GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE

Legal Remedies Far and Near

Legal Authority for Infectious Disease Reporting in the United States: Case Study of the 2009 H1N1 Influenza Pandemic Richard N. Danila, PhD, MPH, Ellen S. Laine, JD, MPH, Franci Livingston, JD, MPH, Kathryn Como-Sabetti, MPH, Lauren Lamers, MPH, Kelli Johnson, MBA, and Anne M. Barry, JD, MPH

Tracking of infectious diseases is a public health core function essential to disease prevention and control. Each state mandates reporting of certain infectious diseases to public health authorities. These laws vary by state, and the variation could affect the ability to collect critical information. The 2009 H1N1 influenza pandemic served as a case study to examine the legal authority in the 50 states; Washington, DC; and New York City for mandatory infectious disease reporting, particularly for influenza and new or emerging infectious diseases. Our study showed reporting laws to be generally present and functioning well; nevertheless, jurisdictions should be mindful of their mandated parameters and review the robustness of their laws before they face a new or emerging disease outbreak. (Am J Public Health. 2015;105:13–18. doi:10.2105/ AJPH.2014.302192)

SURVEILLANCE FOR INFECtious diseases is a core public health function essential to prevention and control efforts. Each state mandates the reporting of

selected infectious disease cases to public health authorities under its constitutional police power. Reporting laws vary by state regarding which diseases must be reported, who must report, whether case laboratory specimens must be submitted, and other features.1---5 This variation could affect a national public health response to a public health emergency, because federal health officials rely on voluntary reporting of epidemiological data from states to the Centers for Disease Control and Prevention (CDC). The recent outbreaks of Middle East respiratory syndrome coronavirus in the Arabian Peninsula and H7N9 influenza in China highlight the risk of emerging infectious diseases.6 A previous study found that some jurisdictions needed to revise inadequate reporting rules for bioterrorism agents.7 If a new infection with characteristics of ease of spread and high pathogenicity emerges, it is critical that every state have the legal authority to collect information to characterize the threat and effectively respond. CDC relies on a variety of systems to monitor influenza, including hospitalized case reporting,

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syndromic surveillance, outbreak reports, overall mortality, and respiratory virus laboratory testing.8 During the 2009 H1N1 influenza pandemic, rapid collection of information on individual hospitalized cases was critical to understanding the nature of the new strain of influenza, the severity of illness it caused, and who was most at risk for infection and severe outcomes, including death.9,10 Risk factors emerged that were different from those associated with seasonal influenza, including pregnancy, obesity, American Indian/Alaska Native ethnicity, and younger age.11,12 However, not all states had the ability and resources to collect information on every case, even severe cases, and CDC needed to make extrapolations and estimates.5 We examined the legal authority in each state; Washington, DC; and New York City for mandatory detailed reporting of infectious diseases, particularly of influenza and new or emerging diseases, and whether jurisdictions made relevant changes in legal authority after the onset of the 2009 H1N1 influenza pandemic. We used the 2009 H1N1 pandemic as a case

study and examined whether a relationship existed between a jurisdiction’s legal authority and its ability to collect and use data on cases during the pandemic period.

METHODS We identified key features of infectious disease reporting laws from sources such as the Turning Point Model State Public Health Act and the Council of State and Territorial Epidemiologists.13,14 Features included which categories of clinicians or other entities were required to report disease cases, whether reporting was required for suspect as well as confirmed cases, what authority health departments had to access additional case medical information, whether clinical specimens or materials were required to be forwarded to public health laboratories, and whether health departments had explicit authority to quickly add a new disease as reportable without going through a formal rulemaking process. Because our focus was on general infectious disease reporting laws and laws specific to influenza and new or emerging infections, other laws related to HIV/AIDS,

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sexually transmitted diseases, tuberculosis, and emergency health powers (which are generally predicated on a governor’s declaration of an emergency) were outside the scope of our study. We concentrated on explicit authority and mandates as written in law, without inferring indirect or enabling authority. We used Westlaw to systematically research key statutes and administrative codes and rules (collectively referred to here as laws) in the 50 states; Washington, DC; and New York City that were in force at the onset of the influenza pandemic (April 15, 2009) and after the pandemic, at the time we conducted our legal research, between February 2011 and September 2012. We included Washington, DC, and New York City because they are independent jurisdictions that report disease data to CDC. Two lawyers (E. S. L. and F. L.) with public health graduate degrees and experience in infectious disease epidemiology independently coded and then concurred on the presence or absence of key legal features for each state. We combined underlying legal feature variables to create composite measures to indicate whether a jurisdiction’s law was robust in 3 infectious disease reporting domains: (1) general, (2) influenza specific, and (3) new or emerging disease specific. We specified several characteristics of a robust general reporting law: (1) mandated reporters include, at a minimum, physicians and clinical laboratories; (2) suspected cases are reportable, at least for some diseases; (3) jurisdictions

