A COVID-19 Lesson: Better Health Emergency Preparedness Standards Are Needed

This article reports on an assessment of the value of 4 widely recognized standards of health sector emergency preparedness as predictors of effective preparedness for, and response to, the COVID-19 pandemic in the United States. The standards are sponsored by the National Health Security Preparedness Index (NHSPI), the Trust for America's Health (TFAH), the Emergency Management Accreditation Program (EMAP), and the Public Health Accreditation Board (PHAB). The measure of effectiveness was states' cumulative COVID-19 deaths per 100,000 population, from January 21, 2020, through January 20, 2022. Linear regression analysis found no statistically significant associations when controlling for 3 intervening variables. Cross-tabulation of states' preparedness status with their COVID-19 death rates found that high NHSPI and TFAH preparedness scores were generally, but not uniformly, associated with lower death rates. EMAP and PHAB accreditation had negligible association with low or high death rates. Lack of accreditation was associated with lower death rates. Higher prior state public health spending related to COVID-19 preparedness and higher state household income, an indicator of state economic strength, were associated with lower death rates. States with Democratic control of the legislative and executive branches of government generally had substantially lower death rates than states with Republican control. A science-based, practice-oriented research initiative is recommended to improve the predictive power of health sector preparedness standards and to enhance protection for US residents from large-scale future health threats.

The laboratory efficiencies initiative: partnership for building a sustainable national public health laboratory system

Beginning in early 2011, the Centers for Disease Control and Prevention and the Association of Public Health Laboratories launched the Laboratory Efficiencies Initiative (LEI) to help public health laboratories (PHLs) and the nation's entire PHL system achieve and maintain sustainability to continue to conduct vital services in the face of unprecedented financial and other pressures. The LEI focuses on stimulating substantial gains in laboratories' operating efficiency and cost efficiency through the adoption of proven and promising management practices. In its first year, the LEI generated a strategic plan and a number of resources that PHL directors can use toward achieving LEI goals. Additionally, the first year saw the formation of a dynamic community of practitioners committed to implementing the LEI strategic plan in coordination with state and local public health executives, program officials, foundations, and other key partners.

Law, public health, and the diabetes epidemic

The prevalence of new cases of diabetes continues to increase, and the health burden for those with diabetes remains high. This is attributable, in part, to low adoption of evidence-based interventions for diabetes prevention and control. Law is a critical tool for health improvement, yet assessments reported in this paper indicate that federal, state, and local laws give only partial support to guidelines and evidence-based interventions relevant to diabetes prevention and control. Public health practitioners and policymakers who are concerned with the human, fiscal, and economic costs of the epidemic can explore new ways to translate the evidence base for diabetes prevention and control into effective laws and policies.

Working mothers, breastfeeding, and the law

Workplace barriers contribute to low rates of breastfeeding. Research shows that supportive state laws correlate with higher rates, yet by 2009, only 23 states had adopted any laws to encourage breastfeeding in the workplace. Federal law provided virtually no protection to working mothers until the 2010 enactment of the "reasonable break time" provision of the Patient Protection and Affordable Care Act. This provision nonetheless leaves many working mothers uncovered, requires break time only to pump for (not feed) children younger than 1 year, and exempts small employers that demonstrate hardship. Public health professionals should explore ways to improve legal support for all working mothers wishing to breastfeed. Researchers should identify the laws that are most effective and assist policymakers in translating them into policy.

Legal preparedness for obesity prevention and control: a framework for action

The Proceedings of the National Summit on Legal Preparedness for Obesity Prevention and Control is based on a two-part conceptual framework composed of public health and legal perspectives. The public health perspective comprises the six target areas and intervention settings that are the focus of the obesity prevention and control efforts of the Centers for Disease Control and Prevention (CDC).

This paper presents the legal perspective. Legal preparedness in public health is the underpinning of the framework for the four “assessment” papers and the four “action” papers that are integral to the application of public health law to any particular health issue. In addition, this paper gives real-world grounding to the legal framework through examples that illustrate the four core elements of legal preparedness in public health that are at work in obesity prevention and control.

