Monkeypox virus (MPXV) can spread among humans through direct contact with lesions, scabs, or saliva; via respiratory secretions; and indirectly from fomites; via percutaneous injuries; and by crossing the placenta to the fetus during pregnancy. Since 2022, most patients with mpox in the United States have experienced painful skin lesions, and some have had severe illness. During 2021-2022, CDC initiated aircraft contact investigations after receiving reports of travelers on commercial flights with probable or confirmed mpox during their infectious period. Data were collected 1) during 2021, when two isolated clade II mpox cases not linked to an outbreak were imported into the United States by international travelers and 2) for flights arriving in or traveling within the United States during April 30-August 2, 2022, after a global clade II mpox outbreak was detected in May 2022. A total of 113 persons (100 passengers and 13 crew members) traveled on 221 flights while they were infectious with mpox. CDC developed definitions for aircraft contacts based on proximity to mpox cases and flight duration, sent information about these contacts to U.S. health departments, and received outcome information for 1,046 (68%) of 1,538 contacts. No traveler was found to have acquired mpox via a U.S. flight exposure. For persons with mpox and their contacts who had departed from the United States, CDC forwarded contact information as well as details about the exposure event to destination countries to facilitate their own public health investigations. Findings from these aircraft contact investigations suggest that traveling on a flight with a person with mpox does not appear to constitute an exposure risk or warrant routine contact tracing activities. Nonetheless, CDC recommends that persons with mpox isolate and delay travel until they are no longer infectious.

OBJECTIVE: In April 2020, the US Centers for Disease Control and Prevention (CDC) recommended community masking to prevent the transmission of SARS-CoV-2. Since then, a total of 39 US states and DC issued mask mandates. Despite CDC recommendations and supporting evidence that masking reduces COVID-19 community transmission, from January to June 20, 2021 states lifted their mask mandates for all individuals. This study examined the association between lifting state-issued mask mandates and mask-wearing behavior in 2021. DESIGN: We estimated a difference-in-difference model, comparing changes in the likelihood for individuals to wear a mask in states that lifted their mask mandate relative to states that kept their mandates in place between February and June of 2021. SETTING: Individuals were surveyed from across the United States. PARTICIPANTS: We used masking behavior data collected by the Porter Novelli View 360 + national surveys (N = 3459), and data from state-issued mask mandates obtained by CDC and the University of Nevada, Las Vegas. MAIN OUTCOMES: The outcome variable of interest was self-reported mask use during the 30 days prior to the survey data collection. RESULTS: In the overall population, lifting mask mandates did not significantly influence mask-wearing behavior. Mask wearing did significantly decrease in response to the lifting of mask mandates among individuals living in rural counties and individuals who had not yet decided whether they would receive a COVID-19 vaccine. CONCLUSION: Policies around COVID-19 behavioral mitigation, specifically amongst those unsure about vaccination and in rural areas, may help reduce the transmission of COVID-19 and other respiratory viruses, especially in communities with low vaccination rates.

Cross jurisdictional collaboration efforts and emergency vaccine plans that are consistent with Tribal sovereignty are essential to public health emergency preparedness. The widespread adoption of clearly written federal, state, and local vaccine plans that address fundamental assumptions in vaccine distribution to Tribal nations is imperative for future pandemic response.

This article summarizes what is currently known about the 2019 novel coronavirus and offers interim guidance.

The first 2 years of combatting the COVID-19 pandemic necessitated an unprecedented use of emergency powers. States responded with an equally unprecedented flurry of legislative changes to the legal underpinnings of emergency response and public health authorities. In this article, we provide a brief background on the framework and use of governors and state health officials' emergency powers. We then analyze several key themes, including both the enhancement and restriction of powers, emerging from emergency management and public health legislation introduced in state and territorial legislatures. During the 2020 and 2021 state and territorial legislative sessions, we tracked legislation related to the emergency powers of governors and state health officials. Legislators introduced hundreds of bills impacting these powers, some enhancing and others restricting emergency powers. Enhancements included increasing vaccine access and expanding the pool of eligible medical professions that could administer vaccinations, strengthening public health investigation and enforcement authority for state agencies, and preclusion of local orders by orders at the state level. Restrictions included establishing oversight mechanisms for executive actions, limits on the duration of the emergency, limiting the scope of emergency powers allowed during a declared emergency, and other restraints. By describing these legislative trends, we hope to inform governors, state health officials, policymakers, and emergency managers about how changes in the law may impact future public health and emergency response capabilities. Understanding this new legal landscape is critical to effectively preparing for future threats. © 2023 Weston Medical Publishing. All rights reserved.