have the authority to obtain additional information about a case beyond the data elements that are expressly required in a report; and (4) clinical material must be submitted to the public health laboratory for at least some diseases, as a matter of routine or upon health department request. In addition to the first 3 general law reporting features, we specified characteristics of a robust influenza reporting law: (1) individual cases of influenza are reportable for at least 1 of the following: all influenza, novel influenza, or influenza-associated hospitalization, and (2) clinical material must be submitted to the public health laboratory, as a matter of routine or upon health department request, for at least 1 of the following: all influenza, novel influenza, or influenza-associated hospitalization. In addition to the first 3 general law reporting features, we specified characteristics of a robust new or emerging disease reporting law: (1) individual cases of a new or emerging disease are reportable, not just outbreaks, unusual patterns, or incidents; (2) clinical material must be submitted to the public health laboratory, as a matter of routine or upon health department request, for new or emerging diseases; and (3) jurisdictions have explicit authority to define a new or emerging disease as reportable effective immediately, outside of standard or emergency administrative rulemaking procedures, such as by simple public notice (we define rulemaking here as either standard or emergency administrative rulemaking).

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For our case study, we contacted all jurisdiction or state epidemiologists to identify key informants in their agency with knowledge of their jurisdiction’s response to the 2009 H1N1 influenza pandemic. We surveyed key informants in writing or by telephone regarding barriers to collecting and using case data; the adoption of federal recommendations regarding kindergarten through 12th grade (K---12) schools, day care settings, antiviral use, and vaccine prioritization; and their use of local data to modify these recommendations.15---18 We also conducted semistructured telephone interviews with a sample of respondents regarding their perception of how their laws functioned during the 2009 H1N1 public health response.

deaths or laboratory-confirmed cases (Table 2). Of the 8 jurisdictions (15%) that had no mandated reporting of individual influenza cases at the onset of the 2009 H1N1 pandemic, 7 changed their laws to mandate reporting of at least some specific influenza cases, and 6 of the 7 changed their laws to make such reporting permanent. Most, but not all, jurisdictions required reporting of confirmed and suspected individual cases of new or emerging diseases (Table 3). Approximately half had explicit authority to immediately mandate reporting of a new disease, at least temporarily, outside of rulemaking procedures. The other half either did not have that authority or could do so only with a time delay.

RESULTS

Robustness of Disease Reporting Laws

Of the 50 states, 18 (36%) had disease reporting primarily to the state health department, 18 (36%) primarily to the local health department, and 14 (28%) to a combination of state and local departments. Only 9 of the 52 jurisdictions we studied mandated reporting of enumerated data elements only; a majority had authority to collect information more broadly and access to medical records for additional information (Table 1). Most (85%) required submission of specimens to the public health laboratory as a matter of routine for specific diseases or upon request. Most (85%) jurisdictions required reporting for at least a subset of influenza cases such as

Both before and after the pandemic, 37 jurisdictions (71%) had robust general reporting laws. In the prepandemic period, 8 jurisdictions (15%) had robust influenza-specific reporting laws; the number rose to 14 (27%) afterward. In the prepandemic period, 2 jurisdictions (4%) had robust new or emerging disease---specific reporting laws; afterward, this increased to 3 (6%; Figure 1). In all, 19 jurisdictions (37%) made postpandemic changes to the reporting laws we examined. These changes were diverse and may or may not have been prompted by or related to the H1N1 experience. Examples of the changes were making specific cases of influenza, such as novel or hospitalized cases, reportable; providing for access to case medical

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GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE

TABLE 1—General Disease Reporting Mandates in US Jurisdictions as of April 15, 2009 Reportable Case Information

Jurisdictionsa (n = 52), No. (%)

Report enumerated data elements only Authority beyond enumerated elements

9 (17) 43 (83)

Report other relevant information clause

26 (50)

Health department authorized to access case medical records

31 (60)

Both report other relevant information clause and medical records access

14 (27)

Suspected cases reportableb

49 (94)

Physicians and laboratories are mandated reporters

52 (100)

Specific mandated reporting by medical examiners, coroners, or veterinarians

28 (54)

Submission of case specimens to public health lab for enumerated diseases or upon health department request

44 (85)

a

Jurisdictions were 50 states; Washington, DC; and New York City. For at least some diseases.

b

records; and expressly providing that new diseases can be made reportable in an expedited manner.