The scientific basis for law as a public health tool

Systematic reviews are generating valuable scientific knowledge about the impact of public health laws, but this knowledge is not readily accessible to policy makers. We identified 65 systematic reviews of studies on the effectiveness of 52 public health laws: 27 of those laws were found effective, 23 had insufficient evidence to judge effectiveness, 1 was harmful, and 1 was found to be ineffective. This is a valuable, scientific foundation-that uses the highest relevant standard of evidence-for the role of law as a public health tool. Additional primary studies and systematic reviews are needed to address significant gaps in knowledge about the laws' public health impact, as are energetic, sustained initiatives to make the findings available to public policy makers.

Public health legal preparedness: a framework for action

Public health emergencies have occurred throughout history, encompassing such events as plagues and famines arising from natural causes, disease pandemics interrelated with wars (such as the influenza pandemic of 1918-1919), and industrial accidents such as the 1986 Chernobyl disaster, among others. Law and legal tools have played an important role in addressing such emergencies. Three prime U.S. examples are Congressional authorization of quarantine as early as 1796, legally mandated smallpox vaccination upheld in a landmark 1905 U.S. Supreme Court ruling, and the President's 2003 executive order adding SARS to the federal government's list of “quarantinable communicable diseases.”

The public health emergencies of the present — both actual and potential — pose equally serious threats but do so in the context of greatly magnified expectations that stem directly from the attacks of September 11, 2001, and the immediately following anthrax attacks.

A review of model public health laws

Model public health laws (public health laws or private policies publicly recommended by at least 1 organization for adoption by government bodies or by specified private entities) are promoted as exemplary. We assessed the information sponsors of model public health laws provide on the methods used in developing their models and on their models' adoption and effectiveness. Through a systematic search, we identified 107 model public health laws published from 1907 to 2004. As of our assessment in 2005, only 18 (44%) of the sponsors presented any information on the procedures and evidence used in developing their model public health laws; information on adoption was provided for only 7 (6.5%) model laws. No sponsors provided information on model effectiveness. We recommend sponsors improve their disclosure of information about the methods and evidence used in developing model public health laws and about their adoption and effectiveness.

A legal framework for preventing cardiovascular diseases

Cardiovascular diseases are major contributors to death, disability, disparities, and reduced quality of life in the United States. Successful prevention and control of these diseases requires a comprehensive approach applied across multiple public health settings and in all life stages. Individual lifestyle and behavior change, as well as the broader social, environmental, and policy changes that enable healthy lifestyles, are necessary. Legal strategies can be powerful tools in this endeavor. This review presents seven such strategies applicable at the federal, state, and local levels that can be employed by healthcare providers, public health practitioners, legislators, and other policymakers. They include direct regulation, economic incentives and disincentives, indirect regulation through private enforcement, government as information provider, government as direct provider of services, government as employer and landlord, and laws directed at other levels of government. These strategies may be accomplished through legislation or administrative changes in practices or procedures. Effective use of these strategies requires a broader understanding of the advantages and limitations of legal frameworks and the importance of tailoring strategies to local conditions and resources. Examples of key roles that health professionals can play in advancing such an understanding are presented.

Public health finance: a conceptual framework

In an attempt to stimulate development of public health finance as a field of practice, policy, and scholarship, this article proposes a working definition of the term "public health finance," embeds it in the context of the maturing literature on the public health system and its infrastructure, and proposes a four-part typology that spans both public-sector and private-sector contributions to the financing of prevention and health promotion. A developmental strategy for the field--in applied research, training and education, and performance standards--is outlined as well.