CONTEXT: Mask mandates are one form of nonpharmaceutical intervention that has been utilized to combat the spread of SARS-CoV2, the virus that causes COVID-19. OBJECTIVE: This study examines the association between state-issued mask mandates and changes in county-level and hospital referral region (HRR)-level COVID-19 hospitalizations across the United States. DESIGN: Difference-in-difference and event study models were estimated to examine the association between state-issued mask mandates and COVID-19 hospitalization outcomes. PARTICIPANTS: All analyses were conducted with US county-level data. INTERVENTIONS: State-issued mask mandates. County-level data on the mandates were collected from executive orders identified on state government Web sites from April 1, 2020, to December 31, 2020. MAIN OUTCOME MEASURES: Daily county-level (and HRR-level) estimates of inpatient beds occupied by patients with confirmed or suspected COVID-19 were collected by the US Department of Health and Human Services. RESULTS: The state issuing of mask mandates was associated with an average of 3.6 fewer daily COVID-19 hospitalizations per 100 000 people (P < .05) and a 1.2-percentage-point decrease in the percentage of county beds occupied with COVID-19 patients (P < .05) within 70 days of taking effect. Event study results suggest that this association increased the longer mask mandates were in effect. In addition, the results were robust to analyses conducted at the HRR level. CONCLUSIONS: This study demonstrated that state-issued mask mandates were associated with reduction in COVID-19 hospitalizations across the United States during the earlier portion of the pandemic. As new variants of the virus cause spikes in COVID-19 cases, reimposing mask mandates in indoor and congested public areas, as part of a layered approach to community mitigation, may reduce the spread of COVID-19 and lessen the burden on our health care system.

Trends in the percentages of the US population covered by state-issued nonpharmaceutical interventions (NPIs), including restaurant and bar restrictions, stay-at-home orders, gathering limits, and mask mandates, were examined by using county-specific data sets on state-issued orders for NPIs from March 1, 2020, to August 15, 2021. Most of the population was covered by multiple NPIs early in the pandemic. Most state-issued orders were lifted or relaxed as COVID-19 cases decreased during summer 2020. Few states reimplemented strict NPIs during later surges in US COVID-19 cases over the winter of 2020-2021. The exceptions were mask mandates, which covered about 80% of the population between August 2020 and February 2021, and the most restrictive gathering limits, which covered a maximum of 66% of the population in early 2020 and 68% of the population in winter 2020-2021. Most NPIs were lifted by the end of the analysis period.

OBJECTIVES: By the end of 2020, 38 states and the District of Columbia had issued requirements that people wear face masks when in public settings to counter SARS-CoV-2 transmission. To examine the role face mask mandates played in economic recovery, we analyzed the interactive effect of having a state face mask mandate in place on county-level consumer spending after state reopening, adjusting for county rates of new COVID-19 cases and deaths, time trends, and county-specific effects. METHODS: We collected county-specific data from state executive orders, consumer spending data from the Opportunity Insights Economic Tracker, and COVID-19 case and death data from the Centers for Disease Control and Prevention COVID-19 tracker. Using an event study approach, we compared county-level changes in consumer spending before and after state-issued closure orders were lifted and assessed the interactive effect of state-issued face mask mandates. RESULTS: The lifting of state-issued closures was associated with an average increase in consumer spending across all counties studied within 1 month. However, the increase was 1.2-1.7 percentage points higher in counties with a state face mask mandate in place than in counties without a state face mask mandate. CONCLUSIONS: In addition to their public health benefits, face mask mandates may have assisted economic recovery during the COVID-19 pandemic, suggesting they are a strong public health strategy for policy makers to consider now and for potential future pandemics arising from airborne viruses.

