Pneumococcal serotype 35B is an important non-conjugate vaccine (non-PCV) serotype. Its continued emergence, post-PCV7 in the USA, was associated with expansion of a pre-existing 35B clone (clonal complex [CC] 558) along with post-PCV13 emergence of a non-35B clone previously associated with PCV serotypes (CC156). This study describes lineages circulating among 35B isolates in South Africa before and after PCV introduction. We also compared 35B isolates belonging to a predominant 35B lineage in South Africa (GPSC5), with isolates belonging to the same lineage in other parts of the world. Serotype 35B isolates that caused invasive pneumococcal disease in South Africa in 2005-2014 were characterized by whole-genome sequencing (WGS). Multi-locus sequence types and global pneumococcal sequence clusters (GPSCs) were derived from WGS data of 63 35B isolates obtained in 2005-2014. A total of 262 isolates that belong to GPSC5 (115 isolates from South Africa and 147 from other countries) that were sequenced as part of the global pneumococcal sequencing (GPS) project were included for comparison. Serotype 35B isolates from South Africa were differentiated into seven GPSCs and GPSC5 was most common (49 %, 31/63). While 35B was the most common serotype among GPSC5/CC172 isolates in South Africa during the PCV13 period (66 %, 29/44), 23F was the most common serotype during both the pre-PCV (80 %, 37/46) and PCV7 period (32 %, 8/25). Serotype 35B represented 15 % (40/262) of GPSC5 isolates within the global GPS database and 75 % (31/40) were from South Africa. The predominance of the GPSC5 lineage within non-vaccine serotype 35B, is possibly unique to South Africa and warrants further molecular surveillance of pneumococci.

Invasive disease caused by Streptococcus pneumoniae (IPD) is one of the leading causes of morbidity and mortality in young children worldwide. In Argentina, PCV13 was introduced into the childhood immunization programme nationwide in 2012 and PCV7 was available from 2000, but only in the private market. Since 1993 the National IPD Surveillance Programme, consisting of 150 hospitals, has conducted nationwide pneumococcal surveillance in Argentina in children under 6 years of age, as part of the SIREVA II-OPS network. A total of 1713 pneumococcal isolates characterized by serotype (Quellung) and antimicrobial resistance (agar dilution) to ten antibiotics, belonging to three study periods: pre-PCV7 era 1998-1999 (pre-PCV), before the introduction of PCV13 2010-2011 (PCV7) and after the introduction of PCV13 2012-2013 (PCV13), were available for inclusion. Fifty-four serotypes were identified in the entire collection and serotypes 14, 5 and 1 represented 50 % of the isolates. Resistance to penicillin was 34.9 %, cefotaxime 10.6 %, meropenem 4.9 %, cotrimoxazole 45 %, erythromycin 21.5 %, tetracycline 15.4 % and chloramphenicol 0.4 %. All the isolates were susceptible to levofloxacin, rifampin and vancomycin. Of 1713 isolates, 1061 (61.9 %) were non-susceptible to at least one antibiotic and 235(13.7 %) were multidrug resistant. A subset of 413 isolates was randomly selected and whole-genome sequenced as part of Global Pneumococcal Sequencing Project (GPS). The genome data was used to investigate the population structure of S. pneumoniae defining pneumococcal lineages using Global Pneumococcal Sequence Clusters (GPSCs), sequence types (STs) and clonal complexes (CCs), prevalent serotypes and their associated pneumococcal lineages and genomic inference of antimicrobial resistance. The collection showed a great diversity of strains. Among the 413 isolates, 73 known and 36 new STs were identified belonging to 38 CCs and 25 singletons, grouped into 52 GPSCs. Important changes were observed among vaccine types when pre-PCV and PCV13 periods were compared; a significant decrease in serotypes 14, 6B and 19F and a significant increase in 7F and 3. Among non-PCV13 types, serogroup 24 increased from 0 % in pre-PCV to 3.2 % in the PCV13 period. Our analysis showed that 66.1 % (273/413) of the isolates were predicted to be non-susceptible to at least one antibiotic and 11.9 % (49/413) were multidrug resistant. We found an agreement of 100 % when comparing the serotype determined by Quellung and WGS-based serotyping and 98.4 % of agreement in antimicrobial resistance. Continued surveillance of the pneumococcal population is needed to reveal the dynamics of pneumococcal isolates in Argentina in post-PCV13. This article contains data hosted by Microreact.

