Paul E. Jarris

Recommendations from the national vaccine advisory committee: Standards for adult immunization practice

National Vaccine Advisory Committee The Advisory Committee on Immunization Practices (ACIP) makes recommendations for routine vaccination of adults in the United States.1 Standards for implementing the ACIP recommendations for adults were published by the National Vaccine Advisory Committee (NVAC) in 20032 and by the Infectious Diseases Society of America in 2009.3 In addition, NVAC published a report in 2012 outlining a pathway for improving adult immunization rates.4 While most of these documents included guidelines for immunization practice, recent changes in the practice climate for adult immunization necessitated an update of existing adult immunization standards. Some of these changes include expansion of vaccination services offered by pharmacists and other community immunization providers both during and since the 2009 H1N1 influenza pandemic; vaccination at the workplace; increased vaccination by providers who care for pregnant women; and changes in the health-care system, including the Affordable Care Act (ACA), which requires first-dollar coverage of ACIP-recommended vaccines for people with certain private insurance plans, or those who are beneficiaries of expanded Medicaid plans.5 The ACA first-dollar provision is expected to increase the number of adults who will be insured for vaccines. Other changes include expanding the inclusion of adults in state immunization information systems (IISs) (i.e., registries) and the Centers for Medicare & Medicaid Services Meaningful Use Stage 2 requirements, which mandate provider reporting of immunizations to registries, including reporting of adult vaccination in states where such reporting is allowed.6 For the purposes of this report, provider refers to any individual who provides health-care services to adult patients, including physicians, physician assistants, nurse practitioners, nurses, pharmacists, and other health-care professionals. While previous versions of the adult immunization standards have been published, recommendations for adult vaccination are published annually, and many health-care organizations have endorsed routine assessment and vaccination of adults, vaccination among adults continues to be low.7–15 Several barriers to adult vaccination include:

The Public Health Workforce Interests and Needs Survey: The First National Survey of State Health Agency Employees.

This article describes a nationally representative survey of central office employees at state health agencies to characterize key components of the public health workforce.

Thinking beyond the silos: emerging priorities in workforce development for state and local government public health agencies.

Supplemental Digital Content is Available in the Text. This study focuses on the existing public health workforce, with the results aiming at informing the revisions public health academic programs and standards are experiencing nationally.

Final recommendations for a voluntary national accreditation program for state and local health departments: steering committee report.

A recently released report of the Exploring Accreditation Project affirmatively answered the questions regarding the desirability and feasibility of establishing a national voluntary public health accreditation program. The reports recommendations were made after 10 months of inquiry from public health experts, elected officials, the general public health workforce, academicians, and other interested parties, more than 650 public health professionals in all. Recommendations regarding how such a program might be implemented insofar as its governance, principles for standards development, financing and incentives, and evaluation were included. The report provides a blueprint for establishing a national voluntary public health accreditation program. This article describes key aspects of the Steering Committee recommendations, with limited linkage to implementation strategies where relevant, in the four areas in which the project was designed. Details are provided in the final reports of the Steering Committee (www.exploringaccreditation.org) and in other articles in this issue.

Quality improvement and accreditation readiness in state public health agencies.

OBJECTIVE There were 3 specific objectives of this study. The first objective was to examine the progress of state/territorial health assessment, health improvement planning, performance management, and quality improvement (QI) activities at state/territorial health agencies and compare findings to the 2007 findings when available. A second objective was to examine respondent interest and readiness for national voluntary accreditation. A final objective was to explore organizational factors (eg, leadership and capacity) that may influence QI or accreditation readiness. DESIGN Cross-sectional study. SETTING State and Territorial Public Health Agencies. PARTICIPANTS Survey respondents were organizational leaders at State and Territorial Public Health Agencies. RESULTS Sixty-seven percent of respondents reported having a formal performance management process in place. Approximately 77% of respondents reported a QI process in place. Seventy-three percent of respondents agreed or strongly agreed that they would seek accreditation and 36% agreed or strongly agreed that they would seek accreditation in the first 2 years of the program. In terms of accreditation prerequisites, a strategic plan was most frequently developed, followed by a state/territorial health assessment and health improvement plan, respectively. CONCLUSIONS Advancements in the practice and applied research of QI in state public health agencies are necessary steps for improving performance. In particular, strengthening the measurement of the QI construct is essential for meaningfully assessing current practice patterns and informing future programming and policy decisions. Continued QI training and technical assistance to agency staff and leadership is also critical. Accreditation may be the pivotal factor to strengthen both QI practice and research. Respondent interest in seeking accreditation may indicate the perceived value of accreditation to the agency.

Public health spending in 2008: on the challenge of integrating PHSSR data sets and the need for harmonization.