OBJECTIVES: To assess if state-issued nonpharmaceutical interventions (NPIs) are associated with reduced rates of SARS-CoV-2 infection as measured through anti-nucleocapsid (anti-N) seroprevalence, a proxy for cumulative prior infection that distinguishes seropositivity from vaccination). METHODS: Monthly anti-N seroprevalence during August 1, 2020 - March 30, 2021 was estimated using a nationwide blood donor serosurvey. Using multivariable logistic regression models, we measured the association of seropositivity and state-issued, county-specific NPIs for mask mandates, gathering bans, and bar closures. RESULTS: Compared with individuals living in a county with all three NPIs in place, the odds of having anti-N antibodies were 2.2 (95% CI: 2.0-2.3) times higher for people living in a county that did not have any of the three NPIs, 1.6 (95% CI: 1.5-1.7) times higher for people living in a county that only had a mask mandate and gathering ban policy, and 1.4 (95% CI: 1.3-1.5) times higher for people living in a county that had only a mask mandate. CONCLUSIONS: Consistent with studies assessing NPIs relative to COVID-19 incidence and mortality, the presence of NPIs were associated with lower SARS-CoV-2 seroprevalence indicating lower rates of cumulative infections. Multiple NPIs are likely more effective than single NPIs.

Monkeypox is a rare, sometimes life-threatening zoonotic infection that occurs in west and central Africa. It is caused by Monkeypox virus, an orthopoxvirus similar to Variola virus (the causative agent of smallpox) and Vaccinia virus (the live virus component of orthopoxvirus vaccines) and can spread to humans. After 39 years without detection of human disease in Nigeria, an outbreak involving 118 confirmed cases was identified during 2017-2018 (1); sporadic cases continue to occur. During September 2018-May 2021, six unrelated persons traveling from Nigeria received diagnoses of monkeypox in non-African countries: four in the United Kingdom and one each in Israel and Singapore. In July 2021, a man who traveled from Lagos, Nigeria, to Dallas, Texas, became the seventh traveler to a non-African country with diagnosed monkeypox. Among 194 monitored contacts, 144 (74%) were flight contacts. The patient received tecovirimat, an antiviral for treatment of orthopoxvirus infections, and his home required large-scale decontamination. Whole genome sequencing showed that the virus was consistent with a strain of Monkeypox virus known to circulate in Nigeria, but the specific source of the patient's infection was not identified. No epidemiologically linked cases were reported in Nigeria; no contact received postexposure prophylaxis (PEP) with the orthopoxvirus vaccine ACAM2000.

PURPOSE: Early COVID-19 mitigation relied on people staying home except for essential trips. The ability to stay home may differ by sociodemographic factors. We analyzed how factors related to social vulnerability impact a community's ability to stay home during a stay-at-home order. METHODS: Using generalized, linear mixed models stratified by stay-at-home order (mandatory or not mandatory), we analyzed county-level stay-at-home behavior (inferred from mobile devices) during a period when a majority of United States counties had stay-at-home orders (April 7 to April 20, 2020) with the Centers for Disease Control and Prevention Social Vulnerability Index. RESULTS: Counties with higher percentages of single-parent households, mobile homes, and persons with lower educational attainment were associated with lower stay-at-home behavior compared with counties with lower respective percentages. Counties with higher unemployment, higher percentages of limited-English-language speakers, and more multi-unit housing were associated with increases in stay-at-home behavior compared with counties with lower respective percentages. Stronger effects were found in counties with mandatory orders. CONCLUSIONS: Sociodemographic factors impact a community's ability to stay home during COVID-19 stay-at-home orders. Communities with higher social vulnerability may have more essential workers without work-from-home options or fewer resources to stay home for extended periods, which may increase risk for COVID-19. Results are useful for tailoring messaging, COVID-19 vaccine delivery, and responses to future outbreaks.

CONTEXT: In response to the COVID-19 pandemic, states across the United States implemented various strategies to mitigate transmission of SARS-CoV-2 (the virus that causes COVID-19). OBJECTIVE: To examine the effect of COVID-19-related state closures on consumer spending, business revenue, and employment, while controlling for changes in COVID-19 incidence and death. DESIGN: The analysis estimated a difference-in-difference model, utilizing temporal and geographic variation in state closure orders to analyze their impact on the economy, while controlling for COVID-19 incidence and death. PARTICIPANTS: State-level data on economic outcomes from the Opportunity Insights data tracker and COVID-19 cases and death data from usafacts.org. INTERVENTIONS: The mitigation strategy analyzed within this study was COVID-19-related state closure orders. Data on these orders were obtained from state government Web sites containing executive or administrative orders. MAIN OUTCOME MEASURES: Outcomes include state-level estimates of consumer spending, business revenue, and employment levels. RESULTS: Analyses showed that although state closures led to a decrease in consumer spending, business revenue, and employment, they accounted for only a small portion of the observed decreases in these outcomes over the first wave of COVID-19. CONCLUSIONS: The impact of COVID-19 on economic activity likely reflects a combination of factors, in addition to state closures, such as individuals' perceptions of risk related to COVID-19 incidence, which may play significant roles in impacting economic activity.