During the past several decades, unprecedented global changes in climate have given rise to an increase in extreme weather and other climate events and their consequences such as heavy rainfall, hurricanes, flooding, heat waves, wildfires, and air pollution. These climate effects have direct impacts on human health such as premature death, injuries, exacerbation of health conditions, disruption of mental well-being, as well as indirect impacts through food- and water-related infections and illnesses. While all populations are at risk for these adverse health outcomes, some populations are at greater risk because of multiple vulnerabilities resulting from increased exposure to risk-prone areas, increased sensitivity due to underlying health conditions, and limited adaptive capacity primarily because of a lack of economic resources to respond adequately. We discuss current governmental public health responses and their future opportunities to improve resilience of special populations at greatest risk for adverse health outcomes. Vulnerability assessment, adaptation plans, public health emergency response, and public health agency accreditation are all current governmental public health actions. Governmental public health opportunities include integration of these current responses with health equity initiatives and programs in communities.

INTRODUCTION: Local health departments (LHDs) are increasingly using national standards to meet the challenges presented by the complex environments in which these agencies operate. Local boards of health (LBoHs) might play an instrumental role in improving LHDs' engagement in activities to meet these standards. OBJECTIVES: To assess the impact of LBoH performance of governance functions on LHDs having a current (completed within 5 years) community health assessment (CHA), community health improvement plan (CHIP), strategic plan, and level of engagement in the Public Health Accreditation Board (PHAB) accreditation program. METHODS: Binary and multinomial logistic regression models were used to analyze linked data from 329 LHDs participating in both the 2015 Local Board of Health Survey and the 2016 National Profile of LHDs Survey. RESULTS: Higher performance of LBoH governance functions, measured by an overall scale of LBoH taxonomy consisting of 60 items, had a significant positive effect on LHDs having completed CHA (P < .001), CHIP (P = .01), and strategic plan (P < .001). LHDs operating in communities with a higher score on the overall scale of LBoH taxonomy had significantly higher odds (P = .03) of having higher level of participation in the PHAB national voluntary accreditation program-that is, being accredited, having submitted application for accreditation, or being in the e-PHAB system (eg, by submitting a letter of intent). CONCLUSIONS: LBoHs serve as governance bodies for roughly 71% of LHDs and can play a significant role in encouraging LHDs' participation in these practices. That positive influence of LBoHs can be seen more clearly if the complexity and richness of LBoH governance functions and other characteristics are measured appropriately. The study findings suggest that LBoHs are a significant component of the public health system in the United States, having positive influence on LHDs having a CHA, CHIP, strategic plan, and participation in accreditation.

National public health accreditation was designed for and built by public health practitioners, through considerable volunteer participation from the field and the leadership of national organizations that represent the agencies to be accredited. Another important ingredient for success was the long-term commitment from 2 cofunders, the Centers for Disease Control and Prevention (CDC) and the Robert Wood Johnson Foundation (RWJF). These organizations provided the necessary fuel and, by continually listening to the field and working collaboratively with many partners, initiated complementary strategies that are serving a vital role in the success of national accreditation and its impact on the field of public health. | Spurred by a 2003 recommendation from the Institute of Medicine,1 the growth of state-specific efforts,2 and interest from their respective organizations,3,4 CDC and RWJF joined forces in 2005 to support the Exploring Accreditation Initiative and the subsequent Public Health Accreditation Board (PHAB).5 These efforts drew information from prior and simultaneous efforts supported by CDC and RWJF, such as the Multi-State Learning Collaborative,2 the National Public Health Performance Standards,6 and the Operational Definition of a Local Health Department.7 | This commentary describes major CDC and RWJF areas of support to the field since the launch of accreditation in 2011. CDC and RWJF have provided a variety of opportunities, such as direct funding related to accreditation readiness and quality improvement (QI), funding and technical assistance through national partner organizations,* and opportunities for training and peer exchange. CDC and RWJF have worked together, sharing observations about needs and successes in the field, to refine opportunities and complement efforts. As a result, several themes emerge that can inform other large-scale collaborative efforts and provide guidance for continued advancement of accreditation.

