of Influence Increase immunization rates and capacity Provider enrollment in COVID-19 vaccine program Practices with ability to link to IIS for vaccination status Provide enrollment incentives Remove administrative burdens to enrollment Enable IIS reminder and recall functions CDC State immunization managers State medical and primary care associations Identify and address COVID-19 health disparities State public health dashboards Completeness of data reports to CDC State and federal data quality measures and benchmarks State disease reporting laws and requirements Data set comparisons and matching Reporting incentives and penalties Provider education Race and ethnicity definitions and standards Electronic transmission capabilities State HIEs State Medicaid agency State FQHC associations State medical and primary care associations CDC, ONC, CMS, OMB, HRSA National public health associations (CSTE, APHL) Expand the capacity and scope of the public health workforce CHW job descriptions, salary ranges, supervision structures in state/local HR system State CHW registries (NACHW) State and local workforce surveys State contracts with CBOs Retention/career ladders Evidence-based practice recommendations Workforce reorganization New funding lines and resources Redirection of existing funding Attrition planning Third party reimbursement State HR systems State contract policies State employee health plans National associations (NACHW, APHA) CDC HHS Office of Minority Health Prepare the public to make risk-based decisions COVID-19 vaccination rates COVID-19 therapeutics utilization rates New state policies, including the expansion of sick leave benefits Public polling COVID-19 community indicators Tax and other incentives for employers to expand benefits Required benefits standards for employers CDC Employer groups Implement environmental interventions in schools, workplaces, and other congregate and indoor settings Infection rates in congregate settings School closures Resources for environmental enhancements Regulatory and statutory requirements Participation in EPA clean air in buildings challenge CDC NIOSH EPA ASHRAE Abbreviations: APHA, American Public Health Association; APHL, Association of Public Health Laboratories; ASHRAE, American Society of Heating, Refrigerating and Air-Conditioning Engineers; CBO, community-based organization; CDC, Centers for Disease Control and Prevention; CHW, community health worker; CMS, Centers for Medicare & Medicaid Services; CSTE, Council of State and Territorial Epidemiologists; EPA, Environmental Protection Agency; FQHC, federally qualified health center; HIE, health information exchange; HR, human resources; HRSA, Health Resources and Services Administration; IIS, Immunization Information System; NACHW, National Association of Community Health Workers; NIOSH, National Institute for Occupational Safety and Health; ONC, Office of the National Coordinator for Health Information Technology; OMB, Office of Management and Budget. Conclusion State and territorial health officials have been tasked with addressing many challenges throughout the COVID-19 response. The considerations listed earlier are not comprehensive. A wide range of other strategies and approaches, such as the use of pharmacies for adult COVID-19 vaccination, have clearly been effective but have not been formally researched or evaluated. Several public health policy interventions have had unintended consequences, and external factors such as worldwide shortages of personal protective equipment and testing materials were never anticipated. The approaches in this technical package provide tangible, evidence-based actions for states and territories to consider as they plan for sustained and improved management of COVID-19 for fall 2022 and beyond.

Context:The COVID-19 pandemic and other public health challenges have increased the need for longitudinal data quantifying the changes in the state public health workforce. Objective:To characterize the state of governmental public health workforce among state health agency (SHA) staff across the United States and provide longitudinal comparisons to 2 prior fieldings of the survey. Design:State health agency leaders were invited to have their workforce to participate in PH WINS 2021. As in prior fieldings, participating agencies provided staff lists used to send e-mail invitations to employees to participate in this electronic survey. Setting and Participants:State health agency staff. Main Outcome Measures:PH WINS 2021 maintains the 4 primary domains from 2014 and 2017 (ie, workplace engagement, training needs assessment, emerging public health concepts, and demographics) and includes new questions related to the mental and emotional well-being; the impact of the COVID-19 pandemic on staff retention; and the workforce's awareness of and confidence in emerging public health concepts. Results:The percentage of SHA staff who self-identify as Black, Indigenous, and people of color increased from 30% (95% confidence interval [CI]: 29%-32%) to 35% (95% CI: 35%-37%) between 2014 and 2021. Staff younger than 31 years accounted for 11% (95% CI: 10%-12%) of the SHA workforce in 2021 compared with 8% in 2014 (95% CI: 8%-9%). From 2014 to 2021, staff who self-identify as a woman increased from 72% (95% CI: 71%-74%) to 76% (95% CI: 75%-77%). Overall, 22% (95% CI: 21%-23%) of the SHA workforce rated their mental health as poor/fair. Conclusion:The 2021 PH WINS results represent unique and current perspectives on the SHA workforce and can inform future public health infrastructure investments, research, and field practice to ensure a strong public health system.