CDC recommends a combination of evidence-based strategies to reduce transmission of SARS-CoV-2, the virus that causes COVID-19 (1). Because the virus is transmitted predominantly by inhaling respiratory droplets from infected persons, universal mask use can help reduce transmission (1). Starting in April, 39 states and the District of Columbia (DC) issued mask mandates in 2020. Reducing person-to-person interactions by avoiding nonessential shared spaces, such as restaurants, where interactions are typically unmasked and physical distancing (≥6 ft) is difficult to maintain, can also decrease transmission (2). In March and April 2020, 49 states and DC prohibited any on-premises dining at restaurants, but by mid-June, all states and DC had lifted these restrictions. To examine the association of state-issued mask mandates and allowing on-premises restaurant dining with COVID-19 cases and deaths during March 1-December 31, 2020, county-level data on mask mandates and restaurant reopenings were compared with county-level changes in COVID-19 case and death growth rates relative to the mandate implementation and reopening dates. Mask mandates were associated with decreases in daily COVID-19 case and death growth rates 1-20, 21-40, 41-60, 61-80, and 81-100 days after implementation. Allowing any on-premises dining at restaurants was associated with increases in daily COVID-19 case growth rates 41-60, 61-80, and 81-100 days after reopening, and increases in daily COVID-19 death growth rates 61-80 and 81-100 days after reopening. Implementing mask mandates was associated with reduced SARS-CoV-2 transmission, whereas reopening restaurants for on-premises dining was associated with increased transmission. Policies that require universal mask use and restrict any on-premises restaurant dining are important components of a comprehensive strategy to reduce exposure to and transmission of SARS-CoV-2 (1). Such efforts are increasingly important given the emergence of highly transmissible SARS-CoV-2 variants in the United States (3,4).

BACKGROUND AND OBJECTIVE: Community mitigation strategies could help reduce COVID-19 incidence. In a national county-level analysis, we examined the probability of being identified as a county with rapidly increasing COVID-19 incidence (rapid riser identification) during the summer of 2020 by implementation of mitigation policies prior to the summer, overall and by urbanicity. METHODS: We analyzed county-level data on rapid riser identification during June 1-September 30, 2020 and statewide closures and statewide mask mandates starting March 19 (obtained from state government websites). Poisson regression models with robust standard error estimation were used to examine differences in the probability of rapid riser identification by implementation of mitigation policies (P-value<.05); associations were adjusted for county population size. RESULTS: Counties in states that closed for 0-59 days were more likely to become a rapid riser county than those that closed for >59 days, particularly in nonmetropolitan areas. The probability of becoming a rapid riser county was 43% lower among counties that had statewide mask mandates at reopening (adjusted prevalence ratio [aPR] = 0.57; 95% confidence intervals [CI] = 0.51-0.63); when stratified by urbanicity, associations were more pronounced in nonmetropolitan areas. CONCLUSIONS: These results underscore the potential value of community mitigation strategies in limiting the COVID-19 spread, especially in nonmetropolitan areas.

SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is transmitted predominantly by respiratory droplets generated when infected persons cough, sneeze, spit, sing, talk, or breathe. CDC recommends community use of face masks to prevent transmission of SARS-CoV-2 (1). As of October 22, 2020, statewide mask mandates were in effect in 33 states and the District of Columbia (2). This study examined whether implementation of statewide mask mandates was associated with COVID-19-associated hospitalization growth rates among different age groups in 10 sites participating in the COVID-19-Associated Hospitalization Surveillance Network (COVID-NET) in states that issued statewide mask mandates during March 1-October 17, 2020. Regression analysis demonstrated that weekly hospitalization growth rates declined by 2.9 percentage points (95% confidence interval [CI] = 0.3-5.5) among adults aged 40-64 years during the first 2 weeks after implementing statewide mask mandates. After mask mandates had been implemented for ≥3 weeks, hospitalization growth rates declined by 5.5 percentage points among persons aged 18-39 years (95% CI = 0.6-10.4) and those aged 40-64 years (95% CI = 0.8-10.2). Statewide mask mandates might be associated with reductions in SARS-CoV-2 transmission and might contribute to reductions in COVID-19 hospitalization growth rates, compared with growth rates during <4 weeks before implementation of the mandate and the implementation week. Mask-wearing is a component of a multipronged strategy to decrease exposure to and transmission of SARS-CoV-2 and reduce strain on the health care system, with likely direct effects on COVID-19 morbidity and associated mortality.