In 2011, the national accreditation program for public health departments was launched, thus establishing national standards that specify and reinforce expectations for health departments. Accreditation can play an important role in stabilizing public health practice, strengthening quality and performance, and driving change. Accreditation-oriented crosswalks are a type of tool that can help realize the benefits of accreditation by highlighting connections between the national accreditation standards and public health programs, policies, and practices. While many different types of accreditation-oriented crosswalks exist, they all provide the same opportunity: to maximize accreditation's impact on improving public health programs specifically and public health agency practices generally. This commentary discusses development and use of crosswalks as a tool that links accreditation to programmatic and strategic priorities.

OBJECTIVES: During 2010-2014, the Centers for Disease Control and Prevention implemented the National Public Health Improvement Initiative (NPHII) to assist 73 public health agencies in conducting activities to increase accreditation readiness, improve efficiency and effectiveness through quality improvement, and increase performance management capacity. A summative evaluation of NPHII was conducted to examine whether awardees met the initiative's objectives, including increasing readiness for accreditation. DESIGN: A nonexperimental, utilization-focused evaluation with a multistrand, sequential mixed-methods approach was conducted to monitor awardee accomplishments and activities. Data analysis included descriptive statistics, as well as subanalyses of data by awardee characteristics. Thematic analysis using deductive a priori codes was used for qualitative analysis. RESULTS: Ninety percent of awardees reported completing at least 1 accreditation prerequisite during NPHII, and more than half reported completing all 3 prerequisites by the end of the program. Three-fourths of awardees that completed a self-assessment reported closing gaps for at least 1 Public Health Accreditation Board (PHAB) standard. Within 3 years of the launch of PHAB accreditation, 7 NPHII awardees were accredited; another 38 had formally applied for accreditation. CONCLUSIONS: Through NPHII, awardees increased collaborative efforts around accreditation readiness, accelerated timelines for preparing for accreditation, and prioritized the completion of required accreditation activities.

BACKGROUND: Local boards of health (LBoHs) serve as the governance body for 71% of local health departments (LHDs). PURPOSE: To assess the impact of LBoH governance functions and other characteristics on the level of LBoH support of LHD accreditation. METHODS: Data from 394 LHDs that participated in the 2015 Local Boards of Health Survey were used for computing summative scores for LBoHs for domains of taxonomy and performing logistic regression analyses in 2016. RESULTS: Increased odds of an LBoH directing, encouraging, or supporting LHD accreditation activities were significantly associated with (a) a higher overall combined score measuring performance of governance functions and presence of other LBoH characteristics (adjusted odds ratio [AOR] = 1.05; P < .001); (b) a higher combined score for the Governance Functions subscale (AOR = 1.06; P < .01); (c) the "continuous improvement" governance function (AOR = 1.15; P < .001); and (d) characteristics and strengths such as board composition (eg, LBoH size, type of training, elected vs nonelected members), community engagement and input, and the absence of an elected official on the board (AOR = 1.14; P = .02). CONCLUSIONS: LBoHs are evenly split by thirds in their attention to Public Health Accreditation Board accreditation among the following categories: (a) encouraged or supported, (b) discussed but made no recommendations, and (c) did not discuss. This split might indicate that they are depending on the professional leadership of the LHD to make the decision or that there is a lack of awareness. The study findings have policy implications for both LBoHs and initiatives aimed at strengthening efforts to promote LHD accreditation.