The COVID-19 pandemic has caused immense hardship and suffering across our nation. It continues to test the capacity and resilience of the US public health system and has put great personal and physical strain on the public health workforce. The development of effective COVID-19 vaccines has been the turning point of the pandemic, and the speed at which these vaccines were developed was a significant scientific accomplishment. Equally impressive was the widespread distribution and administration of this vaccine by state and local health departments. As of July 28, 2022, 78.8% of the US population had received at least one dose of the vaccine,1 a rate that far surpassed administration of any other vaccine that has been offered to the general public. This commentary reviews specific aspects of planning and administration, partnerships, surveillance, and public health policy and regulatory actions that demonstrate strengths our public health system should be built on for the future. Planning and Administration The urgency of the COVID-19 pandemic required unprecedented state planning for vaccine administration, even prior to the Centers for Disease Control and Prevention (CDC) issuing specific vaccine guidance. The single biggest accomplishment in this phase of the vaccine campaign was enrolling tens of thousands of providers to be able to administer COVID-19 vaccines. Partnerships were developed with hundreds of groups to train and educate providers to attest to proper storage and handling capacity and meet requirements to report doses administered within 24 to 72 hours. These groups included medical societies, emergency medical services, city and county governments, hospitals, insurers, pharmacies, nurses, and many more. Significant capacity exists within the US public health system to deliver and administer vaccine. Every state has a CDC-funded immunization program and a Vaccines for Children (VFC) program that ensures widespread access to vaccines. But the effort required for this campaign is far beyond what had been developed for routine childhood immunizations and what was established during the H1N1 pandemic. However, existing infrastructure, previously developed by CDC and the states, allowed the federal government to institute centralized ordering, distribution, and provider enrollment without establishing new processes. The early distribution and administration of vaccine were particularly challenging, given the limited supply. All states initially followed ACIP guidelines and successfully prioritized vaccination of frontline health care workers, residents of long-term care facilities, and older adults.2 As the rollout continued, they diverged from ACIP prioritization guidelines in response to direction from federal policy makers.3 However, despite early inequities in vaccination among racial and ethnic minority groups, as vaccine supply expanded, states were able to implement a variety of interventions to reach these communities and substantially reduce disparities.4,5 The early distribution process was also highly efficient. States adapted to packaging and cold storage requirements of the manufacturers, including developing the capacity to redistribute vaccine in smaller increments than the minimum 100-dose Moderna order and 925-dose Pfizer order. Public Health Partnerships Throughout the pandemic, states drew on their close relationships with CDC and worked closely with a variety of trusted partners. In some cases, these partnerships were long established; however, new partnerships were rapidly built because of the size and scope of the situation. Initially, state and local public health worked with community health care systems to administer vaccine to health care workers. As supply increased, public health responded by establishing large-scale community vaccination clinics. This demonstrated the ability of the public health system to respond to changing needs and environment. States enrolled health care providers to administer vaccine in record numbers, including providers previously enrolled in the state-administered VFC program. When initial uptake was slower than desired at hospital and other traditional health care sites, public health planned and executed large-scale clinics, set up information technology scheduling systems, expanded appointment hours, and established vaccine locator tools. In addition, states worked with sites identified through the federal retail pharmacy program to help ensure success and equitable allocation in long-term care facilities for some of the most vulnerable populations. In some instances, states augmented or even took over administration of vaccine in long-term care sites where capacity did not otherwise exist. To increase vaccination among historically underserved communities, states worked with and often augmented the federal allocations to federally qualified health centers and rural health sites. As the pace of vaccine administration slowed over time, states expanded their partnership with chain and independent pharmacies to increase community-based administration. When vaccine became available for children, states assessed parent preferences and worked to increase enrollment of health care providers and expand distribution capacity in these settings. Surveillance Significant work was put into public health data and surveillance systems to ensure information was collected and reported in an accurate and timely manner to the public and federal partners. States scaled up or enhanced Immunization Information Systems (IIS) that that had varying levels of capacity, technology interface, and provider participation. While most states were not reporting vaccination data to CDC, they quickly built the capacity to share vaccine administration data in near real time, allowing CDC to set up the federal COVID-19 vaccine data tracker and supporting state dashboards to highlight vaccine uptake in their jurisdictions. To accomplish this, every state had to adapt laws and overcome significant data sharing and privacy considerations. In addition, states used the IIS to adjust distribution and allocation priorities and implement recall and reminder functions. Throughout the response, states improved the collection and reporting of race and ethnicity data to better understand vaccine uptake and develop tailored messaging and resource for communities.6 Public Health Regulatory Systems and Vaccination Policies The large-scale administration of a new vaccine necessitated significant requirements, reporting, and quality control systems. Storage and handling were critically important. States developed regulatory systems to ensure safe handling and storage and conducted regular site visits to ensure and assess compliance. They developed regulations and laws requiring providers to report doses administered to state IIS and in some cases incentivized participation. States also developed policies expanding pharmacist scope of practice to administer vaccines. Finally, efforts were made to increase participation in COVID-19 vaccination in specific, high priority groups through state policy interventions. As of April 2021, 22 states had COVID-19 vaccine mandates in place for state employees, health care workers, teachers, or students. Finally, many states have also convened racial equity task forces to focus specifically on addressing inequities in COVID-19 cases, deaths, and vaccinations in minority communities. Conclusion Despite intense scrutiny and critique by the media and the general public, public health leaders and the public health system launched a highly effective COVID-19 vaccination effort through planning and administration, partnerships, surveillance, and public health policy and regulatory actions. While there will be ample time to review what did not work in the vaccination campaign, it is equally important to assess what is working and continue to build upon current capacity and prior successes into the future.