Law as a tool for preventing chronic diseases: expanding the range of effective public health strategies

Law, which is a fundamental element of effective public health policy and practice, played a crucial role in many of public health's greatest achievements of the 20th century. Still, conceptual legal frameworks for the systematic application of law to chronic disease prevention and control have not been fully recognized and used to address public health needs. Development and implementation of legal frameworks could broaden the range of effective public health strategies and provide valuable tools for the public health workforce, especially for state and local health department program managers and state and national policy makers. In an effort to expand the range of effective public health interventions, the Centers for Disease Control and Prevention will work with its partners to explore the development of systematic legal frameworks as a tool for preventing chronic diseases and addressing the growing epidemic of obesity, heart disease, stroke, and other chronic diseases and their risk factors.

What is public health legal preparedness?

Legal preparedness has gained recognition as a critical component of comprehensive public health preparedness for public health emergencies triggered by infectious disease outbreaks, natural disasters, chemical and radiologic disasters, terrorism and other causes. Public health practitioners and their colleagues in other disciplines can prepare for and respond to such an event effectively only if law is used along with other tools. The same is true for more conventional health threats. At first glance, public health legal preparedness may appear to be only a matter of having the right laws on the books. On closer examination, however, it is as complex as the field of public health practice itself. Public health legal preparedness has at least four core elements: laws (statutes, ordinances, regulations, and implementing measures); the competencies of those who make, implement, and interpret the laws; information critical to those multidisciplinary practitioners; and coordination across sectors and jurisdictions. The process of improving public health legal preparedness has begun in earnest with respect to potentially massive public health emergencies. Elected officials, public health, legal, and law enforcement practitioners, and national security organizations have contributed to initial benchmarks for the core elements. A few gaps in legal preparedness have been identified in the context of exercises, actual public health emergencies, and through more general assessments of public health preparedness conducted by CDC and the Department of Justice. While a strong beginning has been made, this work is incomplete. Redoubled effort is needed to define practical, measurable benchmarks or standards of legal preparedness, to identify and correct shortcomings, and to review findings from regular exercises and actual public health emergencies. There is great value in having this work move forward on two converging tracks, one defined by states and localities acting on their own initiative and the other shaped by the federal government as informed by state and local experience. The TOPOFF and Dark Winter exercises exemplify the grounded, case-based approach that teaches practical lessons about benchmarks, gaps, and steps to improve public health's legal preparedness. It goes without saying that action on both tracks should be taken by collaboratives whose membership includes representatives of the many different communities integral to the design and application of laws that affect the health of the public and the effectiveness of the public health system itself. Consistent with the concept of a public health or population health system with which we began this paper, participants in both tracks should include representatives of non-governmental bodies--community-based organizations, non-profit organizations active in disaster preparedness and response, and others. This paper presents a conceptual and analytic framework those groups may apply, one that is sufficiently broad to serve as an integrating schema across sectors and jurisdictions but also sufficiently flexible to accommodate the unique features of the many community and state public health systems which, together with federal partners, comprise the U.S. public health system, in sum, a framework responsive to the exigencies of our times, faithful to the guiding principles of American federalism, and conductive to a new standard of health protection for all our citizens.

Public health legal preparedness for the 21st century

Law is indispensable to the public's health. The twentieth century proved this true as law contributed to each of the century's ten great public health achievements: vaccination, healthier mothers and babies, family planning, safer and healthier foods, fluoridation of drinking water, the control of infectious diseases, the decline in death from heart disease and stroke, recognition of tobacco use as a health hazard, motor vehicle safety, and safer workplaces.

The readers of this journal can give examples of the relevant types of laws with ease: Jacobson v. Massachusetts, the 1905 U.S. Supreme Court case that upheld the constitutionality of compulsory vaccination; mandatory immunization for school admission; authorization of state prenatal care programs; mandatory fortification of foods; Title X of the Public Health Service Act; the Pure Food and Drugs Act of 1906; the Safe Drinking Water Act of 1974, and hundreds of state and local enactments regulating food; fluoridation ordinanceswater, and sanitation; the Surgeon General's warning notices on cigarette packs and restrictions on marketing tobacco; seat belt laws and mandated vehicle and highway design features; and laws like the federal Occupational Safety and Health Act of 1970 that regulate working conditions.