Hurricanes can destroy or overwhelm communities and cause or exacerbate health conditions. Legal mechanisms and practices may aid or impede hurricane response. In the United States, where states have primary public health responsibility, state governors possess legal powers to address hurricanes. They often exercise these powers using executive orders and proclamations-legal mechanisms that direct public and private parties. Although executive orders and proclamations are critical for hurricane preparedness and response, how governors use them to respond to hurricanes is not fully understood. Using legal epidemiology, we systematically identified and analyzed hurricane-related executive orders and proclamations issued in the United States from January 1, 2006, through December 31, 2018. We found 468 relevant executive orders and proclamations, 14% of which were issued, at least in part, to benefit a jurisdiction other than the issuer's state. We observed variations in when and where such orders and proclamations were issued. Executive orders and proclamations were most commonly used to direct government response or recovery (32%), handle and administer government resources (31%), and suspend legal requirements perceived to inhibit response (27%). Fewer orders and proclamations regulated private parties (10%). Understanding how governors use executive orders and proclamations to respond to hurricanes can bolster future preparedness and response efforts.

National Preparedness month is observed every September as a public service reminder of the importance of personal and community preparedness for all events; it coincides with the peak of the hurricane season in the United States. Severe storms and hurricanes can have long-lasting effects at all community levels. Persons who are prepared and well-informed are often better able to protect themselves and others (1). Major hurricanes can devastate low-lying coastal areas and cause injury and loss of life from storm surge, flooding, and high winds (2). State and local government entities play a significant role in preparing communities for hurricanes and by evacuating coastal communities before landfall to reduce loss of life from flooding, wind, and power outages (3). Laws can further improve planning and outreach for catastrophic events by ensuring explicit statutory authority over evacuations of communities at risk (4). State evacuation laws vary widely and might not adequately address information and communication flows to reach populations living in disaster-prone areas who are at risk. To understand the range of evacuation laws in coastal communities that historically have been affected by hurricanes, a systematic policy scan of the existing laws supporting hurricane evacuation in eight southern coastal states (Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, and Texas) was conducted. After conducting a thematic analysis, this report found that all eight states have laws to execute evacuation orders, traffic control (egress/ingress), and evacuation to shelters. However, only four of the states have laws related to community outreach, delivery of public education programs, and public notice requirements. The findings in this report suggest a need for authorities in hurricane-prone states to review how to execute evacuation policies, particularly with respect to community outreach and communication to populations at risk. Implementation of state evacuation laws and policies that support hurricane evacuation management can help affected persons avoid harm and enhance community resiliency (5). Newly emerging and re-emerging infectious diseases, such as SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), have and will continue to additionally challenge hurricane evacuations.

SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is thought to spread from person to person primarily by the respiratory route and mainly through close contact (1). Community mitigation strategies can lower the risk for disease transmission by limiting or preventing person-to-person interactions (2). U.S. states and territories began implementing various community mitigation policies in March 2020. One widely implemented strategy was the issuance of orders requiring persons to stay home, resulting in decreased population movement in some jurisdictions (3). Each state or territory has authority to enact its own laws and policies to protect the public's health, and jurisdictions varied widely in the type and timing of orders issued related to stay-at-home requirements. To identify the broader impact of these stay-at-home orders, using publicly accessible, anonymized location data from mobile devices, CDC and the Georgia Tech Research Institute analyzed changes in population movement relative to stay-at-home orders issued during March 1-May 31, 2020, by all 50 states, the District of Columbia, and five U.S. territories.* During this period, 42 states and territories issued mandatory stay-at-home orders. When counties subject to mandatory state- and territory-issued stay-at-home orders were stratified along rural-urban categories, movement decreased significantly relative to the preorder baseline in all strata. Mandatory stay-at-home orders can help reduce activities associated with the spread of COVID-19, including population movement and close person-to-person contact outside the household.

