Outbreaks: Protecting Americans from Infectious Diseases

December 2014

The Outbreaks: Protecting Americans from Infectious Diseases report finds that the Ebola outbreak exposes serious underlying gaps in the nation's ability to manage severe infectious disease threats.

Half of states and Washington, D.C. scored five or lower out of 10 key indicators related to preventing, detecting, diagnosing and responding to outbreaks. Maryland, Massachusetts, Tennessee, Vermont and Virginia tied for the top score - achieving eight out of 10 indicators. Arkansas has the lowest score at two out of 10.


Click on a state below to access state-specific information and scores:

8 7 6 5 4 3 2
New Hampshire
North Dakota
New York
North Carolina
Rhode Island
South Carolina
South Dakota
New Mexico
West Virginia
New Jersey

"Over the last decade, we have seen dramatic improvements in state and local capacity to respond to outbreaks and emergencies. But we also saw during the recent Ebola outbreak that some of the most basic infectious disease controls failed when tested," said Jeffrey Levi, PhD, executive director of TFAH. "The Ebola outbreak is a reminder that we cannot afford to let our guard down. We must remain vigilant in preventing and controlling emerging threats - like MERS-CoV, pandemic flu and Enterovirus - but not at the expense of ongoing, highly disruptive and dangerous diseases ? seasonal flu, HIV/AIDS, antibiotic resistance and healthcare-associated infections."

Some key findings from the report include progress and gaps in the areas of:

  • Preparing for Emerging Threats: Significant advances have been made in preparing for public health emergencies since the September 11, 2001 and the anthrax attacks, but gaps remain and have been exacerbated as resources were cut over time.
    • 47 states and Washington, D.C. reported conducting an exercise or using a real event to evaluate the time it took for sentinel laboratories to acknowledge receipt of an urgent message from the state's laboratory.
    • Only 27 states and Washington, D.C. met a score equal to or higher than the national average for the Incident and Information Management domain of the National Health Security Preparedness Index.
  • Vaccinations: More than 2 million preschoolers, 35 percent of seniors and a majority of adults do not receive all recommended vaccinations.
    • Only 14 states vaccinated at least half of their population against the seasonal flu (from fall 2013 to spring 2014).
    • Only 35 states and Washington, D.C. met the goal for vaccinating young children against the hepatitis B virus (Healthy People 2020 target is 90 percent of children ages 19 to 35 months receiving at least 3 doses).
  • Healthcare-Associated Infections: While healthcare-associated infections have declined in recent years due to stronger prevention policies, around one out of every 25 people who are hospitalized each year still contracts a healthcare-associated infection.
    • Only 16 states performed better than the national standardized infection ratio for central-line-associated bloodstream infections.
    • Only 10 states reduced the number of central line-associated bloodstream infections between 2011 and 2012.
  • Sexually Transmitted Infections and Related Disease Treatment and Prevention: The number of new HIV infections grew by 22 percent among young gay men, and 48 percent among young Black men (between 2008 and 2010); more than one-third of gonorrhea cases are now antibiotic-resistant; and nearly three million Baby Boomers are infected with hepatitis C, the majority of whom do not know they have it.
    • 37 states and Washington, D.C. require reporting of all (detectable and undetectable) CD4 and HIV viral load data, which are key strategies for classifying stage of disease, monitoring quality of care and preventing further transmission of HIV.
  • Food Safety: Around 48 million Americans suffer from a foodborne illness each year.
    • 38 states met the national performance target of testing 90 percent of reported E.coli O157 cases within four days (in 2011).

"The best offense to fighting infectious diseases is a strong and steady defense," said Paul Kuehnert, a Robert Wood Johnson Foundation director. "Infectious disease control requires having systems in place, continuous training and practice and sustained, sufficient funding. As we work with communities across the nation to build a Culture of Health, we recognize that promoting and protecting health, and readiness to respond to wide-scale health threats are essential."

The Outbreaks report recommends that it is time to rethink and modernize the health system to better match existing and emerging global disease threats. Priority improvements should include:

  • Core Abilities: Every state should be able to meet a set of core capabilities and there must be sufficient, sustained funding to support these capabilities. Some basic capabilities include: investigative expertise, including surveillance systems that can identify and track threats and communicate across the health system and strong laboratory capacity; containment strategies, including vaccines and medicines; continued training and testing for hospitals and health departments for infection control and emergency preparedness; risk communications capabilities that inform the public without creating unnecessary fear; and maintaining a strong research capacity to develop new vaccines and medical treatments;
  • Healthcare and Public Health Integration: Systems must be improved so the healthcare system, hospitals and public health agencies work better together toward the common goals of protecting patients, healthcare workers and the public; and
  • Leadership and Accountability: Stronger leadership is needed for a government-wide approach to health threats at the federal, state and local levels, and there must be increased support for integration and flexibility of programs in exchange for demonstration of capabilities and accountability.

The report was supported by a grant from RWJF.

Score Summary:

For the state-by-state scoring, states received one point for achieving an indicator or zero points if they did not achieve the indicator. Zero is the lowest possible overall score, 10 is the highest. The data for the indicators are from publicly available sources or were provided from public officials. The indicators are developed in consultation with leading public health experts based on data from publicly available sources or information provided by public officials.

  • 8 out of 10: Maryland, Massachusetts, Tennessee Vermont and Virginia
  • 7 out of 10: California, Delaware, Nebraska, New Hampshire, North Dakota, Pennsylvania and Wisconsin
  • 6 out of 10: Colorado, Connecticut, Florida, Hawaii, Illinois, Iowa, Minnesota, New York, North Carolina, Rhode Island, South Carolina, South Dakota and Texas
  • 5 out of 10: Alabama, D.C., Georgia, Indiana, Michigan, New Mexico, Oklahoma, Oregon, Utah and West Virginia
  • 4 out of 10: Alaska, Arizona, Maine, Mississippi, Missouri, Montana, Nevada and Washington
  • 3 out of 10: Idaho, Kansas, Kentucky, Louisiana, New Jersey, Ohio and Wyoming
  • 2 out of 10: Arkansas