“Winnable Battles” in Public Health

Winnable Battles are public heath priorities that target some of the nation’s major health challenges. The Centers for Disease Control and Prevention (CDC) selects public health topics, often in support of Department of Health and Human Services (HHS) initiatives, with the goal of ending epidemics, eliminating diseases and securing America’s preparedness and global health. The Winnable Battles framework focuses on identifying important health issues, setting priorities that have a large-scale impact and implementing evidence-based solutions. CDC and its public health partners aim to make significant progress to address major challenges in a relatively short timeframe by utilizing the most feasible and cost-effective strategies.


Adverse Childhood Experiences (ACEs)

Image of three types of ACEs include Abuse, Neglect and HouseholdAdverse Childhood Experiences (ACEs) are potentially traumatic events that occur before a child reaches the age of 18. The CDC Vital Signs Report on ACEs notes one in six adults have experienced four or more ACEs, while half of the top ten leading causes of death are associated with ACEs. Research has linked adverse experiences to negative health and social outcomes throughout a lifetime, such as unemployment, depression, and cancer. The lifetime economic burden of child abuse and neglect, which comprise five of ten ACEs, is estimated at approximately $401 billion. Fortunately, there are certain protective factors that can help prevent and manage the long-term impacts of ACEs.

State Role:  
Efforts that focus on building healthy families early in the life of a child are cited as among the most influential means of preventing ACEs and reducing their damaging effects. State policies may include strategies to help parents reduce stress, build resilience in children and families, and increase screening and treatment for ACEs. 

NCSL Resources:
Blog, New CDC Report: Preventing Adverse Childhood Experiences Could Reduce Leading Causes of Death
Brief, Preventing and Mitigating the Effects of Adverse Childhood Experiences
Legislative Database, Injury Prevention
Webinar, Opioids and Early Adversity: Connecting Childhood Trauma and Addiction
Webinar, Brain Science: Interventions and policy Implications for Serving Parents and Children
Podcast, Brain Development and Childhood Adversity
Brief, State Strategies for Preventing Child and Adolescent Injuries and Violence

Other Resources:
CDC:
   - Report, Preventing Adverse Childhood Experiences (ACEs): Leveraging the Best Available Evidence 
   - Technical Package, Preventing Child Abuse and Neglect
   - Vital Signs Report, Adverse Childhood Experiences (ACEs)
   - Infographic, Adverse Childhood Experiences
   - Fact Sheet, Essentials for Childhood Framework 
   - Fact Sheet, Children Benefit When Parents Have Safe, Stable, Nurturing Relationships

Association of State and Territorial Health Officials (ASTHO):
   - Podcast, Looking Upstream: The Impact of Preventing Adverse Childhood Experiences
   - State Spotlight, One Approach to Screening for Adverse Childhood Experiences in Delaware
   - Webinar, Primary Prevention of Adverse Childhood Experiences
   - Brief, Adverse Childhood Experiences: Primary Prevention
   - Podcast, Building Healthy and Resilient Communities Across America
   - Blog, State Public Health Strategies for Preventing Adverse Childhood Experiences
   - Blog, Adverse Childhood Experiences Legislation
   - Policy Guide, Essentials for Childhood


HIV and Infectious Consquences of opioids

Communities and states are experiencing an increase in communicable and infectious diseases, including human immunodeficiency virus (HIV), due to a rise in intravenous drug use. HIV weakens a person’s immune system and can lead to acquired immunodeficiency syndrome (AIDS) if left untreated. More than 1.1 million people in the United States are living with HIV, and just under 40,000 are diagnosed each year. Nearly 15 percent of those affected are unaware of their infection. No effective cure exists for HIV, but with proper medical care, HIV can be managed. A federal initiative, Ending the HIV Epidemic: A Plan for America, seeks to reduce the number of new HIV infections in the United States by 75 percent within five years, and then by at least 90 percent within ten years. Supporting the national strategy, the CDC Division of HIV/AIDS Prevention (DHAP) focuses on high-impact prevention following the Strategic Plan 2017-2020, which seeks to prevent new infections, improve outcomes for those living with HIV, and reduce HIV-related disparities and health inequities

State Role:
Prevention is key to mitigate effects of infectious diseases. State strategies to prevent and manage HIV and infectious consequences of opioids can include increased HIV testing and awareness, syringe services programs, enhanced surveillance and improved access to and funding for prevention and treatment medications.

red ribbon

NCSL Resources:
Webpage, Opioid-Related Issues
Webpage, Hepatitis C: Overview
Legisbrief, Treating Hepatitis C
Legislative Database, Prescription Drugs

Other Resources:
CDC: 
   - Webpage, Syringe Services Programs (SSPs)
   - Infographic, Addressing the Infectious Disease Consequences of the U.S. Opioid Crisis
   - Webpage, Opioid Overdose
   - Webpage, HIV Elimination
   - Webpage, Viral Hepatitis

