For decades, the tireless dedication of our public health agencies has saved countless lives by mitigating the spread of disease. The Centers for Disease Control and Prevention (CDC) response to COVID-19, though, highlighted both organizational and operational challenges. Informed by feedback from hundreds of internal and external interviews, CDC announced an agency-wide effort—Moving Forward—to share science faster, to translate science into practical policy, to strengthen partnerships, to communicate better, and to be a more effective public health response agency (1). As CDC’s transformation began, numerous esteemed groups similarly opined on pandemic lessons learned; the position paper from the American College of Physicians (ACP) in this issue of Annals of Internal Medicine speaks to the future of public health from the physician perspective (2), complementing other reviews. Herein, we specifically highlight budget, workforce, and data.

The U.S. Covid-19 vaccination strategy was simple: get safe and effective vaccines into arms as quickly as possible by making them free and accessible. This strategy worked: more than 670 million Covid-19 vaccine doses had been administered to more than 270 million Americans by the end of the national public health emergency. As we look toward the fall, Covid-19 vaccines — the most effective tool for preventing severe disease — will largely be moving to the commercial market, where access to vaccines is often limited for adults without health insurance. | | In keeping with its pandemic-long goal of promoting equitable access to Covid-19 vaccines, the Biden administration in April 2023 introduced the Health and Human Services Bridge Access Program for Covid-19 Vaccines and Treatments to cover Covid-19 vaccines for uninsured people through 2024. Conceived of as a temporary solution until a more comprehensive vaccine-access plan can be authorized and funded by Congress, the program would utilize more than $1 billion of Covid-19 funds to distribute Covid-19 vaccines to state and local health departments and associated providers, clinics supported by the Health Resources and Services Administration (HRSA), and pharmacies. The fact that this program had to be created from scratch — with funding identified, contracts modified, and timelines and end points designated — speaks to the need for a sustainable, comprehensive vaccine program for uninsured adults, to provide protection against vaccine-preventable diseases for both eligible participants and the general public.

Long before joining the Centers for Disease Control and Prevention (CDC)—from my perch as an academic infectious disease physician researcher—I was endlessly grateful for the tireless efforts of the epidemiologists, laboratory scientists, physicians, behavioral scientists, statisticians, communicators, and countless other professionals who work in the field of public health every day. | My appreciation has only grown in the 2 years since I was sworn in as director of CDC and administrator of the Agency for Toxic Substances and Disease Registry and became so closely involved in the agency’s mission to promote a national and global infrastructure of public health. From this seat—through meetings and in one-on-one conversations with colleagues; state, tribal, and local partners; community- and faith-based organizations; and the many individuals devoted to promoting health—I have had the privilege of witnessing every day the power of public health to do good and to protect the lives of millions of people in this country and around the world. | When public health is working well, no one notices. But the once-in-a-century challenge presented by COVID-19 pushed public health into the spotlight. | The COVID-19 pandemic turned out to be what I have been calling the “Superman” moment of public health. In early 2020, we were engaged in our valuable, powerful, day-to-day work. Then, in one dizzying moment, we were called on to enter a telephone booth, don our figurative capes, and emerge as superheroes with the tools to fight COVID-19. While we had knowledge and experience in epidemiology, outbreak response, and behavioral science, we did not have all the answers to the questions posed by this new, unknown health threat. But in those figurative capes, we—the public health community—stood together to confront the most enormous public health challenge of our lifetimes. We rose to the incredible occasion that we trained for, but never asked for, and hoped would never become a reality.

Since SARS-CoV-2 was first identified, the world has witnessed more than 641 million confirmed cases of COVID-19, resulting in more than 6.6 million deaths (1). The global spread of the virus and the resulting destruction of lives and livelihoods brought into sharp focus the interconnectedness of local, domestic, and global public health infrastructure and the global need for a trusted, resilient public health workforce to overcome systemic inequities. | | As the public health agency for the United States, the Centers for Disease Control and Prevention (CDC) invests in global and domestic public health to improve core public health capabilities. CDC collaborates with partners in the interdependent global public health ecosystem to strengthen the systems needed for disease surveillance and reporting, diagnostic testing, outbreak and pandemic responses, and clinical service delivery, including treatment, immunizations, and infection prevention and control.