In recent years, state and local public health department budgets have been cut, sometimes drastically. However, there is no systematic tracking of governmental public health spending that would allow researchers to assess these cuts in comparison with governmental public health spending as a whole. Furthermore, attempts to quantify the impact of public health spending are limited by the lack of good data on public health spending on state and local public health services combined. The objective of this article is to integrate self-reported state and local health department (LHD) survey data from 2 major national organizations to create state-level estimates of governmental public health spending. To create integrated estimates, we selected 1388 LHDs and 46 states that had reported requisite financial information. To account for the nonrespondent LHDs, estimates of the spending were developed by using appropriate statistical weights. Finally, funds from federal pass-through and state sources were estimated for LHDs and subtracted from the total spending by the state health agency to avoid counting these dollars in both state and local figures. On average, states spend

Budgetary decision making during times of scarcity.

106 per capita on traditional public health at the state and local level, with an average of 42% of spending occurring at the local level. Considerable variation exists in state and local public health funding. The results of this analysis show a relatively low level of public health funding compared with state Medicaid spending and health care more broadly.

Structure and Functions of State Public Health Agencies in 2007

Public health is often defined by the sciences on which it is based (eg, epidemiology, tropical medicine, biostatistics) or the programs a health department operates. Far too often the critical role of the health official in garnering political support, financial resources, and public support is not recognized when defining the scope of our system. Because most state health officials are political appointees, their work is sometimes considered to be separate from public health, as if politics and public health were distinct. But the state health official’s interface with the political system and with the state budget office is critical to all aspects of public health. Without political support from the governor and financial support from the legislature, the public health agency cannot effectively protect and improve the health of the population. As is reported at some length in this issue and the March issue of this journal, state and local health departments have seen major budget reductions over the past several years. However, to date there has not been much information regarding the context and decision-making processes around these budget cuts. This column presents select initial findings from a collaborative study with the Johns Hopkins Bloomberg School of Public Health that seeks to provide context and deeper understanding around issues of budgetand priority-setting processes, introduces components of a framework for budgetary decision making identified at the December 2011 ASTHO (Association of State and Territorial Health Officials) Winter Meeting, and links these ideas to the recently released Institute of Medicine (IOM) report For the Public’s Health: Investing in a Healthier Future. The Johns Hopkins-ASTHO study consisted of both qualitative and quantitative research: semistruc-

Better Health Requires Partnerships and a Systems Approach

We sought to document the structure and functions of state public health agencies throughout the United States in 2007 and compare findings with those from a similar 2001 assessment. In 2007 a survey of the structure and functions of state public health agencies was sent to and completed by senior deputies in all 50 states and the District of Columbia (a 100% response rate). The results of the survey showed that all emerging practice areas in 2001 had expanded by 2007. Also, state health departments generally had greater levels of responsibility in 2007 than they did in 2001, emphasizing the need for continued support of governmental public health systems and research on the operations of those systems.

Public Health Preparedness Laws and Policies: Where Do We Go after Pandemic 2009 H1N1 Influenza?

We commend Sprague Martinez et al.1 for highlighting neighborhood sanitation conditions recognized by local Black and Latino youths who then photographed these social and environmental conditions that related to their personal stress. Their experience once again demonstrates the importance of engaging community members in assessing the health of their own communities. This rediscovery2–4 has important implications for “creating the conditions in which people can be healthy.”5 It is timely, too. For example, as a result of Internal Revenue Service regulation6 and accreditation requirements,7 nonprofit hospitals and local and state health departments must now complete community health assessment and improvement plans. Clearly, visual stories used as data are worthwhile elements of any assessment and improvement process. In addition to hospitals and public health agencies conducting these assessments collaboratively, involving community members and community organizations incentivizes engagement and collective responsibility for outcomes. As Sprague Martinez et al. point out, communities have faced similar “nasty” situations in the past. Efforts on the part of residents to identify and voice their concerns likely resulted in political processes that were instrumental in remediating unhealthy situations. We encourage students engaged in research to express their voices through local, state, and federal governmental processes to raise awareness of both visible and hidden upstream causes of injury, illness, and death. While the lives of community residents are in many ways experienced as “local,” efforts to improve the public’s health may also benefit from coordinated action from all parts of the governmental public health enterprise: local, state, and federal levels.8 Law, regulation, security, protection, and financing are important local, state, and federal responsibilities; neglect of these areas by any level of government results in the conditions documented by the students and the poor outcomes present in far too many communities. These are challenging times for local, state, and federal governmental public health agencies and for the communities they protect and keep safe. Collaboration with community partners can help make positive health outcomes more likely. Our communities will thrive as a result.