ASTHO:
   - Blog, State Legislation to Increase Access and Fund HIV Prevention Strategies
   - Podcast, Seeing the Possible: A Conversation with CDC Director Robert Redfield 
   - Blog, State Legislation Aimed at Preventing Hepatitis A Outbreaks Linked to Illicit Drug Use
   - Blog, Health Departments are Key to Eliminating Hepatitis in the United States
   - Webinar, Infectious Disease Consequences of Opioid Use
   - Webinar, Addressing Viral Hepatitis A Outbreaks
   - Case Study, Addressing HIV and Drug Use in Indiana: A Systems Approach
   - Brief, Reducing Opioid-Associated Risks: Key Opportunities and Successes in Kentucky and West Virginia


Hypertension

Cardiovascular disease (CVD) is a leading cause of morbidity, mortality and high health costs across the country. Two types of CVD, heart disease and stroke, are among the top causes of death in the United States. Though preventable, hypertension, or high blood pressure, is a major risk factor for a variety of cardiovascular diseases. According to CDC, about one in three U.S. adults have high blood pressure while about half of these adults have their high blood pressure under control. Hypertension has no warning symptoms and many people do not know they have it. Fortunately, there are steps to prevent high blood pressure and control it if it is already high. 

State Role:  
Policymakers may consider a variety of options to reduce the prevalence and costs of hypertension and related diseases. Strategies may include improving access to quality health services, increasing blood pressure awareness and management through screenings, enhancing health system partnerships and promoting heart-healthy behavioral changes. 

NCSL Resources:
Legisbrief, Reducing the Prevalence and Costs of Heart Disease
Webpage, Heart Disease and Stoke – An Overview of Our Nation’s Leading Killers  
Postcard, Leading Causes of Death in Rural America 

Other Resources:
CDC:    
   - Guide, Best Practices for Cardiovascular Disease Prevention Programs
   - Policy Resources, Division for Heart Disease and Stroke Prevention 
   - Webpage, Million Hearts
   - Morbidity and Mortality Weekly Report, State-Level Variation in Nonfatal and Fatal Cardiovascular Events Targeted for Prevention by Million Hearts 2022 

ASTHO:
   - Tools and Resources, Heart Disease and Stroke
   - Brief, Systems Change Approaches for Engaging Families in Hypertension Control
   - Podcast, Community Health Workers: System Catalysts in Addressing Hypertension 

Health and Human Services:
   - Webpage, Million Hearts 
   - Map, Potential Future Burden of Cardiovascular Events Targeted for Prevention by Million Hearts 2022 


Antibiotic Resistance

Antibiotics, or antimicrobial drugs, are medicines used to prevent and treat bacterial infections. When bacteria are left to grow and multiply after being exposed to an antibiotic, they can develop the ability to defeat the drugs designed to kill them. There are several ways bacteria can become resistant, but overuse and misuse of antibiotics can increase the number of drug-resistant bacteria. CDC reports more than 2.8 million people are infected with antibiotic-resistant bacteria or fungi each year, and more than 35,000 people die as a result. Resistant infections are difficult and sometimes impossible to treat, and generally require costly and extended hospital services. Several efforts, including those by the Federal Drug Administration (FDA), have been launched to address antibiotic resistance.

Prescription pill bottlesState Role:  
Early action can keep germs with unusual resistance from spreading through health care facilities and causing hard-to-treat infections. Stopping the spread of antibiotic resistance saves lives. Ongoing vigilance may include improved prescribing practices and antibiotic use, rapid identification, coordinated responses and active screening measures. . 

NCSL Resources:
Frequently Asked Questions, Hospital Acquired Infections

Other Resources:
CDC:
   - Global Project, Investing to Protect the U.S. and World against Antibiotic Resistance
   - Webpage, Antibiotic Prescribing and Use in Hospitals and Long-Term Care 
   - Vital Signs Report, Staph Infections
   - Vital Signs Report, Containing Unusual Resistance
   - State Fact Sheets:

ASTHO:
   - Toolkit, Healthcare-Associated Infections and Antibiotic Resistance
   - Blog, State Legislation Addressing Antibiotic Resistance
   - Blog, State Legislation to Prevent Antibiotic Resistant Infections
   - Webpage, State Health Agency Antimicrobial Resistance and Stewardship Webpages


Opioid Misuse Prevention

Prescription opioids are used to treat moderate to severe pain, and can provide effective pain management when correctly prescribed and taken as directed. However, prescription opioids can also be misused and lead to addiction, death, and job loss among other health and social problems. Opioid overdoses are on the rise, fueled by a misuse of both prescription (methadone, oxycodone, hydrocodone) and illicit (fentanyl and heroine) opioids. In 2017, nearly three out of every four deaths involved opioids, prompting the Department of Health and Human Services (HHS) to declare a public health emergency. HHS developed a five-point comprehensive strategy in response, which includes: (1) better addiction prevention, treatment and recovery services; (2) better data; (3) better pain management; (4) better targeting of overdose reversing drugs; and (5) better research.