The racial, ethnic, and urban-rural disparities experienced during the COVID-19 pandemic highlight the need for public health leaders to address health equity both nationally and internationally. The resulting attention and resources dedicated to health equity have made the answer to the question of "How can multilevel and multisector systems change strategies transform community health outcomes?" one of the most important contemporary challenges facing health departments. Many promising approaches to health equity are focused at the local level and are tailored to and informed by the community residents. Communities bring with them different perspectives, needs, and expectations, often rooted in historical context and experience. In a previous column, we described work to define tangible outcomes of multisectoral partnerships in addressing social determinants of health, which are the main predictors of equity and health outcomes.1 State and territorial health departments can take important steps to support these partnerships. In addition, there are several evidence-based surveillance, workforce, and organizational issues that states and territories can implement to move toward health equity. In this column, we present a technical package of interventions we have prioritized at ASTHO to support state efforts. We also present an approach to working with rural and frontier communities, as well as a policy statement we have developed to support efforts to address structural racism at the public health agency level. A Technical Package of Focused Interventions ASTHO technical packages are based on our subject matter experts' assessment of evidence-based interventions, expert recommendations, overviews of current activities, and a review of the Centers for Disease Control and Prevention (CDC) and other federal funding guidance. They are not intended to be comprehensive. They provide a more focused and proactive approach to our technical assistance roles. Based on this assessment process, ASTHO has prioritized specific areas of work—outlined in Supplemental Digital Content Table 1 (available at https://links.lww.com/JPHMP/A985)—that will guide our technical assistance work. Our efforts will focus on improving the collection of accurate race and ethnicity data. Public health agencies cannot address inequities in access to services, quality of care, and health outcomes without these basic demographic data. We will also work with states, the National Association of County and City Health Officials (NACCHO), and the newly formed National Association of Community Health Workers (NACHW) to expand and support the community health worker (CHW) workforce in state and local public health departments, as well as explore similar classifications in US territories and freely associated states. CHWs are one of the few interventions shown to both improve outcomes and reduce disparities,2 and many states have expanded their use during the COVID-19 pandemic. In partnership with the National Organization of State Offices of Rural Health (NOSORH), we will support states to increase their capacity to address geographic health disparities, as well as interagency engagement strategies specific to remote locations, and understand the unique challenges facing rural populations, as well as those facing US territories and freely associated states. Finally, we will engage with state leaders to address social determinants of health through policy interventions to promote economic mobility, with an emphasis on expanded access to paid family and sick leave. Disparities in Rural Communities and Remote Areas The COVID-19 pandemic demonstrated the urgent need to address disparate public health outcomes. And, for Americans who call more rural areas home, vanishing access to quality health care further marginalized the population's ability to gain access to testing, treatment, and accurate messaging during the pandemic. COVID-19 health disparities experienced by rural and remote populations are associated with a lack of hospitals and health care facilities, insufficient testing sites with walk-in/drive-up options, inconsistent access to transportation, less than 30-minute drive times, and inaccurate information regarding testing availability. Addressing geographic health disparities will require neighborhood-based, community-centered approaches and federal support to states. CDC created a multifactor Social Vulnerability Index (SVI) used to identify vulnerable rural populations at a greatest risk of impact by hazardous events. Public health leaders serving rural populations can utilize this tool to plan prevention efforts and respond to COVID-19 and other widespread and potentially catastrophic health events. Utilizing an existing framework, this tool helps rural populations target limited resources to the areas with the greatest need and monitor and better respond to changing needs over time. Investments in data management systems can increase public health capacity to make decisions using data visualization products such as the SVI and other geographic information system mapping (GIS mapping). Addressing Discrimination and Structural Racism Even with proposed modernization of public health data systems, and augmenting the community public health work force, strategies will fail to achieve health equity without acknowledging and addressing the implications of historical discrimination and structural racism. Without the fundamental understanding of how structural racism creates and maintains a system of inequities, our efforts will fail to achieve their end goals of improving health for all. Structural racism describes the way in which governmental policies and procedures have historically been constructed and maintained, resulting in racial inequalities in many of the social determinants of health, and ultimately leading to inequities in health and opportunity. Public health agencies have a role to play in ending structural racism. The solutions identified in the technical package are health equity–centered and align with the key recommendations from ASTHO's policy statement, Achieving Optimal Health for All by Eliminating Structural Racism.3 This statement acknowledges structural racism as a fundamental cause of health inequities and provides a series of recommendations for state and territorial health agencies. The technical package prioritizes promising upstream interventions to address health equity, which ASTHO defines as follows: ...when everyone has a fair and just opportunity to be as healthy as possible in a society that values each member equally through focused and ongoing efforts to address avoidable inequities, historical and contemporary injustices, and the elimination of disparities in health and health care. Conclusion Public health agencies are encouraged to create a culture of health equity by examining their institutional practices and supporting organizational changes, which include adopting anti-racist policies and improving the collection of race and ethnicity data. Doing so will strengthen the evidence base on racial health inequities. Public health agencies are also part of the communities they serve. It follows, then, that engaging in local partnerships that foster community leadership and create community-led solutions will contribute to promising interventions and provide workforce opportunities. This work begins with hiring a workforce that reflects, and is from, the community being served—as is seen with CHWs. Finally, ASTHO's policy statement and technical package emphasize leveraging law and policy as a critical tool to advance equity. Policy approaches to expand sick leave and paid family leave benefits are a timely approach to address underlying inequities in the social determinants of health.

The COVID-19 pandemic has caused immense hardship and suffering across our nation and the globe. It tested the capacity and resilience of the US public health system, which has been long neglected and underresourced, and put great personal and physical strain on the public health workforce. There have been missteps, errors, and lessons for improvement. Despite intense scrutiny and critique by the media and the general public, public health leaders and the public health system performed well in many areas. This commentary reviews specific aspects of response and readiness, workforce expansion and resilience, and public health policy and regulatory actions that demonstrate strengths our national public health system should build on for the future. While there will be ample time to review what did not work in the overall COVID-19 response, it is equally important to assess what is working and continue to build upon prior successes into the future. State, Territorial, and Local Response and Readiness State, territorial, and local (S/T/L) health agencies have been planning and responding to disasters for decades, although a formal national program was not funded until after September 11, 2001, and the subsequent anthrax attacks. The Centers for Disease Control and Prevention's Public Health Emergency Preparedness (PHEP) program supports extensive influenza pandemic planning efforts that enabled public health agencies to assertively posture for the onset of the COVID-19 pandemic. The combination of planning and exercising, supported by the PHEP program, informed decision making during a time when data and knowledge about the emerging COVID-19 novel virus were scarce. Relying on these jurisdictional pandemic plans and lessons learned from previous infectious disease outbreaks, state and territorial governments followed National Incident Management System guidance and stood up coordinated emergency operations centers to support the complexities of large-scale response and recovery. Acknowledging increased demands, health agencies forged alliances that fostered coordination in multiple areas, one of which was to strategically offset supply shortages and avoid bidding wars over personal protective equipment and other supplies in limited availability nationwide. An overlooked component of public health preparedness is the overall management of operations, referred to as administrative preparedness.1 Building on lessons learned from the 2009 H1N1 influenza pandemic, S/T/L health agencies have spent years improving policies and processes to better streamline areas of response such as the acquisition of human resources and procurement of professional