CONTEXT: Public health enabling authorities establish the legal foundation for financing, organizing, and delivering public health services. State laws vary in terms of the content, depth, and breadth of these fundamental public health activities. Given this variance, the Institute of Medicine has identified state public health laws as an area that requires further examination. To respond to this call for further examination, the Centers for Disease Control and Prevention's Public Health Law Program conducted a fundamental activities legal assessment on state public health laws. OBJECTIVE: The goal of the legal assessment was to examine state laws referencing frameworks representing public health department fundamental activities (ie, core and essential services) in an effort to identify, catalog, and describe enabling authorities of state governmental public health systems. DESIGN: In 2013, Public Health Law Program staff compiled a list of state statutes and regulations referencing different commonly-recognized public health frameworks of fundamental activities. The legal assessment included state fundamental activities laws available on WestlawNext as of July 2013. The results related to the 10 essential public health services and the 3 core public health functions were confirmed and updated in June 2016. RESULTS: Eighteen states reference commonly-recognized frameworks of fundamental activities in their laws. Thirteen states have listed the 10 essential public health services in their laws. Eight of these states have also referenced the 3 core public health functions in their laws. Five states reference only the core public health functions. CONCLUSIONS: Several states reference fundamental activities in their state laws, particularly through use of the essential services framework. Further work is needed to capture the public health laws and practices of states that may be performing fundamental activities but without reference to a common framework.

In 2011, the nonprofit Public Health Accreditation Board (PHAB) launched the national, voluntary public health accreditation program for state, tribal, local, and territorial public health departments. As of May 2016, 134 health departments have achieved 5-year accreditation through PHAB and 176 more have begun the formal process of pursuing accreditation. In addition, Florida, a centralized state in which the employees of all 67 local health departments are employees of the state, achieved accreditation for the entire integrated local public health department system in the state. PHAB-accredited health departments range in size from a small Indiana health department that serves approximately 17,000 persons to the much larger California Department of Public Health, which serves approximately 38 million persons. Collectively, approximately half the U.S. population, or nearly 167 million persons, is covered by an accredited health department. Forty-two states and the District of Columbia now have at least one nationally accredited health department. In a survey conducted through a contract with a social science research organization during 2013-2016, >90% of health departments that had been accredited for 1 year reported that accreditation has stimulated quality improvement and performance improvement opportunities, increased accountability and transparency, and improved management processes.

Environmental health is a critical component of governmental public health, as provided in state, tribal, local, and territorial jurisdictions. The environmental health services provided by each health department can vary; common examples include the following: | | inspecting food establishments, | monitoring the quality of drinking and recreational water, | managing solid and liquid waste, | performing vector control, and | inspecting buildings to assure compliance with environmental codes. | Difficulty in finding qualified personnel (especially in small jurisdictions) coupled with challenges in paying for the cost of providing the desired services have been important drivers for health departments to explore alternative options. One of these options is cross-jurisdictional sharing (CJS) (Madamala et al., 2014). | | Cross-jurisdictional sharing enables collaboration across jurisdictional boundaries to deliver essential public health services (Center for Sharing Public Health Services, 2015). Sharing models range from informal agreements limited in scope to full consolidation of local health department agencies (Figure 1).

BACKGROUND: Standardized methodologies for assessing economic burden of injury at the national or international level do not exist. OBJECTIVE: To measure national incidence, medical costs, and productivity losses of medically treated injuries using the most recent data available in the United States, as a case study for similarly developed countries undertaking economic burden analyses. METHOD: The authors combined several data sets to estimate the incidence of fatal and non-fatal injuries in 2000. They computed unit medical and productivity costs and multiplied these costs by corresponding incidence estimates to yield total lifetime costs of injuries occurring in 2000. MAIN OUTCOME MEASURES: Incidence, medical costs, productivity losses, and total costs for injuries stratified by age group, sex, and mechanism. RESULTS: More than 50 million Americans experienced a medically treated injury in 2000, resulting in lifetime costs of $406 billion; $80 billion for medical treatment and $326 billion for lost productivity. Males had a 20% higher rate of injury than females. Injuries resulting from falls or being struck by/against an object accounted for more than 44% of injuries. The rate of medically treated injuries declined by 15% from 1985 to 2000 in the US. For those aged 0-44, the incidence rate of injuries declined by more than 20%; while persons aged 75 and older experienced a 20% increase. CONCLUSIONS: These national burden estimates provide unequivocal evidence of the large health and financial burden of injuries. This study can serve as a template for other countries or be used in intercountry comparisons.