Community mitigation activities (also referred to as nonpharmaceutical interventions) are actions that persons and communities can take to slow the spread of infectious diseases. Mitigation strategies include personal protective measures (e.g., handwashing, cough etiquette, and face coverings) that persons can use at home or while in community settings; social distancing (e.g., maintaining physical distance between persons in community settings and staying at home); and environmental surface cleaning at home and in community settings, such as schools or workplaces. Actions such as social distancing are especially critical when medical countermeasures such as vaccines or therapeutics are not available. Although voluntary adoption of social distancing by the public and community organizations is possible, public policy can enhance implementation. The CDC Community Mitigation Framework (1) recommends a phased approach to implementation at the community level, as evidence of community spread of disease increases or begins to decrease and according to severity. This report presents initial data from the metropolitan areas of San Francisco, California; Seattle, Washington; New Orleans, Louisiana; and New York City, New York* to describe the relationship between timing of public policy measures, community mobility (a proxy measure for social distancing), and temporal trends in reported coronavirus disease 2019 (COVID-19) cases. Community mobility in all four locations declined from February 26, 2020 to April 1, 2020, decreasing with each policy issued and as case counts increased. This report suggests that public policy measures are an important tool to support social distancing and provides some very early indications that these measures might help slow the spread of COVID-19.

Emergency declarations are a vital legal authority that can activate funds, personnel, and material and change the legal landscape to aid in the response to a public health threat. Traditionally, declarations have been used against immediate and unforeseen threats such as hurricanes, tornadoes, wildfires, and pandemic influenza. Recently, however, states have used emergency declarations to address public health issues that have existed in communities for months and years and have risk factors such as poverty and substance misuse. Leaders in these states have chosen to use emergency powers that are normally reserved for sudden catastrophes to address these enduring public health issues. This article will explore emergency declarations as a legal mechanism for response; describe recent declarations to address hepatitis A and the opioid overdose epidemic; and seek to answer the question of whether it is appropriate to use emergency powers to address public health issues that are not traditionally the basis for an emergency declaration.

Public Health Laboratories (PHLs) in Puerto Rico did not escape the devastation caused by Hurricane Maria. We implemented a quality management system (QMS) approach to systematically reestablish laboratory testing, after evaluating structural and functional damage. PHLs were inoperable immediately after the storm. Our QMS-based approach began in October 2017, ended in May 2018, and resulted in the reestablishment of 92% of baseline laboratory testing capacity. Here, we share lessons learned from the historic recovery of the largest United States' jurisdiction to lose its PHL capacity, and provide broadly applicable tools for other jurisdictions to enhance preparedness for public health emergencies.

Legal Perspectives is aimed at informing healthcare providers, emergency planners, public health practitioners, and other decision makers about important legal issues related to public health and healthcare preparedness and response. The articles describe these potentially challenging topics and conclude with the authors' suggestions for further action. The articles do not provide legal advice. Therefore, those affected by the issues discussed in this column should seek further guidance from legal counsel. Readers may submit topics of interest to the column's editor, Lainie Rutkow, JD, PhD, MPH, at lrutkow@jhu.edu. This article describes and analyzes the body of emergency preparedness, response, and recovery litigation that has arisen since the September 11, 2001, terrorist attacks. Search terms were developed to identify judicial opinions related to emergency preparedness, response, and recovery activities. Using the Thomson Reuters Westlaw legal database, searches were conducted to collect judicial opinions related to disasters that occurred in the United States between September 11, 2001, and December 31, 2015. An electronic form was used for data abstraction. Cases that did not directly involve emergency response, preparedness, or recovery activities were excluded. Data were summarized with descriptive statistics. We identified 215 cases for data abstraction. Many of the cases stemmed from preparedness, response, and recovery activities related to hurricanes (57.7%) and terrorist attacks (16.7%). The most prevalent emergency response activities at issue were disaster mitigation (29.3%), disaster clean-up (21.9%), a defendant's duty to plan (14.4%), evacuation (12.6%), and conditions of incarceration (12.1%). Although it can be anticipated that litigation will arise out of all phases of disaster preparedness, response, and recovery, policymakers can anticipate that the most litigation will result from pre-event mitigation and post-event recovery activities, and allocate resources accordingly.