services. During COVID-19, these policies and processes supported efforts to navigate the strained supply chain, a challenge that persisted despite the Administration's invoking of the Defense Production Act to help expand access to needed equipment. S/T/L health agencies have maximized established relationships with emergency management, federal agencies, and state and local partners, engaging with peers to share best practices and credible supply sources throughout the pandemic. Workforce Expansion and Resiliency The public health workforce has shown extraordinary capability and resilience during the COVID-19 response. S/T/L public health leaders emerged as trusted experts and advisors for governors and policy makers across the nation. Recognizing the profound impact that the economy ultimately has on health and well-being, public health leaders reached compromises, and sometimes common ground, with business leaders while enacting mitigation interventions to limit disease spread. Despite intense criticism and pushback from a vocal minority of citizens, health officials regularly communicated with the public about the state of the pandemic, evolving measures to bring it under control, and the hardships the virus wrought on families and communities. Health officials also led other state and local leaders in efforts to maximize limited testing capacity, track and trace infections, monitor outcomes, increase hospital capacity, enforce restrictions, distribute new therapeutic advances, and plan and implement efficient and fair vaccine distribution systems. S/T/L health agencies quickly stood up an impressive expansion of the workforce during the COVID-19 response. Tens of thousands of new and contract personnel were trained and integrated into the contact tracing workforce nationwide, and while this effort continues to be a work in progress, the extent of state efforts cannot be underestimated. At the outset, approximately 2200 public personnel at US health agencies were trained in case investigation and contact tracing, primarily within tuberculosis, HIV/AIDS, and sexually transmitted infection (STI) programs.2 As of December 2020, state and territorial health agencies reported an estimated workforce of more than 70 500 contact tracers—representing more than a 30-fold increase in under a year.3 While this number may be an underestimate due to a lack of a uniform national survey to enumerate the contact tracing workforce during COVID-19, it serves as an indicator of the magnitude and progress of this effort. These nascent contact tracing programs adapted to numerous challenges, including the evolution of COVID-19 science, guidelines, and phases of response, which impacted operational definitions, quarantine recommendations, and workforce capacity to respond to surging caseloads. COVID-19 contact tracing serves as an example for how core public health infrastructure can be expanded in a manner that is responsive and potentially disease-agnostic for future response. While battling the international COVID-19 crisis, the US public health workforce endured multiple other challenges as the nation faced an awakening to systemic racism, politicization of scientific decision-making, and threats to the personal security and safety of public health leaders. Health officials and their staff displayed impressive resilience, advancing evidence-based public health practice, working to maintain continuity of other core public health program and service efforts, and battling coexisting disasters such as wildfires and hurricanes. Routine public health activities were also sustained: for example, as COVID-19 impacted routine food safety inspections, public health agencies pivoted to develop protocols to support virtual inspections. Public Health Policy and Regulatory Action In the early stages of the pandemic, state and local jurisdictions enacted policies and regulations—including requiring the use of face coverings in public settings, restricting social gatherings, and limiting movement through stay-at-home orders—that protected the majority of the population.4 States have continued to take actions to restrict gatherings and activities as additional infection surges have occurred in specific regions of the county, while those most hard-hit early in the pandemic have maintained strict adherence to mitigation protocols. Jurisdictions exercised these regulatory powers in a challenging environment that featured inconsistent federal messaging and opposition from a vocal subculture focused on personal freedom and limited government. Despite the opposition, health officials used emerging evidence to support mitigation efforts, relying upon sound science and evidence to support the development of public health policy. In addition, S/T/L governments used regulatory powers to enact policy and environmental controls in worksite settings to manage and ultimately control a spate of outbreaks occurring in congregate settings including meatpacking plants, poultry processing centers, and correctional facilities.5 States also took regulatory measures to reduce infection and death rates in long-term care facilities, implemented policy and environmental changes to limit disease transmission in the 2020 election,6 and took a cautious and measured approach to in-person public school attendance. These efforts were not easy, but they did prevent transmission and avert greater morbidity and mortality. Attention to health equity has figured prominently in state health program and policy work. As COVID-19 morbidity and mortality disproportionately impacted racial and ethnic minority communities, jurisdictions took steps to develop a contact tracing workforce that reflects the racial and linguistic diversity of the communities they serve. Jurisdictions leveraged partnerships with community-based organizations to create jobs and long-term career pathways for members of impacted communities.2 Finally, in anticipation of limited vaccine supply early in the immunization effort, states attempted to address equity and maximize infectious disease control by adopting phased eligibility tiers prioritizing groups at greatest risk or most to likely spread infection. However, they immediately faced intense public and political pressure to expand these eligibility criteria and their ability to maintain these standards has been attenuated. Conclusion There is ample need for productive critique of the public health system and response to the COVID-19 pandemic. There is also critical need to highlight strengths and successes of the system that must be recognized and protected as we take steps to better prepare for the future. Previous investments in preparedness programs through the PHEP program made a difference in allowing the system to quickly and efficiently posture early in the pandemic. This program should continue and expand for the future. A considerable workforce has been recruited and trained for contact tracing, in many cases using paraprofessionals who have intimate and trusted relationships with communities most affected by public health issues. This workforce expansion must also be sustained. Once the pandemic is controlled, these contact tracers—hired because of their acceptance and trusted relationships within the community—can bolster public health capacity to control infectious diseases like HIV/AIDS and other STIs. Cross-training may also provide on-ramps for this workforce to engage in other areas, including control of chronic disease risk factors such as diabetes, hypertension, and tobacco use. Finally, while many of the regulatory and policy interventions to control the pandemic have been difficult and controversial, it was imperative that S/T/L public health systems had the authority to enact these interventions early in the pandemic. These public health powers are now being challenged in a number of state legislatures.7 Many of these actions would drastically undermine the most effective public health infection control interventions in our arsenal, and they must not be weakened. Finally, we believe the most notable aspect of this response has been the perseverance—despite tremendous adversity—of dedicated scientists, civil servants, and leaders who comprise the governmental public health workforce. Efforts to support the workforce and expand capacity to respond to public health emergencies must be prioritized in the future. The COVID-19 pandemic strained the public health system and tested the limits of underresourced public health programs. Despite the strain, public leaders rose to the challenges posed by COVID-19. Certainly, there were mistakes made, especially early in the pandemic when the understanding of the virus was still emerging. However, there were also many successes. These bright spots should be analyzed as well, as these illustrate parts of the system that were conducive to success. A significant asset of the system are the dedicated public health leaders and practitioners who have devoted countless hours to assure the health of their jurisdictions. In the rush to critique their work, we should not forget the many accomplishments they achieved in responding to a global pandemic of historic proportions.