This study estimated the health and economic burden of child maltreatment in the East Asia and Pacific region, addressing a significant gap in the current evidence base. Systematic reviews and meta-analyses were conducted to estimate the prevalence of child physical abuse, sexual abuse, emotional abuse, neglect, and witnessing parental violence. Population Attributable Fractions were calculated and Disability-Adjusted Life Years (DALYs) lost from physical and mental health outcomes and health risk behaviors attributable to child maltreatment were estimated using the most recent comparable Global Burden of Disease data. DALY losses were converted into monetary value by assuming that one DALY is equal to the sub-region's per capita GDP. The estimated economic value of DALYs lost to violence against children as a percentage of GDP ranged from 1.24% to 3.46% across sub-regions defined by the World Health Organization. The estimated economic value of DALYs (in constant 2000 US$) lost to child maltreatment in the EAP region totaled US $151 billion, accounting for 1.88% of the region's GDP. Updated to 2012 dollars, the estimated economic burden totaled US $194 billion. In sensitivity analysis, the aggregate costs as a percentage of GDP range from 1.36% to 2.52%. The economic burden of child maltreatment in the East Asia and Pacific region is substantial, indicating the importance of preventing and responding to child maltreatment in this region. More comprehensive research into the impact of multiple types of childhood adversity on a wider range of putative health outcomes is needed to guide policy and programs for child protection in the region, and globally.

We conducted a literature review in 2011 to determine if accepted governance functions continue to reflect the role of public health governing entities. Reviewing literature and other source documents, as well as consulting with practitioners, resulted in an iterative process that identified 6 functions of public health governance and established definitions for each of these: policy development; resource stewardship; continuous improvement; partner engagement; legal authority; and oversight of a health department. These functions provided context for the role of governing entities in public health practice and aligned well with existing public health accreditation standards. Public health systems research can build from this work in future explorations of the contributions of governance to health department performance.

Public health services and systems research (PHSSR) provides the evidence and scientific foundation for increasing understanding of the public health system, supporting health system improvements, and advancing the field of public health practice. A focus on the "system" in "public health systems and services research" remains as important as ever and is becoming more complex over time.

A decade ago, the Turning Point Performance Management Excellence Collaborative (Turning Point) developed the first public health-specific performance management (PM) system, with accompanying resource materials, assisted by the Public Health Foundation. Since then, dramatic advancements in PM and quality improvement activities have occurred in public health. Public Health Foundation gathered data that revealed Turning Point was still relevant but difficult to implement within public health. To reflect recent advances and current challenges, Public Health Foundation refreshed the Turning Point model and related guidance tools and developed new resources to facilitate PM implementation. In addition, a new fifth component, "Visible Leadership," was added to the 4-quadrant model and the Self-Assessment Tool. In the future, public health organizations should take an active leadership role in innovating and sustaining PM systems, ensuring they become accountable for producing outcomes, leveraging technology advances, and incorporating best practices from all stakeholders.

CONTEXT: Recent years have seen rising interest in initiatives that focus on public health improvement. This includes support for accreditation of public health departments-administered by the Public Health Accreditation Board (PHAB)-and increasing expectations that health departments should use evidence-based programs, services, and policies (interventions) such as those described in The Guide to Community Preventive Services (The Community Guide). OBJECTIVE: This project was initiated to explore the potential connections between Community Guide interventions and PHAB domains, standards, and measures. DESIGN: The project team focused on developing a Crosswalk tool to assist health departments in identifying evidence-based interventions from The Community Guide whose implementation could help document conformity with PHAB domains, standards, and measures. All Community Preventive Services Task Force-recommended interventions were reviewed to determine whether they reflect the intent and requirements of the PHAB standards and measures. MAIN OUTCOME MEASURES: Three types of connections were defined through which Community Guide interventions could be relevant to the required documentation for a PHAB measure. All instances of these connections were identified and included in the Crosswalk. RESULTS: The Crosswalk tool consists of 2 tables. The first table cross-references individual PHAB domains, standards, and measures with interventions from The Community Guide that could help provide documentation for accreditation. The second table can help accreditation preparation staff to engage with program staff. It is searchable by Community Guide topic, identifying the PHAB measures that relate to each Community Guide intervention within that topic. The type, location, and extent of connections between Community Guide interventions and PHAB domains, standards, and measures are presented and discussed. CONCLUSIONS: Tools such as the Crosswalk can be instrumental in advancing the use of evidence-based interventions in public health practice.