Legal Perspectives is aimed at informing healthcare providers, emergency planners, public health practitioners, and other decision makers about important legal issues related to public health and healthcare preparedness and response. The articles describe these potentially challenging topics and conclude with the authors' suggestions for further action. The articles do not provide legal advice. Therefore, those affected by the issues discussed in this column should seek further guidance from legal counsel. Readers may submit topics of interest to the column's editor, Lainie Rutkow, JD, PhD, MPH, at lrutkow@jhu.edu. Governors play a fundamental role in emergency preparedness and can help facilitate rapid responses to emergencies. However, laws that operate successfully under normal circumstances can inadvertently create barriers during emergencies, delaying a timely response. State laws could thus limit, or even prohibit, necessary response efforts. To combat this risk, legislatures have passed emergency powers laws in each state granting governors the authority to declare a state of emergency and to exercise certain emergency powers to meet the needs of the emergency. Researchers conducted a 50-state legal assessment, which identified and examined state laws that give governors the discretion to modify existing laws or create new laws to respond effectively to any type of declared emergency. This article outlines the findings of that assessment, which identified 35 states that explicitly permit governors to suspend or amend both statutes and regulations; 7 states in which governors are permitted to amend regulations during a declared emergency but are not explicitly authorized to modify or remove statutes; and 8 states and the District of Columbia that provide no explicit authority to governors to change statutes or regulations during a declared emergency. The article also provides examples of how this power has been used in the past to demonstrate the utility and scope of this authority in a variety of public health threats.

Hurricane Maria made landfall in Puerto Rico on September 20, 2017, causing major damage to infrastructure and severely limiting access to potable water, electric power, transportation, and communications. Public services that were affected included operations of the Puerto Rico Department of Health (PRDOH), which provides critical laboratory testing and surveillance for diseases and other health hazards. PRDOH requested assistance from CDC for the restoration of laboratory infrastructure, surveillance capacity, and diagnostic testing for selected priority diseases, including influenza, rabies, leptospirosis, salmonellosis, and tuberculosis. PRDOH, CDC, and the Association of Public Health Laboratories (APHL) collaborated to conduct rapid needs assessments and, with assistance from the CDC Foundation, implement a temporary transport system for shipping samples from Puerto Rico to the continental United States for surveillance and diagnostic and confirmatory testing. This report describes the initial laboratory emergency response and engagement efforts among federal, state, and nongovernmental partners to reestablish public health laboratory services severely affected by Hurricane Maria. The implementation of a sample transport system allowed Puerto Rico to reinitiate priority infectious disease surveillance and laboratory testing for patient and public health interventions, while awaiting the rebuilding and reinstatement of PRDOH laboratory services.

Disasters can come from unforeseeable sources and create unforeseeable problems. The nation’s response system is built to be flexible and responsive to all threats, including those we cannot predict. As a result, federal, state, and local governments adopted the National Incident Management System (NIMS), a framework developed by the U.S. Department of Homeland Security, for responding to all forms of emergencies, including terrorist attacks,1 natural disasters,2 oil spills,3 and emerging infectious diseases.4 NIMS’s defining characteristics—a clear chain of command and flexible organizational structure—allow it to adapt to any situation.5 | | While NIMS creates a clear structure for emergency response, state and local responders must still operate within their respective jurisdiction’s legal system. The law establishes both the powers and limitations for how government officials protect citizens’ health and well-being.6 While many laws have been drafted specifically for the benefit of responding to disasters,7 complex and inflexible legal structures might impede efficient and effective responses.8 To minimize this impact, streamlined and flexible legal systems are vital to address the unforeseeable circumstances that disasters create.9 Centralized emergency response authorities and emergency declarations can act more efficiently than separate groups of officials and various types of emergency declarations.10 Further, an adaptable legal system requires the ability to remove legal barriers. A streamlined and adaptable emergency response legal system allows disaster responders to react as quickly and efficiently as possible in our world of ever-changing threats.11

OBJECTIVES: In all health system sectors, electronic health information (EHI) is created, used, released, and reused. We examined states' efforts to address EHI uses in law to provide an understanding of the EHI legal environment. METHODS: Attorney researchers used WestlawNext to search for EHI-related statutes and regulations of the US states, US territories, and the District of Columbia in effect as of January 2014. The researchers independently catalogued provisions by the EHI use described in the law. Researchers resolved discrepancies through peer review meetings and recorded the consensus codes for each law. RESULTS: This study identified 2364 EHI-related laws representing 49 EHI uses in 54 jurisdictions. A total of 18 EHI uses were regulated by ≥10 jurisdictions. More than 750 laws addressed 2 or more EHI uses. Jurisdictions varied by the number of EHI laws in effect, with a mean of 44 laws. Texas had the most EHI laws (n = 145). Hawaii and South Carolina had the fewest (n = 14 each). CONCLUSIONS: The EHI legal landscape is complex. The large quantity and diversity of laws complicate legal analysis, likely delay implementation of public health solutions, and might be detrimental to the development of emerging health information technology. Research is needed to understand the effect of EHI-related laws.