Collection and Use of Case-Based Data Of the 49 jurisdictions (94%) responding to our survey concerning data collection on 2009

H1N1 cases, none reported problems collecting data on cases of 2009 H1N1 because of lack of legal authority. Only 1 reported concerns with submitting data to CDC because of lack of legal authority. Thirty of the 49 jurisdictions (61%) reported not collecting case data, particularly

race/ethnicity and obesity status, for other reasons, such as lack of staff resources or unavailability of data from medical providers. Although all 49 responding jurisdictions submitted some form of case-based data to CDC, 19 (39%) reported barriers, such as time constraints, limited resources, and

TABLE 2—Influenza-Specific Reporting Mandates in US Jurisdictions as of April 15, 2009 Reportable case information Report individual cases for at least some subset of casesb

Jurisdictionsa (n = 52), No. (%) 44 (85)

Influenza-associated pediatric mortality

26 (50)

Laboratory-confirmed influenza

23 (44)

Novel influenza

19 (37)

Influenza-associated hospitalizations

7 (13)

Influenza-associated deaths

5 (10)

Avian influenza Influenza-associated infant mortality

5 (10) 1 (2)

Suspect cases reportablec

35 (80)

Physicians and laboratories are mandated reportersc

40 (91)

Specific mandated reporting by medical examiners, coroners, or veterinariansc

17 (39)

Submission of case specimens to public health lab for at least some subset of influenza casesc

11 (25)

a

Jurisdictions were 50 states; Washington, DC; and New York City. Categories are not mutually exclusive. c Out of the 44 jurisdictions with case-based influenza reporting. b

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complications arising from CDC not accepting the electronic format in which the jurisdiction stored its data. Some jurisdictions reported that their information technology systems have improved since 2009 and now better facilitate electronic disease reporting and sharing of information with local health departments and CDC. Of the 46 jurisdictions (88%) responding to our survey on adoption of public health recommendations issued by CDC during the pandemic, the vast majority adopted CDC recommendations relating to antiviral use and vaccine prioritization without modification. For 6 antiviral recommendations issued by CDC between May and October 2009, the percentage of jurisdictions that adopted the recommendations ranged from 83% to 100%. For 3 vaccine prioritization recommendations issued between July and December 2009, jurisdiction adoption rates were greater than 93% for each recommendation. Fewer jurisdictions adopted CDC’s K---12 school and day care recommendations without modification, ranging from 44% to 96% for various recommendations over the course of the pandemic.

Perceptions of Reporting Laws We identified the following recurring themes in communications from key informants in 13 jurisdictions concerning their perception of how their laws functioned during the 2009 H1N1 public health response. Jurisdictions had varying experiences with H1N1: some had widespread cases earlier

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TABLE 3—New and Emerging Disease Reporting Mandates in US Jurisdictions as of April 15, 2009 Jurisdictionsa (n = 52), No. (%)

Case Reporting Reportable case information Yes, individual cases

46 (88)

Yes, pattern/unusual incidence

5 (10)

No

1 (2)

Suspected cases reportableb

44 (96)

Physicians and laboratories are mandated reportersb

37 (80)

Specific mandated reporting by medical examiners, coroners, or veterinariansb

20 (43)

Submission of case specimens to public health lab, at least upon requestb

4 (9)

Express authority to add a disease to reportable list, outside of administrative rulemaking procedures Yes, without delay

27 (52)

Yes, but with delay in implementation

5 (10)

No a

20 (38)

Jurisdictions were 50 states; Washington, DC; and New York City. Out of the 46 jurisdictions where individual cases were reportable.

b

with many jurisdictions following CDC’s lead and focusing on tracking hospitalizations and deaths after the spring 2009 wave. Generally, respondents said that their disease reporting laws functioned well during the pandemic, and they were

Jurisdictions With Robust Laws, No.

than much of the rest of the country, and some had a later onset or a diffuse geographic spread. Jurisdictions had different approaches to prioritizing data collection methods for specific cases as the pandemic evolved,

confident that the laws were adequate to respond to future emerging threats, often citing general provisions requiring the reporting of any new or emerging disease. Jurisdictions did not report problems procuring specimens

52 50 40

37 (71%)

37 (71%)

30

Prepandemic Postpandemic

20 14 (27%)

10

8 (15%) 2 (4%)

3 (6%)

0 General

Influenza

New/Emerging

Disease Reporting Domain FIGURE 1—Robustness of laws in 3 disease reporting domains, before and after the 2009 H1N1 influenza pandemic: United States.