BACKGROUND: Public health officials must frequently demonstrate the quality and value of public health services, especially during challenging fiscal climates. One of the ways that public health quality and accountability have been demonstrated is through the use of accreditation and standard setting initiatives. OBJECTIVE: The objective of this analysis was to identify existing alignment opportunities between standards established by the Public Health Accreditation Board (PHAB) and the Centers for Disease Control and Prevention's (CDC's) public health preparedness (PHP) capabilities in order to optimize and leverage the connections for state and local public health professionals. DESIGN: During March-May 2012, a PHAB/PHP crosswalk was developed by a research team from the CDC's Office for State, Tribal, Local and Territorial Support and Office of Public Health Preparedness and Response's Division of State and Local Readiness to examine the intersection of the PHP capabilities and the PHAB standards. The PHAB/PHP crosswalk used the CDC Public Health Preparedness Capabilities: National Standards for State and Local Planning (PHP Capabilities) and the PHAB Standards and Measures, Version 1.0 (PHAB Standards) as its source documents. To help illustrate the results of the crosswalk, alignment was also depicted through a network graph to transform the results into a visual depiction of the linkages between PHP capabilities and PHAB standards. RESULTS: The most direct links to emergency preparedness were found in PHAB Domains 2 and 5. Opportunities for improved alignment were found throughout the standard documents, particularly in PHAB Domains 3, 8, and 11. The most direct links to accreditation were found in PHP capabilities 1, 2, 3, and 4. CONCLUSIONS: The results highlight the synergy between the infrastructure and foundational elements represented by accreditation and targeted programmatic activities supported by preparedness funding.

The commentary describes the role of the Centers for Disease Control and Prevention's National Public Health Improvement Initiative in advancing health department accreditation readiness activities. | For more than 2 decades, the Institute of Medicine has drawn national attention to the need for strengthening the public health infrastructure and related capabilities to protect and ensure the public's health.1,2 A strong and sustainable public health infrastructure is critical for public health departments to operate efficiently and effectively in delivering the 10 essential public health services necessary to meet the health needs of communities. | In its 2003 report, The Future of the Public's Health in the 21st Century, the Institute of Medicine called for strengthening public health performance and exploring health department accreditation as a way to ensure that public health services and programs are efficient and effective in addressing the public health challenges of today and tomorrow.3 Four years later and with support from the Centers for Disease Control and Prevention (CDC) and the Robert Wood Johnson Foundation, the Public Health Accreditation Board (PHAB) was established and work began to develop a national program to improve the quality of practice and performance within public health departments. Based on the 10 essential public health services, PHAB accreditation provides a means for a health department to identify performance improvement opportunities, enhance management, develop leadership, and strengthen community relationships; leading organizations to improved accountability, credibility, and better health outcomes. The program was successfully launched in fall 2011, and the first 11 PHAB-accredited public health departments were announced in March 2013, with many more health department applications in process.4

CONTEXT: Accreditation of public health agencies through the Public Health Accreditation Board is voluntary. Incentives that encourage agencies to apply for accreditation have been suggested as important factors in facilitating participation by state and local agencies. OBJECTIVE: The project describes both current and potential incentives that are available at the federal, state, and local levels. DESIGN: Thirty-nine key informants from local, state, tribal, federal, and academic settings were interviewed from March through May 2012. Through open-ended interviews, respondents were asked about incentives that were currently in use in their settings and incentives they thought would help encourage participation in Public Health Accreditation Board accreditation. RESULTS: Incentives currently in use by public health agencies based on interviews include (1) financial support, (2) legal mandates, (3) technical assistance, (4) peer support workgroups, and (5) state agencies serving as role models by seeking accreditation themselves. Key informants noted that state agencies are playing valuable and diverse roles in providing incentives for accreditation within their own states. Key informants also identified the Centers for Disease Control and Prevention and other players, such as private foundations, public health institutes, national and state associations, and academia as providing both technical and financial assistance to support accreditation efforts. CONCLUSIONS: State, tribal, local, and federal agencies, as well as related organizations can play an important role by providing incentives to move agencies toward accreditation.

