Report Finds Major Gaps in Country’s Ability to Prevent and Control Infectious Disease Outbreaks


28 States and Washington, D.C. Reach Half or Fewer of Key Indicators

Washington, D.C., December 17, 2015 – A new report released today found that more than half (28) of states score a five or lower out of 10 key indicators related to preventing, detecting, diagnosing and responding to outbreaks. The report, from Trust for America’s Health (TFAH) and the Robert Wood Johnson Foundation (RWJF), concluded that the United States must redouble efforts to better protect the country from new infectious disease threats, such as MERS-CoV and antibiotic-resistant superbugs, and resurging illnesses like whooping cough, tuberculosis and gonorrhea.

Five states—Delaware, Kentucky, Maine, New York and Virginia—tied for the top score, achieving eight out of 10 indicators. Seven states—Idaho, Kansas, Michigan, Ohio, Oklahoma, Oregon and Utah—tied for the lowest score at three out of 10.

“The overuse of antibiotics and underuse of vaccinations along with unstable and insufficient funding have left major gaps in our country’s ability to prepare for infectious disease threats,” said Jeffrey Levi, PhD, executive director of TFAH. “We cannot afford to continue to be complacent. Infectious diseases – which are largely preventable – disrupt the lives of millions of Americans and contribute to billions of dollars in unnecessary healthcare costs each year.”

Some key findings from the Outbreaks: Protecting Americans from Infectious Diseases report include:

  • Healthcare-associated Infections: Around one out of every 25 people who are hospitalized each year contracts a healthcare-associated infection, leading to some 75,000 deaths a year.
    • Only nine states reduced the standardized infection ratio (SIR) for central line-associated blood stream infections (CLABSI) between 2012 and 2013.
  • Childhood Vaccinations: In 2014, there were more than 600 cases of measles and nearly 33,000 cases of whooping cough reported. While more than 90 percent of all U.S. kindergarteners receive all recommended vaccinations, rates are lower in a number of communities and states. More than 28 percent of preschoolers do not receive all recommended vaccinations.
    • 20 states have laws that either exclude philosophical exemptions entirely or require a parental notarization or affidavit to achieve a religious or philosophical exemption for school attendance.
  • Flu Vaccinations: Based on the severity of the strain, the flu can cause 3,000 to 49,000 deaths a year, more than $10 billion in direct medical expenses and more than $16 billion in lost earnings.
    • 18 states vaccinated at least half of their population (ages 6 months and older) for the seasonal flu from Fall 2014 to Spring 2015. The national average is 47.1 percent. Rates are lowest among young and middle age adults (only 38 percent of 18- to 64-year-olds are vaccinated).
  • Hepatitis C and HIV/AIDS: Of the more than 1.2 million Americans living with HIV, almost one in eight do not know they are infected. Hepatitis C infections—related to a rise in heroin and injection drug use from people transitioning from prescription painkillers—increased more than 150 percent from 2010 to 2013.
    • 16 states and Washington, D.C. explicitly authorize syringe exchange programs.
    • 43 states and Washington, D.C. require reporting all (detectable and undetectable) CD4 cell count (a type of white blood cell) and HIV viral load data to their state HIV surveillance program, as of July 2013.
  • Food Safety: Around 48 million Americans get sick from a foodborne illness each year.
    • 39 states met the national performance target of testing 90 percent of E.coli O157 cases within four days (in 2013).
  • Preparing for Emerging Threats: Significant advances have been made in preparing for public health emergencies, including potential bioterror or natural disease outbreaks, since the September 11, 2001 and anthrax attacks. Gaps remain, however, and have been exacerbated as resources have been cut.
    • 36 states have a biosafety professional in their state public health laboratories – which are responsible for helping detect, diagnose and contain disease outbreaks.
    • 15 states have completed climate change adaption plans that include the impact on human health.
  • Superbugs: More than two million Americans contract antibiotic-resistant infections each year, leading in excess of 23,000 deaths, $20 billion in direct medical costs and more than $35 billion in lost productivity.

“America’s investments in infectious disease prevention ebb and flow, leaving our nation challenged to sufficiently address persistent problems,” said Paul Kuehnert, a Robert Wood Johnson Foundation director. “We need to reboot our approach so we support the health of every community by being ready when new infectious threats emerge.”

The Outbreaks report features priority recommendations, including:

  • Increase resources to ensure every state can maintain and modernize basic capabilities – such as epidemiology and laboratory abilities – that are needed to respond to new and ongoing outbreaks;
  • Update disease surveillance to be real-time and interoperable across communities and health systems to better detect, track and contain disease threats;
  • Incentivize the development of new medicines and vaccines, and ensure systems are in place to effectively distribute them when needed;
  • Decrease antibiotic overuse and increase vaccination rates;
  • Improve and maintain the ability of the health system to be prepared for a range of potential threats – such as an influx of patients during a widespread outbreak or the containment of a novel, highly infectious organism that requires specialty care;
  • Strengthen efforts and policies to reduce healthcare-associated infections;
  • Take strong measures to contain the rising hepatitis C epidemic and other sexually transmitted infections, particularly among young adults; and
  • Adopt modern strategies to end AIDS in every state and city.

The indicators represent examples of important capabilities, policies and trends, and were selected in consultation with leading public health and healthcare officials.

Score Summary: 

A full list of all of the indicators and scores and the full report are available on TFAH’s website. For the state-by-state scoring, states received one point for achieving an indicator or zero points if they did not achieve the indicator, with zero the lowest possible overall score and 10 the highest. The data for the indicators are from publicly available sources or were provided from public officials.

8 out of 10: Delaware, Kentucky, Maine, New York and Virginia

7 out of 10: Alaska, California, Maryland, Massachusetts, Minnesota and Nebraska

6 out of 10: Arkansas, Illinois, Iowa, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Vermont, West Virginia and Wisconsin

5 out of 10: Arizona, Colorado, Connecticut, Georgia, Hawaii, Mississippi, Missouri, Montana, Pennsylvania, Rhode Island, Texas and Washington

4 out of 10: Alabama, District of Columbia, Florida, Indiana, Louisiana, Nevada, South Carolina, South Dakota, Tennessee and Wyoming

3 out of 10: Idaho, Kansas, Michigan, Ohio, Oklahoma, Oregon and Utah



Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.

For more than 40 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are striving to build a national Culture of Health that will enable all to live longer, healthier lives now and for generations to come. For more information, visit Follow the Foundation on Twitter at or on Facebook at