Building the legal foundation for an effective public health system

Work has been underway nationally since the mid-1990s to equip state and community public health systems with the infrastructure needed to perform essential public health services. Key components of that infrastructure are a competent workforce, information and communication systems, health department and laboratory capacity, and legal authorities. As part of this transformative work, standards and assessment tools have been developed to measure the capacity and actual performance of public health systems. In addition, a number of states have examined the legal foundation for public health services and have revised and updated those authorities to improve their system's capacity in the context of evolving health challenges. Among those states are Nebraska, New Jersey, and Texas, all of which, beginning in 1999, have adopted dynamic new approaches to aligning public health's legal authorities with new missions and expectations for performance and accountability. This article describes the approaches that these three states have taken to strengthen their legal foundation for public health practice, to illuminate the perspectives legislators and health officials bring to the process, and to give decision makers in other states practical insight into the potential benefits of reviewing and restructuring public health's legal authorities. The underlying stimuli for the states' initiatives differed significantly, yet shared an important, common core. What they held in common was concern that outdated elements of the public health system and infrastructure hindrered delivery of essential public health services at the community level. Where they differed was in the type of tools they found most suitable for the job of rejuvenating those structures. The approaches taken, and the policy tools selected, reflect the unique health needs of each state, establish relationships among state and community health authorities and agencies, and provide guidance by elected and appointed policy makers. Each state continues to refine its approach as it gains experience with the new authorities.

Other branches of science are necessary to form a lawyer: teaching public health law in law school

Over two hundred years ago, Thomas Jefferson suggested the need for a broader legal curriculum. As the twenty-first century begins, the practice of law will increasingly demand interdisciplinary knowledge and collaboration — between those trained in law and a broad range of scientific and technical fields, including engineering, biology, genetics, ethics, and the social sciences. The practice of public health law provides a model for both the substantive integration of law with science, and for the way its practitioners work. In addition, public health law also provides a model for interdisciphuy and integrative teaching.

The dimensions of public health law research

Applied public health law research is an essential element for improving the legal foundation of public health practice. This article focuses on the proper scope and the methodology related to conducting public health law research. In addition to considering the issue of translating research into practice, the article provides overviews of three current public health law research projects and the lessons they provide for researchers.

Strengthening the legal foundation for public health practice: a framework for action

Growing concern that public health laws may be inadequate to the challenges that confront public health practitioners has led to adoption of a Healthy People 2010 objective for improved laws and policies. It has also led to concerted efforts to strengthen the legal foundation for public health practice. In this editorial, the authors present a framework for collaborative research, analysis, and development to strengthen public health laws, skill in applying laws, and law-related information resources.

Xenotransplantation: the potential and the challenges

Clinical use of xenotransplants is a potential way to provide care for a population of seriously ill patients and alleviate the demand for human organs. However, xenotransplantation also presents a spectrum of concerns, not only for individual patients but also for the public health, that must be discussed and dealt with in a science-based and public manner. Such discussions should take place on a national level and should include scientists, physicians, and policy makers from all countries in which the clinical use of xenografts is being considered.

Xenotransplantation: the potential and the challenges

Clinical use of xenotransplants is a potential way to provide care for a population of seriously ill patients and alleviate the demand for human organs. However, xenotransplantation also presents a spectrum of concerns, not only for individual patients but also for the public health, that must be discussed and dealt with in a science-based and public manner. Such discussions should take place on a national level and should include scientists, physicians, and policy makers from all countries in which the clinical use of xenografts is being considered.