In 2003, the Institute of Medicine recommended serious examination of health department accreditation as one strategy to improve public health agency performance.1 Three years later and just over 6 years ago, national voluntary public health accreditation was a promising idea with a blueprint for implementation, courtesy of the Exploring Accreditation Project, jointly funded by the Robert Wood Johnson Foundation and the Centers for Disease Control and Prevention.2,3 The concept had the broad support of national public health practice organizations and drew from the experiences of states such as Michigan, Missouri, North Carolina, and Washington, which had developed their own state-driven accreditation or standards programs.4,5 Nonetheless, the road ahead has not always been a straight, unwavering line, with a guaranteed successful outcome. | In 2007, the Public Health Accreditation Board (PHAB) was formed as a fledgling organization under the auspices of a board of incorporators made up of the executives of the American Public Health Association, the Association of State and Territorial Health Officials, the National Association of Local Boards of Health, and the National Association of County & City Health Officials, representing the larger practice community. The Robert Wood Johnson Foundation and the Centers for Disease Control and Prevention co-supported PHAB's activities to lead the field-driven development and testing of the many critical elements of a national accreditation program. In September 2011, national voluntary public health accreditation launched to receptive audiences, even as health departments grappled with budget reductions and staffing shortages. Throughout the years of exploring and developing a national accreditation program, the nexus between accreditation and strengthening health department performance has remained a central tenet, essential to PHAB, to its earliest applicants and to the hundreds of health departments preparing to apply.

Health department accreditation is one of the most important initiatives in the field of public health today. The Public Health Accreditation Board (PHAB) is establishing a voluntary accreditation system for more than 3000 state, tribal, territorial, and local health departments using domains, standards, and measures with which to evaluate public health department performance. In addition, public health department accreditation has a focus on continuous quality improvement to enhance capacity and performance of health departments in order to advance the health of the population. In the accreditation effort, a practice-based research agenda is essential to build the scientific base and advance public health department accreditation as well as health department effectiveness. This paper provides an overview of public health accreditation and identifies the research questions raised by this accreditation initiative, including how the research agenda will contribute to better understanding of processes underlying the delivery of services by public health departments and how voluntary accreditation may help improve performance of public health departments.

In September 2011, an inaugural national public health department voluntary accreditation program will re-invigorate efforts to strengthen our nation’s public health infrastructure. The program’s goal is to advance the quality and performance of public health departments. As such, the program intends to strengthen health departments’ internal procedures and the services they provide. | The Centers for Disease Control and Prevention (CDC) and the Robert Wood Johnson Foundation (RWJF) co-funded the national accreditation program’s development and startup. Key national partners, some of whom represent constituencies the program will accredit, also supported the program’s development. In May 2007, the Public Health Accreditation Board (PHAB) was established as a nonprofit organization to serve as the accrediting body. Since then, PHAB has provided leadership for the program’s development and startup. | Collaboration between PHAB and its critical partners and constituencies has been an important aspect of these efforts. And PHAB’s work with the environmental public health community has been a successful initial example of such collaboration. The National Center for Environmental Health (NCEH) and the Office for State, Tribal, Local and Territorial Support (OSTLTS) at CDC work with many partners to strengthen the nation’s public health infrastructure and to improve environmental public health practice. To this end, PHAB, NCEH, and OSTLTS worked together to explore how the PHAB standards can best relate to environmental public health (EPH) and how EPH staff can become involved in accreditation. This resulted in numerous actions that have measurably enhanced the visibility and accuracy of EPH within the accreditation process and standards.