State Role:  
Improving prescribing practices and the way pain is treated can help prevent opioid misuse, addiction and overdose. States may limit opioid prescriptions, increase the use of prescription drug monitoring programs, improve access to naloxone and enhance provider education and training among other measures.

NCSL Resources:prescription pills
Legislative Database, Opioid Abuse Prevention
Webpage, Prescribing Policies: States Confront Opioid Overdose Epidemic
Brief, Prescription for Pain Management – 10 State Strategies  
Legisbrief, Preventing Prescription Drug Abuse
Legisbrief, Using Prescription Drug Monitoring Programs to Address Drug Abuse
Legisbrief, Methadone and Prescription Drug Overdose  

Other Resources:
CDC:
   - Fact Sheet, Opioid Guidelines for Healthcare Providers
   - Report, Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States
   - Overview, CDC Rx Awareness Campaign  

ASTHO:
   - Podcast, The Epidemic of Epidemics: Opioids, Part I and Part II
   - Webpage, Preventing Opioid Misuse and Overdose in the States and Territories


Vaccine Preventable Diseases

Vaccines play a crucial role in preventing certain deadly diseases by protecting the individual and the larger population. Some diseases like polio and diphtheria have become rare in the United States thanks to vaccines. Not only does vaccination reduce the incidence of diseases and protect those who cannot be vaccinated, it also reduces social and economic burdens. An ASTHO Immunization Resource Guide reports that for each $1 spent on childhood vaccines, more than $10 is saved in direct costs. Like many public health programs, immunization initiatives are invisible when they are working well. Outbreaks highlight the critical role vaccines play in our public health system and the importance of following recommended immunization schedules. CDC provides a strategic framework, Vaccinate with Confidence, to protect communities, empower families and stop myths eroding the public trust in vaccines.

State Role:  
All 50 states have school entry requirements for vaccinations and all feature medical exemptions. Recent state action focuses on promoting increased coverage rates by eliminating personal belief exemptions, strengthening vaccine requirements and promoting better education and communication about vaccines. 

NCSL Resources:
Webpage, Immunizations Policy Issues Overview 
Webpage, States with Religious and Philosophical Exemptions from School Immunization Requirements
Legisbrief, State Vaccination Policies: Requirements and Exemptions for Entering School 

Other Resources:
CDC:
   - Webpage, Vaccine Preventable Disease
   - Webpage, Vaccines & Immunizations
   - Webpage, Vaccine Safety 

ASTHO:
   - Immunization Resource Guide
   - Program, Immunization Project
   - Webpage, Communicating Effectively About Vaccines


Obesity

Increasing obesity rates reflect a growing epidemic across the United States. The latest annual State of Obesity report by Trust for America’s Health reported historically high levels throughout the country. About one in three Americans of all ages have obesity and levels are closely tied to social and economic conditions. Obesity prevalence is highest in certain minority communities, areas that are more likely to have few options for healthy foods and physical activity, and are often the target of widespread marketing for unhealthy foods. Obesity is linked to a variety of serious health conditions and is estimated to drive approximately $149 billion in annual medical costs. Despite a country-wide increase in obesity rates, some communities have experienced improvements thanks to strengthened policies and programs.

State Role:  
There are several strategies designed to improve access to nutritious foods and provide safe opportunities for physical activities. States may consider policies that strengthen nutrition supports for low-income families, change the way unhealthy foods and beverages are priced and marketed, and build and expand access to safe environments.

NCSL Resources:
Report, State Actions to Reduce and Prevent Childhood Obesity in Schools and Communities
Legisbrief, Improving the Supplemental Nutrition Assistance Program 
Guide, Feeding Hungry Children 
Webpage, Health Reform and Health Mandates for Obesity 

Other Resources:
Trust for America’s Health:
   - Webpage, Obesity
   - Fact Sheet, State of Obesity 2019

CDC:
   - Webpage, Overweight & Obesity
   - Webpage, Strategies to Prevent Obesity 
   - Division of Nutrition, Physical Activity, and Obesity

ASTHO:
   - Blog, To Combat the Childhood Obesity Epidemic, States and Territories Leverage School Nutrition and Physical Activity Policies
   - Podcast, Preventing Childhood Obesity Through Healthy Communities 


Additional Resources

NCSL Resources:

CDC Resources:

Other Resources:

  •  The Community Guide: A collection of evidence-based findings of the Community Preventative Services Task Force, establish by HHS and supported by CDC, intended to improve health directly, prevent or reduce risky behaviors and diseases, and promote healthy behaviors and environments. 
  •  Healthy People 2020: Healthy People provides science-based, 10-year national objectives for improving the health of all Americans. Healthy People 2020 has more than 1,200 objectives, including Winnable Battles topics.