Public health initiatives, from promoting vaccines and family planning to ensuring safe drinking water, have effectively improved the health and quality of life of all people living in the United States. As the nation addresses the COVID-19 epidemic, the important role of public health science, polices, and interventions is becoming increasingly clear. The profound impact COVID-19 has had on older populations has drawn our attention to the impact that mitigation interventions have had on social isolation, safety, and access. Disparities in outcomes and suffering from COVID-19 have been particularly prominent among Black and Latino communities and American Indian and Alaska Native Tribes, and the burden has been even greater in these populations for those who are older.1 The pandemic has drawn national attention to a number of societal inequities and shortcomings that we may now have the ability to address. Creating a culture of healthy aging for all is one of those imperatives. Public health agencies can use their authority through policies and regulations designed to protect these groups and can leverage their influence in government and society to address issues that are outside the immediate realm of public health. In this commentary, we discuss specific approaches public health officials and agencies can take to develop a culture of healthy aging in our communities, creating positive health outcomes for all older adults. Enact and advocate for healthy aging policies. Public health leaders have both authority and influence on policy decision making.2 In ASTHO's Essential Policies for Chronic Disease Prevention and Control and in the Healthy Aging Policy Statement, there are recommendations for policies that can both prevent poor outcomes in older adulthood and support quality of life among older adults, such as the adoption of community design policies to ensure infrastructure is conducive to all ages or strengthening preparedness plans to ensure it addresses the unique needs of older adults.1,2 Public health leaders, such as state, territorial, and local health officials, may be able to implement and promote policies as part of their existing authority. This could include promoting long-term care benefits and flexible work hours for employees reaching older adulthood and for those providing care to someone aging with a chronic condition and/or disability. For other policies, public health leaders can leverage their influence by building relationships and partnering with agencies that work in aging, social services, city planning, and other sectors that impact older adults to collectively work toward policy development and implementation. Integrate aging and public health plans. Public health leaders are encouraged to work with leaders in agencies that serve older adults to integrate jurisdiction-wide public health plans with jurisdiction-wide aging plans to identify overlapping strategies and opportunities to prevent poor health outcomes. State, territorial, and local health departments have led the way by assessing the state health improvement plan (SHIP), state plan on aging, state Alzheimer disease plan, jurisdiction-wide strategic plans, emergency preparedness plans, and/or other plans informed by HHS's Healthy People objectives. There are several frameworks available to aid in integrating aging and public health plans, including Trust for America's Health's Age-Friendly Public Health Systems, the Alzheimer's Association and CDC's Healthy Brain Initiative Road Map Series, and AARP's Network of Age-Friendly States and Communities (a part of the World Health Organization's Global Network for Age-Friendly Cities and Communities). The forthcoming updated Public Health Accreditation Board requirements will include standards and measures specific to healthy aging. State and local health departments seeking accreditation or re-accreditation will need to ensure their organization is well suited to identify ongoing efforts to address the unique needs of older adults.3–5 Inclusion of aging in public health communications. A key role of every public health leader is telling the story of public health, and it is important that these stories include narratives of older adults and promote age-friendly policies and programs. As public health practitioners address prevention across the life span, they must consider all public health issues through an aging perspective. Chronic disease directors have developed innovative messaging for health topics such as heart disease and stroke prevention featuring positive images of older adults and promoting data and findings specific to the older adult population. These efforts provide an opportunity to promote a positive view of aging and build capacity of the public health workforce to address the well-being of older adults and their caregivers. Public health agencies are suited to apply that perspective now by identifying the unique needs of older adults for COVID-19 vaccine distribution and updating emergency preparedness plans with lessons learned from the COVID-19 pandemic response. A culture of healthy aging will vary by jurisdiction but should ultimately underscore the value every person brings into helping communities to thrive. While it is important to take a life course perspective to promote health from an early age and support quality of life into older adulthood, it is also critical that health agencies apply a specific perspective to older adults as a population group throughout all public health areas of practice. Aging is a privilege developed through centuries of health advancements. Given the many challenges facing the nation, it is more critical now than ever for state and territorial agencies to collaborate on creating a culture of healthy aging and in supporting quality of life for all older adults.

Climate impacts on human health are an urgent public health issue. The effects of climate change are clear. During the past several years, states and territories have wrestled with extreme temperatures, historic rains and flooding, and the worst wildfire and drought conditions ever recorded. These events have become more severe, more frequent, and more costly in recent years.1 State and territorial health agencies (S/THAs), as well as local and tribal health departments, must be prepared for the inevitability of climate-related impacts on human health. They can take direct action in areas where they have authority, and they can help influence other policy actions that protect health. While responsibility for setting and enforcing federal environmental policy largely falls to the US Environmental Protection Agency (EPA) and other federal agencies, state and local agencies can play a significant role in advancing policy. An example of such local authority is actions taken by state governments to move toward 100% clean energy.2–5 These actions have led to more far-reaching and ambitious regulations than those established by the federal government. S/THAs can continue to take similarly bold, progressive action and work toward mitigating impacts of a changing climate based on sound science and public health impact. In this column, we outline a technical package of capacity building and policy interventions for state and territorial health officials (S/THOs) to address the range of health impacts associated with climate change. Ensuring Adequate Surveillance Capacity Public health policy must be driven by reliable data. The capacity to systematically collect, manage, analyze, and interpret climate, extreme weather, and related human health data is critical to making informed climate policy and developing effective responses to climate and extreme weather events. The Centers for Disease Control and Prevention's (CDC's) National Environmental Public Health Tracking (EPHT) program, which collects, integrates, and analyzes noninfectious disease and environmental data from a nationwide network of partners, provides a critical platform to guide and evaluate public health actions that can prevent or mitigate the impact of environmental hazards on health. The platform also facilitates identification of trends that may increase our understanding of relationships between environmental hazards and health.6 The CDC currently funds 25 states and 1 city to build, operate, and maintain this platform. States that are not participating may not have a sufficient array of environmental surveillance tools to inform effective climate action. One state has taken individual action to develop its own system. Other states that do not have this surveillance capacity could build it into their data modernization efforts. Potential sources of funding may emerge through federal resources (eg, CDC's Environmental Health Capacity Program). Every S/THA must have an environmental health surveillance system on par with those built through the CDC's EPHT program. Expansion of the CDC's National EPHT Network is critical: increasing the surveillance capacity of S/THAs empowers states and territories to detect and track climate change–related disease and health burdens that are locally relevant.7 Enacting and Influencing Public Policy Interventions that target policy and systems change may be effective in mitigating the health impacts of climate change. While S/THAs may have limited authority to exclusively develop environmental and climate-related policies, they can creatively and strategically build alliances with their state agency counterparts, community organizations, and the public. Health in All Policies (HiAP) is a collaborative approach that adds a framework for providing evidence-based health and equity considerations to policy and program development in other sectors.8,9 S/THAs often work with colleagues in state departments of housing, environment, energy, transportation, and other related partners to provide a health lens to policies and projects under development to improve places where people live, work, and play. Specific climate-related HiAP initiatives include emergency management cooperation, water conservation policies, weatherization policies—such as the Home Energy Assistance Program—and multimodal transportation policies, such as complete streets. A HiAP approach to climate change can lead to policies that improve resilience to the health effects caused by a changing climate. In the first half of 2020, outdoor air quality improved because of infectious disease mitigation activities that reduced traffic emissions.10,11 To maintain these gains, S/THOs could use this experience to pursue cross-sector policy making that aims to curtail sources of greenhouse gas emissions. By working with partners on policies that reduce automobile travel such as continued expansions of teleworking or engaging in economic development efforts that incentivize development of clean energy industry, S/THOs can influence policies that prevent, prepare for, and respond to the current and future health impacts of climate change. In addition to policy-making levers, S/THAs can educate the public about potential health implications of individual and social behaviors, consumption of goods and services, and decision making that may contribute to negative impacts of climate change. Promoting responsible use and protection of natural environments empowers communities to take actionable steps to protect food systems, water supplies, and air quality, which can, in turn, mitigate catalysts of climate change and extreme weather. Most importantly, health equity and environmental justice must be centrally incorporated into this climate work. As we have seen with countless examples of hurricanes, flooding, and extreme heat events, climate change disproportionately affects communities of color and groups that have been socioeconomically marginalized.12 Children, seniors, and people with underlying health conditions are at an increased risk for the negative health impacts of climate change.12 Some S/THAs already take a HiAP approach to address disparities between populations of different racial and ethnic groups, which can easily be employed to increase health equity in their climate-related work. Climate change also stresses our health care infrastructure and delivery systems. All states and territories have vulnerabilities to climate-related health impacts. Just as state and local health agencies have taken bold action to prevent and mitigate the impacts of environmental hazards such as lead in the past, they are in a position to lead and influence policies that encourage resilience to, and mitigation of, the human health impacts associated with climate change. Climate and health leaders must also stay attuned to the disproportionate impacts climate change will have on people at a greater risk for significant health impacts and encourage equitable policies and programs. Using public health tools such as surveillance and early warning systems, cross-sector partnerships, and proven risk communication and education strategies, S/THAs can work with their state and federal counterparts to inform and influence equitable climate and health policies.