Since its inception in 1998, the Centers for Disease Control and Prevention's National Public Health Performance Standards Program (NPHPSP) has helped lay the groundwork for public health quality improvement (QI) activities at the state and local levels. This article describes how the NPHPSP has promoted QI through its instruments and guidance and how it has continually strengthened the focus on QI over the years. The NPHPSP Version 2 instruments and enhanced guidance have been designed to more strongly reinforce QI and catalyze the transition from assessment to action. Despite positive reports from some state and local users that emphasize the value the NPHPSP holds for those that do successfully move forward with improvement actions, 2005 evaluation results from the Association of State and Territorial Health Officials and the National Association of County and City Health Officials indicated challenges in transitioning the assessments results into performance improvement. More recent data are promising; a 2009 postassessment survey of early Version 2 respondents indicates that the majority (75% of all respondents) report action in one or more performance improvement steps. The NPHPSP has played an important role in fostering QI in many states and local jurisdictions. Furthermore, its experiences and lessons learned in supporting QI have helped to pave the way for other initiatives, such as the emerging national accreditation system for state and local health departments.

This article comments on Centers for Disease Control and Prevention's strategies to strengthen public health and its system components in order to create the necessary operational capacity and infrastructure vital to the success of all public health prevention, protection, and wellness activities. | Simply put, in the absence of a radical shift towards prevention and public health, we will not be successful in containing medical costs or improving the health of the American people. | President Barack Obama | Within the context of health reform, the Obama administration's ambitious goal of integrating prevention, public health, and healthcare delivery systems anticipates greatly expanding prevention and wellness activities as the primary means to reduce the burden of disease, injury, and disability in the United States. This prescription for change represents a significant challenge. If public health is to succeed in delivering on the “promise of prevention,” as well as exert our leadership role, then we need to counter with bold initiatives that promote accountability, performance, and improvements in public health. The reason is clear—without a high-performing public health system, we will not be able to attain the goals of the new administration and, most important, the health aspirations of communities across the nation.

Many industries commonly use quality improvement (QI) techniques to improve service delivery and process performance. Yet, there has been scarce application of these proven methods to public health settings and the public health field has not developed a set of shared principles or a common definition for quality improvement. This article discusses a definition of quality improvement in public health and describes a continuum of quality improvement applications for public health departments. Quality improvement is a distinct management process and set of tools and techniques that are coordinated to ensure that departments consistently meet the health needs of their communities.

Today, more than ever, health departments are seeking funding in a hostile environment, in which other institutions such as schools and jails have already received the imprimatur of approval from accreditation. The public's demands for greater accountability, a nationwide call to action for a smarter and more effective health system, and an economic crisis that requires strategic investments have all been growing as the importance of public health has been reinforced by the emergence of the H1N1 virus. In these uncertain economic times, accountability via accreditation may confer a substantial competitive advantage in the governmental marketplace and set us on the road to fostering an improved health system. | Building on earlier initiatives, the Public Health Accreditation Board (PHAB) was formed in May 2007 with the goal of improving and protecting the health of every community by advancing the quality and performance of local, state, and tribal health departments through a voluntary national accreditation program. Via an open and deliberate process, PHAB is collaborating with national partners and the public health community to create and launch a voluntary national accreditation program in 2011.

OBJECTIVES: We sought to identify the incentives most likely to encourage voluntary participation in the national public health accreditation model. METHODS: We reviewed existing incentives, held meetings with key informants, and conducted a survey of state and local public health agency representatives. The survey was sent to all state health departments and a sample of local health departments. Group-specific differences in survey responses were examined. RESULTS: Survey response rates were 51% among state health department representatives and 49% among local health department representatives. Both state health department and local health department respondents rated financial incentives for accredited agencies, financial incentives for agencies considering accreditation, and infrastructure and quality improvement as important incentives. State health department respondents also indicated that grant administration and grant application would encourage their participation in the national accreditation model, and local health department respondents also noted that technical assistance and training would encourage their participation. CONCLUSIONS: Incentives to encourage participation of state and local agencies in the national voluntary accreditation model should include financial support as well as support for agency infrastructure and quality improvements. Several initiatives are already under way to support agency infrastructure and quality improvement, but financial support incentives have yet to be developed.