The 2014 Ebola epidemic is the largest epidemic of Ebola virus disease in history, with current widespread transmission in three countries in West Africa: Guinea, Liberia, and Sierra Leone.2 As of this writing, there have been four confirmed cases of Ebola in the United States.3 Public health and healthcare lawyers are addressing complicated legal issues, including concerns related to states’ authority to quarantine individuals who are infected with or have been exposed to Ebola, along with issues related to the Emergency Medical Treatment and Labor Act, the privacy and security of information, and vaccine liability.

Planning, simulations, and post-emergency assessments have demonstrated that successful public health emergency response hinges on the effective use of relevant legal authorities for legal preparedness.1 Public health practitioners must have a better understanding of the legal underpinnings of emergency preparedness and response systems, including knowing what actions are authorized and how to minimize liabilities during large-scale public health emergencies.2 In May 2015, the Public Health Law Program (PHLP) at the Centers for Disease Control and Prevention (CDC) embarked on a unique effort to train state and local public health personnel on the intricacies of legal issues in emergency preparedness and response over the course of one summer. This course was also offered to CDC staff because knowledge regarding state and local legal issues in emergencies is vital to their ability to work with partners in the field. | By August, PHLP staff had travelled to 11 states and delivered 13 Public Health Emergency Law 4.0 trainings to nearly 550 people. The summer road trip was exciting and enlightening and made the case for providing future public health law trainings.

Tribes are sovereign nations that maintain a government-to-government relationship with the Unites States.2 There are currently 567 federally recognized tribes throughout the contiguous United States and Alaska.3 As sovereign nations, tribal authority cannot be infringed upon by states;4 however, the U.S. Supreme Court has held that Congress holds the authority to legislate on issues related to tribes and American Indians and Alaska Natives.5 The federal government also maintains a trust responsibility towards tribes based on treaties, agreements, statutes, and case law.6 This trust responsibility, known as the Trust Doctrine, is “a legally enforceable fiduciary obligation on the part of the United States to protect tribal treaty rights, lands, assets, and resources, as well as a duty to carry out the mandates of federal law with respect to American Indian and Alaska Native tribes and villages.”7 | In addition to political sovereignty, tribes exercise cultural sovereignty in the form of traditions and religious practices unique to each tribe’s own history and culture.8 “[C]ultural sovereignty encompasses the spiritual, emotional, mental, and physical aspects” of native people’s lives and serves as a foundation to tribal exercise of political sovereignty.9

The 2014–2015 Ebola virus disease (Ebola) outbreak in West Africa is the largest in history, and as of October 4, 2015, had claimed 11,297 lives in Guinea, Liberia, and Sierra Leone (1). On August 7, 2014, CDC first posted guidance on monitoring and movement of persons who might have been exposed to Ebola virus to prevent the spread of Ebola into the United States. Since that time, the Interim U.S. Guidance for Monitoring and Movement of Persons with Potential Ebola Virus Exposure (2) has been regularly updated based on the latest information available, most recently on May 13, 2015. On October 11, 2014, after the first case of Ebola was diagnosed in the United States, entry screening was implemented in five U.S. airports to identify travelers from countries with widespread Ebola transmission who might have been exposed to Ebola during the days before arrival or who had signs or symptoms of Ebola at the time of arrival (3). | On October 24, 2014, New York and New Jersey, both home to airports conducting entry screening, announced monitoring and movement policies for incoming travelers returning from Ebola-affected countries (4). The New York and New Jersey policies included mandatory quarantine for any person who had direct contact with a person with Ebola while in one of the Ebola-affected countries, including any medical personnel who had provided medical services for persons infected with Ebola, as well as active monitoring and possible quarantine for all persons with travel history to the affected countries, including those who had no direct contact with an infected person (4).