In the wake of the significant health disparities in communities of color highlighted during the COVID-19 pandemic, a national commitment to address long-standing systemic health and social inequities has emerged. Addressing the underlying causes of poor health outcomes and inequity including poverty, education, housing, and access to affordable, quality health care can drive meaningful change. These social determinants of health (SDoH) are critical factors that can limit or enhance our opportunities to lead healthy lives. During the pandemic, the federal government recognized the importance of income protection and wraparound services through the paycheck protection program and by providing funding to states to support housing and food security. Significant resources were also provided to support virtual learning in communities with limited access to computers and broadband. Recent funding has provided additional resources to enhance public health infrastructure and services. The Centers for Disease Control and Prevention (CDC) received funding to support an SDoH pilot program to provide grants to state, local, territorial, and tribal jurisdictions to develop plans to accelerate action to address SDoH. These plans have tremendous potential to help communities narrow disparities through multisector partnerships to address systemic and unfair barriers to practicing healthy behaviors. Approaches to SDoH in the health care setting have focused primarily on connecting individuals to resources and services to fulfill their social needs1 and developing data standards for SDoH information captured in electronic health records.2 This individualized approach does not address underlying social conditions or lack of adequate access to basic resources in most communities.3 These factors require complementary solutions nested in community engagement and collaboration. There is extensive literature on the processes of collaboration and the importance of addressing SDoH. However, more attention is needed to connect SDoH work directly to health outcomes, as well as to identify community strategies for attaining these goals. This includes developing and sustaining multisector partnerships, braiding funding, community engagement in data gathering, and problem solving in communities directly impacted by the targeted SDoH.4 To better understand which SDoH approaches result in positive health outcomes, we need to evaluate what types of local partnerships and roles are most likely to succeed, as well as how these practices can be supported by local, state, and federal policies and resources. This column describes a project to gather more information on successful approaches. Starting in early 2020, CDC partnered with National Association of County and City Health Officials (NACCHO) and the Association of State and Territorial Health Officials (ASTHO) to identify multisector coalitions that have improved SDoH in their communities. Healthy People 2030 groups SDoH into 5 domains: Economic Stability, Education Access and Quality, Healthcare Access and Quality, Neighborhood and Built Environment, and Social and Community Context. Using these domains as a foundation, CDC's National Center for Chronic Disease Prevention and Health Promotion developed an integrated framework to address SDoH in areas with the greatest potential to impact chronic disease outcomes.5 The Social Determinants of Health—Getting Further Faster pilot project focuses on the following SDoH areas: Built Environment: Human-made surroundings that influence overall community health and individual behaviors that drive health. Community-Clinical Linkages: Connections made among health care systems and services, public health agencies, and community-based organizations to improve population health. Food and Nutrition Security: An economic and social condition characterized by limited or uncertain access to adequate and nutritious food. Social Connectedness: The degree to which individuals or groups of individuals have and perceive a desired number, quality, and diversity of relationships that create a sense of belonging and being cared for, valued, and supported. Tobacco-Free Policy: Population-based preventive measures to reduce tobacco use and tobacco-related morbidity and mortality. Communities Making a Difference ASTHO and NACCHO, through a competitive national application process, selected 42 community multisector partnerships and coalitions to participate in the project. Selection was based on criteria that focused on the structure of the multisector partnership and coalition, program design, availability of data to show success, and level of engagement of stakeholders.6 Successful candidates demonstrated success implementing strategies in 1 or more of the 5 defined domains.7 In addition to receiving targeted technical assistance around community coalition building and evaluation, the communities will participate in a retrospective evaluation to identify lessons learned about successful efforts to address SDoH. The selected community partnerships and coalitions are primarily located in medium- to large-sized jurisdictions. Seventy-two percent are led by nonprofit community-based organizations, with others led by a local health department (18%), a school or university (8%), or a health care organization (5%). Among partnerships and coalitions not led by a health department, 76% reported active participation from a local health department and 26% involved a state health department. At least 10 partnerships and coalitions are working in each of the 5 targeted domains, with several (48%) working in more than one. Fifty-five percent are focused on community-clinical linkages, 48% on nutrition security, 33% on the built environment, 31% on social isolation, and 26% on tobacco cessation. Fifty percent of partnerships and coalitions report they are implementing evidence-based interventions, and 57% report they are using culturally tailored interventions. The coalitions reported outcomes that include implementing smoke-free policies, making improvements in the built environment, increasing social connectedness, and improving the management of chronic conditions. Documenting the Evidence Base for Social Determinants of Health Considerable efforts are occurring at the local level to address policies, environments, and conditions that improve SDoH. These efforts build on the work of large federally funded programs, such as Racial and Ethnic Approaches to Community Health (REACH), and on a considerable number of efforts supported by private national foundations, such as the Robert Wood Johnson Foundation, the Kellogg Foundation, and the de Beaumont Foundation. As the nation invests resources in addressing SDoH, it is important to understand these efforts and build an evidence base of what works. The community partnerships and coalitions identified in this project provide leadership, experience, and outcomes to inform future efforts and funding opportunities. CDC, ASTHO, and NACCHO have partnered with RTI International to conduct an evaluation using a participatory, mixed-methods approach to synthesize reported outcomes and factors that contributed to coalitions' success. The evaluation includes a review of evaluation reports and other key coalition documents, a secondary analysis of administrative data, and discussions with coalition partners to gain a better understanding of key implementation strategies. Anticipated by late 2021, the findings will provide insights into community, coalition, and initiative factors that contribute to SDoH improvements. We anticipate that successful efforts in these communities could help define the role of local and state health departments and CDC in advancing health equity by improving SDoH. This evidence may assist local health departments in shaping their own efforts to support community partnerships and address SDoH. As a result, they will be better positioned to educate local policy makers and engage community stakeholders. State health departments will be better equipped to prioritize how and where to provide resources, create supportive environments for local work, and introduce policy and systems changes with a more far-reaching population-based scale. CDC and other federal agencies can use the findings to further promote, expand, and foster an environment that supports collaboration of new partnerships and strategic approaches toward addressing SDoH and improving health outcomes.