Intradermal vaccination delivers antigen into the space between the epidermis and the dermis. This space is an anatomically favorable site for immune stimulation, enriched in a heterogenous population of dendritic cells, macrophages, and monocytes that endow this tissue with a potent capacity to detect and respond robustly to immunologic stimuli, including those present in vaccines. For these reasons, the role of the dermis in adaptive immunity has been exploited for allergen testing and tuberculosis skin testing. And smallpox vaccination was developed by Jenner using something similar to intradermal administration: variolation, or the practice of scratching immunizing material into the skin.

BACKGROUND: Pediatric international travelers account for nearly half of measles importations in the United States. Over one third of pediatric international travelers depart the United States without the recommended measles-mumps-rubella (MMR) vaccinations: 2 doses for travelers 12 months and 1 dose for travelers 6 to <12 months. METHODS: We developed a model to compare 2 strategies among a simulated cohort of international travelers (6 months to <6 years): (1) No pretravel health encounter (PHE): travelers depart with baseline MMR vaccination status; (2) PHE: MMR-eligible travelers are offered vaccination. All pediatric travelers experience a destination-specific risk of measles exposure (mean, 30 exposures/million travelers). If exposed to measles, travelers' age and MMR vaccination status determine the risk of infection (range, 3%-90%). We included costs of medical care, contact tracing, and lost wages from the societal perspective. We varied inputs in sensitivity analyses. Model outcomes included projected measles cases, costs, and incremental cost-effectiveness ratios ($/quality-adjusted life year [QALY], cost-effectiveness threshold $100 000/QALY). RESULTS: Compared with no PHE, PHE would avert 57 measles cases at $9.2 million/QALY among infant travelers and 7 measles cases at $15.0 million/QALY among preschool-aged travelers. Clinical benefits of PHE would be greatest for infants but cost-effective only for travelers to destinations with higher risk for measles exposure (ie, 160 exposures/million travelers) or if more US-acquired cases resulted from an infected traveler, such as in communities with limited MMR coverage. CONCLUSIONS: Pretravel MMR vaccination provides the greatest clinical benefit for infant travelers and can be cost-effective before travel to destinations with high risk for measles exposure or from communities with low MMR vaccination coverage.

BACKGROUND: The HIV Prevention Trials Network (HPTN) 083 trial demonstrated the superiority of long-acting injectable cabotegravir (CAB-LA) compared with oral emtricitabine-tenofovir disoproxil fumarate (F/TDF) for HIV preexposure prophylaxis (PrEP). OBJECTIVE: To identify the maximum price premium (that is, greatest possible price differential) that society should be willing to accept for the additional benefits of CAB-LA over tenofovir-based PrEP among men who have sex with men and transgender women (MSM/TGW) in the United States. DESIGN: Simulation, cost-effectiveness analysis. DATA SOURCES: Trial and published data, including estimated HIV incidence (5.32, 1.33, and 0.26 per 100 person-years for off PrEP, generic F/TDF and branded emtricitabine-tenofovir alafenamide (F/TAF), and CAB-LA, respectively); 28% 6-year PrEP retention. Annual base-case drug costs: $360 and $16800 for generic F/TDF and branded F/TAF. Fewer side effects with branded F/TAF versus generic F/TDF were assumed. TARGET POPULATION: 476700 MSM/TGW at very high risk for HIV (VHR). TIME HORIZON: 10 years. PERSPECTIVE: Health care system. INTERVENTION: CAB-LA versus generic F/TDF or branded F/TAF for HIV PrEP. OUTCOME MEASURES: Primary transmissions, quality-adjusted life-years (QALYs), costs (2020 U.S. dollars), incremental cost-effectiveness ratios (ICERs; U.S. dollars per QALY), maximum price premium for CAB-LA versus tenofovir-based PrEP. RESULTS OF BASE-CASE ANALYSIS: Compared with generic F/TDF (or branded F/TAF), CAB-LA increased life expectancy by 28000 QALYs (26000 QALYs) among those at VHR. Branded F/TAF cost more per QALY gained than generic F/TDF compared with no PrEP. At 10 years, CAB-LA could achieve an ICER of at most $100000 per QALY compared with generic F/TDF at a maximum price premium of $3700 per year over generic F/TDF (CAB-LA price <$4100 per year). RESULTS OF SENSITIVITY ANALYSIS: In a PrEP-eligible population at high risk for HIV, rather than at VHR (n = 1906800; off PrEP incidence: 1.54 per 100 person-years), CAB-LA could achieve an ICER of at most $100000 per QALY versus generic F/TDF at a maximum price premium of $1100 per year over generic F/TDF (CAB-LA price <$1500 per year). LIMITATION: Uncertain clinical and economic benefits of averting future transmissions. CONCLUSION: Effective oral PrEP limits the additional price society should be willing to pay for CAB-LA. PRIMARY FUNDING SOURCE: FHI 360; Eunice Kennedy Shriver National Institute of Child Health and Human Development; National Institute of Allergy and Infectious Diseases; National Heart, Lung, and Blood Institute; National Institute on Drug Abuse; the Reich HIV Scholar Award; and the Steve and Deborah Gorlin MGH Research Scholars Award.