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from clinical laboratories for H1N1 testing, but such submissions were generally voluntary (not legally mandated). In fact, jurisdictions reported receiving more laboratory submissions than they wanted and needing to put limits on what was tested.

DISCUSSION Although the majority of jurisdictions have laws mandating reporting of infectious disease cases in general, laws addressing influenza and emerging disease reporting could be strengthened. The low proportion of jurisdictions with robust laws for new or emerging diseases was primarily attributable to our strict definition, which required explicit authority for both clinical material submission and immediately requiring reporting of a new disease. Thirty-eight percent of jurisdictions did not have express authority, outside of rulemaking procedures, to immediately require reporting of a new disease. Although 85% had an explicit mandate to report individual cases of influenza for at least a subset of cases, only 25% of these had an explicit requirement to submit clinical specimens for at least a subset of influenza cases. Not all jurisdictions included medical examiners, coroners, and veterinarians as mandated disease reporters, even though they may be important sentinel reporters in a new or emerging disease. More than one third of states changed their laws since the beginning of the 2009 H1N1 pandemic in ways that enhanced their infectious disease reporting mandates.

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Responding jurisdictions did not report difficulties collecting data on cases of 2009 H1N1 because of lack of legal authority. In interviews, informants noted that clinicians generally cooperated voluntarily and enthusiastically with health department requests for case reports and clinical specimens during the 2009 H1N1 pandemic. Another study similarly found few surveillance problems except that systems across the country were inconsistent and not all states collected hospitalized case data.19 The reliance on voluntary cooperation may not be generalizable to other emerging infectious diseases, especially those that might not result in severe morbidity or mortality, for several reasons. First, influenza is a well-characterized disease with several national voluntary surveillance systems.8 Therefore, even though 2009 H1N1 was a novel pandemic strain that presented new challenges, a framework was already in place for public health surveillance and response. Second, incentives for reporting are recognized as important, and in the first weeks of the 2009 H1N1 pandemic, public health laboratories were the only laboratories capable of detecting the new viral strain in patient specimens via polymerase chain reaction assays.20 That alone may have strongly encouraged voluntary reporting and cooperation with public health officials. Third, although the 2009 H1N1 influenza strain generally did not have greater severity or mortality than seasonal influenza, the pandemic was long anticipated, and its

arrival generated much global attention. Responding jurisdictions generally reported adopting H1N1 recommendations from CDC without modification. Because they saw no major deviations of their own data from the national data picture, they saw no need to develop jurisdiction-specific recommendations. Officials were more likely to have relied on their own epidemiological data concerning the spread of the disease when deciding whether to adopt or modify recommendations about K---12 schools and day care settings than about antiviral use and vaccine prioritization. In separate surveys of public health officials, changes in guidance for school closures were noted to be confusing and often at odds with how local communities were experiencing the outbreak.19,21 The locus of decision-making on adopting or modifying CDC recommendations may be different in an outbreak that is more local or regional in scope: officials may rely more on jurisdiction-specific case data than on aggregated national case data, leading to more jurisdictiongenerated public health recommendations. Although jurisdictions reported no legal barriers to case-based data collection or specimen submission during the 2009 H1N1 pandemic, a truly novel pathogen, perhaps one that infects members of a historically stigmatized group (as happened with HIV in the early 1980s), might present surveillance challenges that require greater reliance on legal mandates for reporting. Public health must act within its legislatively

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authorized mandates. Lack of explicit law makes agencies vulnerable to challenge, particularly when the issues are politically sensitive.22 Reluctance to report may arise, and pressure may be exerted on clinicians not to report cases, particularly if there is fear of coercive actions toward patients.23,24 Submission of laboratory isolates to the public health laboratory might be critical to confirm the diagnosis and to determine other characteristics that might help the epidemiological investigation, determine the spread, or provide data for treatment. In at least 1 report, lack of mandatory isolate submission is blamed for delay in recognition of a national outbreak by 1 state and increasing the risk of disease in another state.25 Our study showed that reporting laws generally were in place and functioned well during the 2009 H1N1 pandemic. Nevertheless, jurisdictions should be mindful of their mandated reporting parameters and review the robustness of their laws before they are faced with a new or emerging disease outbreak. j