BACKGROUND:Mailed reminders to promote colorectal cancer (CRC) screening by fecal immunochemical testing (FIT) have been shown to be effective in the Medicaid population, in which screening is underused. However, little is known regarding the cost-effectiveness of these interventions, with or without an included FIT kit.METHODS:The authors conducted a cost-effectiveness analysis of a randomized controlled trial that compared the effectiveness of a reminder + FIT intervention versus a reminder-only intervention in increasing FIT screening. The analysis compared the costs per person screened for CRC screening associated with the reminder + FIT versus the reminder-only alternative using a 1-year time horizon. Input data for a cohort of 35,000 unscreened North Carolina Medicaid enrollees ages 52 to 64 years were derived from the trial and microcosting. Inputs and outputs were estimated from 2 perspectives-the Medicaid/state perspective and the health clinic/facility perspective-using probabilistic sensitivity analysis to evaluate uncertainty.RESULTS:The anticipated number of CRC screenings, including both FIT and screening colonoscopies, was higher for the reminder + FIT alternative (n = 8131; 23.2%) than for the reminder-only alternative (n = 5533; 15.8%). From the Medicaid/state perspective, the reminder + FIT alternative dominated the reminder-only alternative, with lower costs and higher screening rates. From the health clinic/facility perspective, the reminder + FIT versus the reminder-only alternative resulted in an incremental cost-effectiveness ratio of $116 per person screened.CONCLUSIONS:The reminder + FIT alternative was cost saving per additional Medicaid enrollee screened compared with the reminder-only alternative from the Medicaid/state perspective and likely cost-effective from the health clinic/facility perspective. The results also demonstrate that health departments and state Medicaid programs can efficiently mail FIT kits to large numbers of Medicaid enrollees to increase CRC screening completion.

Preventable chronic diseases represent the nation's leading causes of death, disability, and health care costs. State and territorial public health agencies consistently prioritize chronic disease prevention and control in their health improvement plans either as general prevention and reduction of chronic diseases or as a focus on one or more specific chronic diseases or behavioral risk factors such as tobacco use, lack of physical activity, and poor nutrition.1 Based on these priorities, ASTHO has sought to provide technical assistance and staff expertise to better support state health officials and partner in the implementation of evidence-based chronic disease prevention and control efforts. A wide range of evidence-based interventions is effective to prevent and control chronic diseases at the population level,2,3 and among the most effective are interventions that target policy and systems change.4,5 State and territorial legislative policies and regulatory actions are important because they affect entire populations and often require fewer resources than individually focused programs and interventions. Policy and regulatory actions have been used to discourage tobacco use and encourage tobacco cessation, as well as to remove barriers to improved nutrition and to promote physical activity. Such policy approaches are intended to make the healthy choice the “default” or “easy”6 choice. Policy-Making Authority A principal role of state and territorial health officials (S/THOs) is formulating sound public health policy. As health policy advisors to governors and secretaries of health and human services agenices, health officials are positioned to advise the executive and legislative branches of government. In addition to policy formulation and development, state and territorial public health officials have specific statutory authorities that allow them to develop and enforce specific policies. In their efforts to address chronic disease, public health officials frequently lead efforts to implement tobacco control, as well as policies that promote healthy food access and proper nutrition—including healthy food procurement and contracting policies—and policies that promote and support breastfeeding. Influence on Policy Decision Making Many policies that impact the public's health are not specific to the direct authority of public health agencies. For example, school nutrition and physical education standards are important policy interventions to prevent childhood obesity, but state health officials often do not have authority over state or local education agency policy making. Organizations outside government—from private schools to major corporations—create internal policies on matters as diverse as tobacco use and paid sick leave. Health care systems and insurers set coverage and payment policies that can be highly effective and far-reaching. Developing policy change in these areas of public health requires practitioners to use their professional influence and boundary-spanning leadership skills7 to develop and leverage relationships with leaders in other local and state agencies, tribal communities, health care organizations, and community settings. As such, S/THOs can play a key role in influencing policies that promote health even in areas in which they have no direct authority but do have influence. National Work to Support State and Territorial Policy Making A central tenet of ASTHO's strategic plan is to improve public health through capacity building, technical assistance, and thought leadership. Over the last year, ASTHO has expanded its efforts to increase state and territorial health leaders' competency in evidence-based public health. Given the priority placed on chronic disease and prevention across state and territorial public health agencies, ASTHO focused its attention on opportunities for health officials to advance evidence-based policies to prevent chronic disease. This included forming learning and practice communities around specific topics, supporting state policy academies, and holding training opportunities for state and territorial heath officials and their leadership teams. In most state and territorial public health agencies, chronic disease programmatic work is organized around categorical federal funding lines. A workforce dedicated to each disease area typically leads program intervention efforts and is often supported by the National Association of Chronic Disease Directors (NACDD) and other national partners. In partnership with chronic disease directors, S/THOs work to support, champion, and lead initiatives to address chronic conditions and risk factors. ASTHO used several sources to identify and categorize evidence-based chronic disease policy areas. The main sources were evidence reviews compiled by The Guide to Community Preventive Services, the World Health Organization's Non-Communicable Disease (Best Buys), the Centers for Disease Control and Prevention's (CDC's) 6-18 Initiative, CDC's Winnable Battles Initiative, and CDC's Chronic Disease Indicators. In addition, ASTHO reviewed a wide range of secondary resources and scientific recommendations including Harvard University's CHOICES Project, Trust for America's Health's (TFAH's) State of Obesity Report and Promoting Health and Cost Control in States (PHACCS), the American Lung Association's tobacco control guidelines, the US Guide to Clinical Preventive Services, the University of Wisconsin's County Health Rankings, CDC's HI-5 Initiative, CDC's Healthy Brain Initiative Road Map, and the CEO Cancer Gold Standard. These evidence-based policy focus areas were categorized