The Georgia Information Network for Public Health Officials (INPHO): a demonstration of the CDC INPHO concept

The Georgia Division of Public Health is serving as the first demonstration model of a statewide implementation of the Centers for Disease Control and Prevention Information Network for Public Health Officials. The goals of the project are to make communication easy, to make information accessible, and to make data exchange as swift and as smooth as technology will allow. By having a state-of-the-art telecommunications network, public health officials will be able to rapidly collect health data and transform them into meaningful health status information that can be used to inform health policy decisions. The Georgia Information Network for Public Health Officials is a unique consortium of private and public sector partners funded with a grant from the Robert W. Woodruff Foundation. The project will install the telecommunications infrastructure and the supporting software to position Georgia public health as the health information leader of the state.

CDC's Information Network for Public Health Officials (INPHO): a framework for integrated public health information and practice

To strengthen the public health infrastructure, the Centers for Disease Control and Prevention (CDC) initiated the Information Network for Public Health Officials (INPHO). CDC INPHO has three goals: (1) to make communication among public health practitioners throughout the United States easy, (2) to make information accessible, and (3) to make secure data exchange as swift and smooth as contemporary technology will allow. Based on a systems approach to supporting the core functions of public health, CDC INPHO achieves its goals by creating a flexible and user-responsive infrastructure of open communications and information exchange.

Specific prolongation of skin graft survival following retroviral transduction of bone marrow with an allogeneic major histocompatibility complex gene

Engrafted allogeneic hematopoietic cells have a unique capacity to induce a state of donor-specific transplantation tolerance across major histocompatibility complex barriers. This state allows permanent acceptance of donor-type organ grafts, with otherwise normal immunocompetence. We hypothesized that introduction of allogeneic MHC genes into autologous bone marrow which is then returned to recipient mice might similarly induce specific tolerance to products of the introduced MHC genes, without the risk of graft-vs-host disease. We demonstrate here that the introduction of MHC class I Kb cDNA by retrovirus-mediated gene transfer into B10.AKM (Kk) hematopoietic cells confers specific hyporesponsiveness to allogeneic skin grafts expressing Kb.

Inducible production of c-fos antisense RNA inhibits 3T3 cell proliferation

Antisense RNA complementary to c-fos mRNA was produced in mouse 3T3 cells by gene transfer techniques. Transcriptional units were constructed consisting of a steroid-inducible mouse mammary tumor virus (MMTV) promoter, mouse or human 5' c-fos gene fragments in either the sense (5' to 3') or antisense (3' to 5') orientation, and splice and poly(A) signals from the human beta-globin gene. A gene that confers neomycin resistance was included in the vectors to allow isolation of stable transformants. Dexamethasone caused a marked induction of hybrid MMTV-fos-globin RNA. Induction of the hybrid transcript containing antisense c-fos RNA decreased colony formation following DNA transfer and inhibited the proliferation of cells into which the antisense transcriptional unit had been integrated. In contrast, colony formation and cell proliferation were not inhibited by induction of hybrid RNA containing c-fos RNA sequences in the sense orientation. These results indicate that the strategy of generating antisense RNA to inhibit gene expression may be useful in delineating the function of protooncogenes. The c-fos gene product appears to have a required role in normal cell division.

Promoter sequences required for function of the human gamma globin gene in erythroid cells

The human gamma- and beta-globin genes are expressed during the fetal and adult developmental periods, respectively. Differences in the sequences of their promoters may be relevant to their developmental regulation. The gamma globin gene promoter was found to be stronger than that of the beta gene. In HeLa cells co-transfected with plasmids containing the two genes, transcripts arising from the gamma promoter accumulated to a level 3-fold higher than those initiated from the beta-promoter. We have recently shown that deletion of the most distal of the conserved elements of the promoter (CACCC) reduces function to 25% of the wild-type, whereas the removal of the proximal of the two duplicated (CCAAT) elements increases promoter function 2- to 4-fold in HeLa cells during transient gene expression. Both the wild-type promoter and the truncation and linker-scanning mutants from which one of the two duplicated "CCAAT' elements had been removed, exhibited regulated expression when stably integrated into chromosomes of mouse erythroleukemia (MEL) cells. Thus, duplication of the "CCAAT' element, the feature by which the gamma promoter differs most strikingly from the beta, is not essential for function in erythroid cells.