About the Authors Richard N. Danila, Ellen S. Laine, Franci Livingston, Kathryn Como-Sabetti, and Lauren Lamers are with the Minnesota Department of Health, St Paul. Kelli Johnson and Anne M. Barry are with the University of Minnesota School of Public Health, Minneapolis. Correspondence should be sent to Richard N. Danila, Infectious Disease Epidemiology, Prevention and Control, Minnesota Department of Health, 625 Robert St North, St Paul, MN (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted July 3, 2014.

Contributors R. N. Danila and A. M. Barry originated the study. R. N. Danila, A. M. Barry, F. Livingston, K. Como-Sabetti, and K. Johnson designed the study. E. S. Laine and L. Lamers conducted data analyses. R. N. Danila oversaw the project staff and wrote the initial draft of the article with E. S. Laine. All authors interpreted the data and revised the article.

Acknowledgments This study was funded by a grant from the Robert Wood Johnson Foundation Public Health Law Research program. We gratefully acknowledge state and local health department personnel who participated in this study.

Human Participant Protection This study did not involve human participants and was thus exempted by the Minnesota Department of Health institutional review board.

References 1. Thacker SB, Stroup DF. Origins and progress in surveillance systems. In: M’inkanatha NM, Lynfield R, Van Beneden CA, de Valk H, eds. Infectious Disease Surveillance. 2nd ed. Oxford, UK: Wiley Blackwell; 2013:21---31. 2. Roush S, Birkhead G, Koo D, Cobb A, Fleming D. Mandatory reporting of diseases and conditions by health care professionals and laboratories. JAMA. 1999;282(2):164---170. 3. Smith PF, Hadler JL, Stanbury M, Rolfs RT, Hopkins RS; CSTE Surveillance Strategy Group. “Blueprint Version 2.0”: updating public health surveillance for the 21st century. J Public Health Manag Pract. 2013;19(3):231---239. 4. Jajosky R, Rey A, Park M, Aranas A, Macdonald S, Ferland L. Findings from the Council of State and Territorial Epidemiologists’ 2008 assessment of state reportable and nationally notifiable conditions in the United States and considerations for the future. J Public Health Manag Pract. 2011;17(3):255---264. 5. Katz R, Rosenbaum S. Challenging custom: rethinking national population surveillance policy in a global public health age. J Health Polit Policy Law. 2010;35(6):1027---1055. 6. World Health Organization. International travel and health. Available at: http://www.who.int/ith/en. Accessed June 11, 2014.

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7. Horton HH, Misrahi JJ, Mathews GW, Kocher PL. Critical biological agents: disease reporting as a tool for determining bioterrorism preparedness. J Law Med Ethics. 2002;30(2):262---266. 8. Sell TK, Nuzzo JB, Toner E. Where does H1N1 influenza information come from? An overview of influenza surveillance in the United States. Biosecur Bioterror. 2010;8(1):55---57. 9. Lipsitch M, Finelli L, Heffernan RT, Leung GM, Redd SC. Improving the evidence base for decision making during a pandemic: the example of 2009 influenza A/H1N1. Biosecur Bioterror. 2011;9(2):89---115. 10. Balter S, Gupta LS, Lim S, Fu J, Perlman SE; New York City 2009 H1N1 Flu Investigation Team. Pandemic (H1N1) 2009 surveillance for severe illness and response, New York, New York, USA, April---July 2009. Emerg Infect Dis. 2010;16(8):1259---1264. 11. Centers for Disease Control and Prevention. Prevention and control of seasonal influenza with vaccines. Recommendations of the Advisory Committee on Immunization Practices—United States, 2013---2014. MMWR Recomm Rep. 2013;62(RR-07):1---43.