on the basis of whether S/THOs were likely to have direct authority to introduce and champion these policies through the executive or legislative branches of government or whether officials would use their influence and relationships to advocate for other entities to implement these policies. The policies were further refined through meetings with CDC subject matter experts, focus groups with health officials, and input from ASTHO's community health and prevention policy committee. ASTHO then examined existing reviews and reports to assess state-by-state progress in the policy areas (Table). TABLE - Essential Policies for Chronic Disease Prevention and Control: Priorities for State and Territorial Health Officials Authority Influence Jurisdictions With Progress Toward the Policy Areas Tobacco 1. Increase taxes on all tobacco products • 16 2. Create and enforce comprehensive tobacco-free air policies • 10 3. Restrict all forms of tobacco product advertising • 1 5. Protect local authority to enact tobacco control policies • 39 6. Promote policies that increase access to tobacco cessation programs • 16 Nutrition 1. Implement multicomponent policies that reduce sugar consumption • 23 2. Implement policies that promote breastfeeding • • 27 3. Implement procurement, contracting, and retail policies that increase access to healthy foods • • 51 4. Implement nutrition policies in early childcare facilities • 35 5. Enhance access to, utilization of, and nutritional quality of school meals • 47 Physical activity 1. Increase support and resources for physical activity in community settings • 47 2. Support built environment policies that promote physical activity • 31 3. Enhance physical education and recess standards in schools • 51 4. Implement policies to increase physical activity and reduce screen time in early childhood education settings • 30 Chronic disease control 1. Create policies and structures to establish community health workers in the public health workforce • • Pending 2. Prohibit tanning bed use among minors younger than 18 y • 24 3. Introduce policies that increase access to diabetes prevention programs • 27 4. Support policies that improve prescribing of, and adherence to, hypertensive treatment plans including blood pressure self-monitoring • Pending 5. Support policies that incentivize the early detection and diagnosis of cognitive impairment and dementia in health care settings • 3 Data on tobacco policy were compiled from a review of state tobacco policy analyses completed by the American Lung Association, the Campaign for Tobacco-Free Kids, Public Health Law Center, the National Conference of State legislatures (NCSL), the American Nonsmokers' Rights Foundation, and the CDC Office of Smoking and Health. Data on nutrition policy were compiled from analyses completed by TFAH, the Robert Wood Johnson Foundation (RWJF), Healthy Food America, NCSL, Healthy Food Access portal, the Center for Science in the Public Interest, National Resource Center for Health and Safety in Child Care and Early Education, and the School Nutrition Association. Data on physical activity policy were taken from data compiled by TFAH, NCSL, and RWJF, and data on skin cancer policy were based on reports from the Melanoma Foundation. Data on diabetes policy were based on reports from TFAH and NACDD, and the data on cognitive impairment policy were based on reports from the Alzheimer's Association and NACDD. Published data are not currently available to document (1) policies or structures to establish community health workers in the public health workforce, or (2) policies that improve prescribing of and adherence to hypertensive treatment plans including blood pressure self-monitoring. ASTHO is developing mechanisms to monitor progress in these areas. See Supplemental Digital Content Appendix A (available at https://links.lww.com/JPHMP/A706) for complete description of the policy criteria and data sources for the chronic disease essential policies. Expanding Essential Chronic Disease Policies Across the Nation S/THOs are tasked with addressing many areas of public health and oftentimes have a short tenure to make an impact on the health of their state. Many S/THOs focus on improving chronic disease risk factors because of the significant human burden and cost of these conditions. The essential chronic disease policies represent an approach to technical assistance at ASTHO that is evidence-based, policy-oriented, and proactive. It will be used as a guide for health officials and their leadership to prioritize state efforts in addressing chronic disease and will allow states to determine areas of success as well as opportunities for significant impact. In terms of implementation, ASTHO staff will work with states individually to review progress in each of the policy areas and will assess policy interventions that have not been addressed or that could benefit from a more comprehensive approach. ASTHO staff will also work proactively to identify opportunities to increase implementation of these policies across the nation by engaging state public health leaders, identifying existing best practices, seeking funding opportunities to support this work, and collaborating with CDC. ASTHO will work with its membership to introduce and prioritize the recommended chronic disease policies within policy committees and the government affairs annual priorities and position statements. ASTHO will engage in partnerships with affiliates and other national organizations to ensure the state health leadership is supported beyond their individual efforts. Overall, the essential policies for chronic disease framework serves as a guide for health officials to use in their unique position to ensure that the greatest amount of impact is made to address the burden of chronic disease.

BACKGROUND Mailed at-home stool testing offers a promising strategy for overcoming barriers to colorectal cancer (CRC) screening in vulnerable populations. This paper evaluates the facilitators and barriers of successful implementation of a mailed fecal testing program among Medicaid populations within a health department setting. METHOD Interviews were conducted with key informants involved in intervention start-up and implementation tasks. The Consolidated Framework for Implementation Research (CFIR) was used to design the interview guide and structure the analysis. Axial coding was used to connect the themes to each other under the major categories of facilitators and barriers. RESULTS Overall, the process evaluation suggests that with strong partnerships, effective champions, and existing infrastructure, a large county health department can successfully implement a mailed fecal testing program targeted at Medicaid beneficiaries. The identified facilitators and challenges to implementation provide important information for similar emerging programs. LIMITATIONS The sample size of this evaluation is small. Additionally, we are unable to discern whether participating stakeholders' responses represent the feelings of non-interviewed staff, program implementers, or participants. We were not able to collect data on patient perspectives of the intervention. The nursing staff and interns were not able to be included in the process evaluation. Lastly, the information taken from this process evaluation may not be applicable to organizations and systems with different attributes. CONCLUSION The process evaluation suggests strong partnerships, effective champions, and elegant program designs were key contributors to successful implementation of a CRC screening program targeted at Medicaid beneficiaries in a large county health department.