Many States Not Prepared to Respond to Public Health Emergencies, Report Finds

Even as hantavirus cases on a cruise ship continue to cause concern, about one-fourth of states are not fully prepared to manage a public health emergency if one should come their way, a report found.

“The nation faced the most severe flu season in nearly a decade, the highest annual measles case count since 1991, and devastating weather-related emergencies, even as federal public health funding, staffing, and operational support were destabilized,” J. Nadine Gracia, MD, president and CEO of the Trust for America’s Health (TFAH), which sponsored the report, said in a press release. “These challenges make clear that emergency preparedness cannot rely on a patchwork of limited and unpredictable resources. Effective readiness requires strong federal leadership, stable investment, and coordinated action across states and communities, especially as the United States prepares to host matches during the 2026 World Cup.”

The 112-page annual report examined how prepared states are to safeguard residents during health emergencies. Factors considered in the analysis included healthcare workforce mobility, public health and emergency management accreditation, state public health funding, water system safety, paid sick leave access, vaccination coverage, hospital patient safety, laboratory surge capacity, and avoidable mortality.

Based on the results, the researchers divided states in low-, middle-, and high-performance tiers. Overall, 13 states were in the low tier, 17 states plus the District of Columbia were in the middle tier, and 20 states were in the high tier. Compared with last year, Montana achieved the most notable gain, advancing from the low tier to the high tier — the only jurisdiction to move two tiers, the report noted. Montana’s big advancement occurred because the state increased public funding and because it gained accreditation from the Emergency Management Accreditation Program during the course of the year. Montana is also one of 44 states accredited by the Public Health Accreditation Board.

In addition to Montana’s jump, seven additional states moved up one tier: California, Hawaii, Illinois, Kansas, Louisiana, Nevada, and Oregon, the report found. Ten states, as well as the District of Columbia, moved down one tier: Alabama, Georgia, Idaho, Iowa, Kentucky, Missouri, Ohio, Oklahoma, Texas, and Washington. “The stability of many states suggests that tier placement reflects durable patterns of preparedness capacity, but movement among others demonstrates that these patterns are not fixed — policy decisions, institutional investments, and attention to multiple preparedness domains can shift a state’s relative position within a single measurement cycle,” the authors wrote.

The report included several recommendations for enhancing preparedness, including:

Provide stable and sufficient health security funding. “An estimated 80% of CDC’s domestic budget goes to external partners, underpinning preparedness for health threats across the country,” the authors wrote. “TFAH recommends increasing overall CDC funding to at least $11.58 billion annually, expanding Public Health Emergency Preparedness funds to $1 billion, sustaining CDC’s Public Health Infrastructure Grant program at a minimum of $1 billion annually, investing in modernized disease detection and data systems, and increasing the Administration for Strategic Preparedness and Response’s base budget.”

Ensure effective leadership and coordination. The federal health workforce and any capabilities eliminated in 2025 should be restored, and Congress should reauthorize the Pandemic and All-Hazards Preparedness Act, the report said. “The administration should protect the scientific integrity of public health agencies, ensure timely demographic data-collection, reject laws weakening public health authorities, demonstrate a sustainable commitment to global health security, and invest in effective public health communications.”

Prevent and respond to outbreaks and pandemics. “Congress should support funding and workforce for CDC’s National Immunization Programs, enact legislation ensuring vaccine access for uninsured and underinsured adults, and support policies that enable universal childhood vaccinations,” the authors wrote. They also recommended that Congress conduct oversight of changes to federal immunization schedules, and suggested that antimicrobial resistance needs to be addressed, “including new financing mechanisms for novel antimicrobials and increased support for CDC’s Antimicrobial Resistance Solutions Initiative.”

Although the report does show progress in some areas, “I [also] see a story of increasing fragility,” Jennifer Nuzzo, DrPH, director of Brown University’s Pandemic Center, in Providence, Rhode Island, said during a press conference last week sponsored by TFAH. “We have social vulnerabilities that have increased, our abilities to protect people against deadly disease threats — say, through vaccinations — have decreased, and the preparedness gains that we’ve made are increasingly threatened by federal instability, budget uncertainty, workforce reductions, and the overall erosion of the various systems that preparedness depends on.”

She added that in relation to the recent hantavirus outbreak on a cruise ship, media reports have suggested that the CDC sanitation workers who inspect cruise ships were fired by the Trump administration despite the fact that their positions were being funded by the cruise ship industry rather than the federal government. Comparing the short update about the outbreak on the CDC’s website with the detailed threat assessment released by the European CDC, “I have to conclude that we just don’t have access to the right information, because there’s no justifiable reason for why we wouldn’t be putting out information to help Americans understand disease threats and understand what risk of any they pose to themselves or their families. That’s really concerning,” Nuzzo said.

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