12. Centers for Disease Control and Prevention. Deaths related to 2009 pandemic influenza A (H1N1) among American Indians/Alaska Natives—12 States, 2009. MMWR Morb Mortal Wkly Rep. 2009;58(48):1341---1344. 13. Turning Point Collaborative. The Turning Point model state public health act: a tool for assessing public health laws. 2003. Available at: http://www. turningpointprogram.org. Accessed June 11, 2014. 14. Council of State and Territorial Epidemiologists. CSTE list of nationally notifiable conditions. Available at: http://www.cste.org. Accessed June 11, 2014. 15. Centers for Disease Control and Prevention. CDC guidance for state and local public health officials and school administrators for school (K---12) responses to influenza during the 2009--2010 school year. Available at: http:// www.cdc.gov/h1n1flu/schools/ schoolguidance.htm. Accessed June 11, 2014. 16. Centers for Disease Control and Prevention. CDC guidance on helping child care and early childhood programs respond to influenza during the

2009---2010 influenza season. Available at: http://www.cdc.gov/h1n1flu/ childcare/guidance.htm. Accessed June 11, 2014. 17. Centers for Disease Control and Prevention. Updated interim recommendations for the use of antiviral medications in the treatment and prevention of influenza for the 2009---2010 season. Available at: http://www.cdc.gov/ H1N1flu/recommendations.htm. Accessed June 11, 2014. 18. National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention. Use of influenza A (H1N1) 2009 monovalent vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. MMWR Recomm Rep. 2009;58(RR-10):1---8. 19. Association of State and Territorial Health Officials. Assessing policy barriers to effective public health response in the H1N1 influenza pandemic. 2010. Available at: http://www.astho.org/Programs/ Infectious-Disease/H1N1/H1N1Barriers-Project-Report-Final-hi-res. Accessed September 8, 2014. 20. Hopkins RS. Design and operation of state and local infectious disease

surveillance systems. J Public Health Manag Pract. 2005;11(3):184---190. 21. Rebmann T, Elliott MB, Swick Z, Reddick D. US school morbidity and mortality, mandatory vaccination, institutional closure, and interventions implemented during the 2009 influenza A H1N1 pandemic. Biosecur Bioterror. 2013;11(1):41---48. 22. Stier DD, Thombley ML, Kohn MA, Jesada RA. The status of legal authority for injury prevention practice in state health departments. Am J Public Health. 2012;102(6):1067---1078. 23. Lee LM, Heilig CM, White A. Ethical justification for conducting public health surveillance without patient consent. Am J Public Health. 2012;102(1):38---44. 24. Bayer R, Fairchild AL. Public health. surveillance and privacy. Science. 2000; 290(5498):1898---1909. 25. Levy M, Yerardi J, Volz D. In Florida flawed state reporting raises risks for foodborne illness. Florida Center for Investigative Reporting. Available at: http:// fcir.org/2011/10/05/in-florida-flawedstate-reporting-raises-risks-for-foodborneillness. Accessed June 11, 2014.

Public Health and Solitary Confinement in the United States David H. Cloud, JD, MPH, Ernest Drucker, PhD, Angela Browne, PhD, and Jim Parsons, MsC

The history of solitary confinement in the United States stretches from the silent prisons of 200 years ago to today’s supermax prisons, mechanized panopticons that isolate tens of thousands, sometimes for decades. We examined the living conditions and characteristics of the populations in solitary confinement. As part of the growing movement for reform, public health agencies have an ethical obligation to help address the excessive use of solitary confinement in jails

and prisons in accordance with established public health functions (e.g., violence prevention, health equity, surveillance, and minimizing of occupational and psychological hazards for correctional staff). Public health professionals should lead efforts to replace reliance on this overly punitive correctional policy with models based on rehabilitation and restorative justice. (Am J Public Health. 2015;105:18–26. doi: 10.2105/AJPH.2014.302205)

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WITH 2.3 MILLION PEOPLE IN its jails and prisons, the United States incarcerates more people than any other nation. At 716 per 100 000 people, the US per capita incarceration rate is more than 7 times the average in European Union countries. With only 5% of the world’s population, the United States now accounts for one quarter of its prisoners.1 The United States not only incarcerates the most people, but also exposes more of its citizenry to solitary confinement than any other nation. The best available data

suggest that about 84 000 individuals endure extreme conditions of isolation, sensory deprivation, and idleness in US correctional facilities.2 Federal data indicate that from 1995 to 2005, the number of people held in solitary confinement increased by 40%, from 57 591 to 81 622 people.3 Even in jurisdictions where the prison population has declined in recent years, the number of people in solitary has grown. For instance, from 2008 through 2013, the number of people in solitary confinement in federal prisons grew

American Journal of Public Health | January 2015, Vol 105, No. 1

Legal Authority for Infectious Disease Reporting in the United States: Case Study of the 2009 H1N1 Influenza Pandemic.

Tracking of infectious diseases is a public health core function essential to disease prevention and control. Each state mandates reporting of certain...
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