One year after the first authorized COVID-19 vaccine was administered in the US, the nation celebrates a historic achievement in vaccine development and delivery. In 12 months, more than an estimated 200 million people in the US have completed their primary vaccine series. Vaccination has prevented millions of COVID-19 cases and hospitalizations and saved hundreds of thousands of lives. A report released in December 2021 by the Office of the Assistant Secretary of Planning and Evaluation highlights the large effects of vaccine on health, and also the estimated social value of avoiding COVID-19 hospitalizations and deaths.1

On December 11, 2020, the US reached an extraordinary milestone in the efforts to end the COVID-19 pandemic: the Food and Drug Administration authorized emergency use of the first COVID-19 vaccine, manufactured by Pfizer-BioNTech. Since then, 2 additional COVID-19 vaccines, Moderna and Janssen (Johnson & Johnson), have received Emergency Use Authorization in the US and, as of March 8, 2021, more than 31 million people, or 9.4% of the total population, have completed a vaccination series.1

On January 10, 2020, the first genomic sequence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) isolated from a patient in Wuhan, China, was posted online. As of February 3, 2021, 468 000 sequences of SARS-CoV-2 from COVID-19 cases globally have been uploaded into publicly available data-bases, including more than 93 000 from individuals in the US. SARS-CoV-2, like other RNA viruses, constantly changes through mutation, with new variants occurring over time. Generally, when new variants become more common, they do so because of some selective advantage to the virus. Among the numerous SARS-CoV-2 variants that have been detected, only a very small proportion are of public health concern because they are more transmissible, cause more severe illness, or can elude the immune response that develops following infection and possibly from vaccination. In the recent months, 3 specific viral lineages reflecting variants of concern have emerged and merit close monitoring: B.1.1.7, B.1.351, and P.1.

Communication interventions to enhance linkage to HIV care have been successful in sub-Saharan Africa but have not been assessed among refugees. Refugees and Ugandan nationals participating in HIV testing in Nakivale Refugee Settlement were offered weekly phone call and short message service (SMS) reminders. We assessed linkage to care and predictors of linkage within 90 days of testing, comparing Intervention participants to those unwilling or ineligible to participate (Non-Intervention). Of 208 individuals diagnosed with HIV, 101 (49%) participated in the intervention. No difference existed between Intervention and Non-intervention groups in linkage to care (73 [72%] vs. 76 [71%], p = 0.88). Excluding those who linked prior to receipt of intervention, the intervention improved linkage (69 [68%] vs. 50 [47%], p = 0.002). Participants were more likely to link if they were older (aOR 2.39 [1.31, 4.37], p = 0.005) or Ugandan nationals (aOR 3.76 [1.12, 12.66], p = 0.033). Although the communication intervention did not significantly improve linkage to HIV care, the linkage was improved when excluding those with same-day linkage. Excluding participants without a phone was a significant limitation; these data are meant to inform more rigorous designs moving forward. Innovative methods to improve linkage to HIV care for this vulnerable population are urgently needed.