The functional human dihydrofolate reductase gene

Molecular cloning, mapping, and DNA sequencing techniques have been used to characterize the functional human dihydrofolate reductase (DHFR) gene. The gene is about 30 kilobases in length. Its coding portions are separated into 6 exons, the intron-exon boundaries of which are identical to those of the previously characterized mouse DHFR gene. The 5 introns vary in length from 362 to 12,000 base pairs. The position of the DHFR gene promoter was identified as being shortly upstream from the initiation codon in an in vitro transcription reaction by polymerase II. A DHFR minigene was constructed in a plasmid expression vector by combining a DNA fragment containing exon 1, intron I, and a small part of exon 2 from the functional gene, with a second DNA fragment containing exons 2-6 from a processed intronless gene, the coding sequences of which are identical to those of the normal locus. Transcription initiation from the DHFR promoter was localized to a position 71 +/- 2 base pairs upstream from the initiation codon, both in monkey kidney cells transfected with vectors containing the DHFR minigene, and in human HeLa cells. This single transcription start and the three previously identified polyadenylation sites account for the 800-, 1,000-, and 3,800-nucleotide DHFR mRNA species found in human cells. On comparison of the mouse and human DHFR genes, sequence homology was shown to be limited to the coding regions and 100 base pairs of the 3' untranslated region up to the first polyadenylation site of both genes. In addition, there is fairly extensive homology in the 5' flanking region, although the quadruply repeated 48-base pair sequence found in the mouse genome is represented only once in human DNA.

Intronless human dihydrofolate reductase genes are derived from processed RNA molecules

Three groups of recombinant bacteriophage containing coding sequences for dihydrofolate reductase (DHFR; tetrahydrofolate dehydrogenase; 5,6,7,8-tetrahydrofolate:NADP+ oxidoreductase, EC 1.5.1.3) were isolated from two human DNA clone libraries. One recombinant (lambda hDHFR-1) contains three exons that encode the COOH-terminal portion of human DHFR. The other two human DHFR genes (hDHFR-psi 1 and hDHRF-psi 2) lack introns. hDHFR-psi 2 contains several in-phase termination codons and is only 93% homologous to the normal human DHFR coding sequences, whereas hDHFR-psi 1 has an open reading frame and is virtually identical to the coding sequence of the normal DHFR gene. The region of DNA sequence homology between each intronless gene and the normal DHFR gene extends 2.9 kilobases beyond the end of the coding sequences. At the 3' end of this homologous sequence, each intronless gene has an A-rich tract. The lack of introns and the presence of the 3' A-rich tract suggest that hDHFR-psi 1 and hDHFR-psi 2 were derived from processed RNA molecules. A short DNA sequence, 60 nucleotides 5' to the ATG start codon in lambda hDHFR-psi 2, is directly repeated immediately after the 3' A-rich tract; such terminal direct repeats also flank integrated proretroviruses and transposable DNA elements and are thought to be the hallmark of inserted DNA sequences.

Differences in human alpha-, beta- and delta-globin gene expression in monkey kidney cells

We have compared the function of the human alpha-, beta- and delta-globin genes using various plasmid expression vectors derived from pBR322. Amplification of recombinants occurred after their introduction, by calcium-phosphate-mediated DNA transfer, into monkey kidney cells that constitutively produce T antigen (COS cells). The human alpha-globin gene promoter functioned independently, but the beta-globin gene promoter was nearly totally dependent on the enhancing activity of the 72 bp direct repeats from the SV40 genome. Furthermore, when the human alpha- and beta-globin genes were linked in the same vector, the alpha promoter was active but the beta promoter was not. Function of the delta-globin gene promoter also depended on the enhancer element. In vectors containing the 72 bp repeats and the beta- or delta-globin gene, the activity of the beta-globin gene was approximately 50 times greater than that of the delta-globin gene, approximating the ratio of beta and delta mRNA observed in normal human bone marrow cells.