Importance: The US population is experiencing a resurgence of measles, with more than 1000 cases during the first 6 months of 2019. Imported measles cases among returning international travelers are the source of most US measles outbreaks, and these importations can be reduced with pretravel measles-mumps-rubella (MMR) vaccination of pediatric travelers. Although it is estimated that children account for less than 10% of US international travelers, pediatric travelers account for 47% of all known measles importations. Objective: To examine clinical practice regarding MMR vaccination of pediatric international travelers and to identify reasons for nonvaccination of pediatric travelers identified as MMR eligible. Design, Setting, and Participants: This cross-sectional study of pediatric travelers (ages >/=6 months and <18 years) attending pretravel consultation at 29 sites associated with Global TravEpiNet (GTEN), a Centers for Disease Control and Prevention-supported consortium of clinical sites that provide pretravel consultations, was performed from January 1, 2009, through December 31, 2018. Main Outcomes and Measures: Measles-mumps-rubella vaccination among MMR vaccination-eligible pediatric travelers. Results: Of 14602 pretravel consultations for pediatric international travelers, 2864 travelers (19.6%; 1475 [51.5%] males; 1389 [48.5%] females) were eligible to receive pretravel MMR vaccination at the time of the consultation: 365 of 398 infants aged 6 to 12 months (91.7%), 2161 of 3623 preschool-aged travelers aged 1 to 6 years (59.6%), and 338 of 10581 school-aged travelers aged 6 to 18 years (3.2%). Of 2864 total MMR vaccination-eligible travelers, 1182 (41.3%) received the MMR vaccine and 1682 (58.7%) did not. The MMR vaccination-eligible travelers who did not receive vaccine included 161 of 365 infants (44.1%), 1222 of 2161 preschool-aged travelers (56.5%), and 299 of 338 school-aged travelers (88.5%). We observed a diversity of clinical practice at different GTEN sites. In multivariable analysis, MMR vaccination-eligible pediatric travelers were less likely to be vaccinated at the pretravel consultation if they were school-aged (model 1: odds ratio [OR], 0.32 [95% CI, 0.24-0.42; P < .001]; model 2: OR, 0.26 [95% CI, 0.14-0.47; P < .001]) or evaluated at specific GTEN sites (South: OR, 0.06 [95% CI, 0.01-0.52; P < .001]; West: OR, 0.10 [95% CI, 0.02-0.47; P < .001]). The most common reasons for nonvaccination were clinician decision not to administer MMR vaccine (621 of 1682 travelers [36.9%]) and guardian refusal (612 [36.4%]). Conclusions and Relevance: Although most infant and preschool-aged travelers evaluated at GTEN sites were eligible for pretravel MMR vaccination, only 41.3% were vaccinated during pretravel consultation, mostly because of clinician decision or guardian refusal. Strategies may be needed to improve MMR vaccination among pediatric travelers and to reduce measles importations and outbreaks in the United States.

BACKGROUND: Measles importations and the subsequent spread from US travelers returning from abroad are responsible for most measles cases in the United States. Increasing measles-mumps-rubella (MMR) vaccination among departing US travelers could reduce the clinical impact and costs of measles in the United States. METHODS: We designed a decision tree to evaluate MMR vaccination at a pretravel health encounter (PHE), compared with no encounter. We derived input parameters from Global TravEpiNet data and literature. We quantified Riskexposure to measles while traveling and the average number of US-acquired cases and contacts due to a measles importation. In sensitivity analyses, we examined the impact of destination-specific Riskexposure, including hot spots with active measles outbreaks; the percentage of previously-unvaccinated travelers; and the percentage of travelers returning to US communities with heterogeneous MMR coverage. RESULTS: The no-encounter strategy projected 22 imported and 66 US-acquired measles cases, costing $14.8M per 10M travelers. The PHE strategy projected 15 imported and 35 US-acquired cases at $190.3M per 10M travelers. PHE was not cost effective for all international travelers (incremental cost-effectiveness ratio [ICER] $4.6M/measles case averted), but offered better value (ICER <$100 000/measles case averted) or was even cost saving for travelers to hot spots, especially if travelers were previously unvaccinated or returning to US communities with heterogeneous MMR coverage. CONCLUSIONS: PHEs that improve MMR vaccination among US international travelers could reduce measles cases, but are costly. The best value is for travelers with a high likelihood of measles exposure, especially if the travelers are previously unvaccinated or will return to US communities with heterogeneous MMR coverage.

PURPOSE: To assess the optimal age at which a one-time HIV screen should begin for adolescents and young adults (AYA) in the U.S. without identified HIV risk factors, incorporating clinical impact, costs, and cost-effectiveness. METHODS: We simulated HIV-uninfected 12-year-olds in the U.S. without identified risk factors who faced age-specific risks of HIV infection (.6-71.3/100,000PY). We modeled a one-time screen ($36) at age 15, 18, 21, 25, or 30, each in addition to current U.S. screening practices (30% screened by age 24). Outcomes included retention in care, virologic suppression, life expectancy, lifetime costs, and incremental cost-effectiveness ratios in $/year-of-life saved (YLS) from the health-care system perspective. In sensitivity analyses, we varied HIV incidence, screening and linkage rates, and costs. RESULTS: All one-time screens detected a small proportion of lifetime infections (.1%-10.3%). Compared with current U.S. screening practices, a screen at age 25 led to the most favorable care continuum outcomes at age 25: proportion diagnosed (77% vs. 51%), linked to care (71% vs. 51%), retained in care (68% vs. 44%), and virologically suppressed (49% vs. 32%). Compared with the next most effective screen, a screen at age 25 provided the greatest clinical benefit, and was cost-effective ($96,000/YLS) by U.S. standards (<$100,000/YLS). CONCLUSIONS: For U.S. AYA without identified risk factors, a one-time routine HIV screen at age 25, after the peak of incidence, would optimize clinical outcomes and be cost-effective compared with current U.S. screening practices. Focusing screening on AYA ages 18 or younger is a less efficient use of a one-time screen among AYA than screening at a later age.

Background: Measles outbreaks continue to occur in the United States and are mostly due to infections in returning travelers. Objective: To describe how providers assessed the measles immunity status of departing U.S. adult travelers seeking pretravel consultation and to assess reasons given for nonvaccination among those considered eligible to receive the measles, mumps, rubella (MMR) vaccine. Design: Observational study in U.S. pretravel clinics. Setting: 24 sites associated with Global TravEpiNet (GTEN), a Centers for Disease Control and Prevention-funded consortium. Patients: Adults (born in or after 1957) attending pretravel consultations at GTEN sites (2009 to 2014). Measurements: Structured questionnaire completed by traveler and provider during pretravel consultation. Results: 40 810 adult travelers were included; providers considered 6612 (16%) to be eligible for MMR vaccine at the time of pretravel consultation. Of the MMR-eligible, 3477 (53%) were not vaccinated at the visit; of these, 1689 (48%) were not vaccinated because of traveler refusal, 966 (28%) because of provider decision, and 822 (24%) because of health systems barriers. Most MMR-eligible travelers who were not vaccinated were evaluated in the South (2262 travelers [65%]) or at nonacademic centers (1777 travelers [51%]). Nonvaccination due to traveler refusal was most frequent in the South (1432 travelers [63%]) and in nonacademic centers (1178 travelers [66%]). Limitation: These estimates could underrepresent the opportunities for MMR vaccination because providers accepted verbal histories of disease and vaccination as evidence of immunity. Conclusion: Of U.S. adult travelers who presented for pretravel consultation at GTEN sites, 16% met criteria for MMR vaccination according to the provider's assessment, but fewer than half of these travelers were vaccinated. An increase in MMR vaccination of eligible U.S. adult travelers could reduce the likelihood of importation and transmission of measles virus. Primary Funding Source: Centers for Disease Control and Prevention, National Institutes of Health, and the Steve and Deborah Gorlin MGH Research Scholars Award.