Interim Local Health Department Strategy for Response, Control, and Prevention of Healthcare Associated Infections (HAI) and Antibiotic Resistance (AR)

Download the LHD HAI/AR Strategy Action Planning Worksheet Template [Excel – 457 KB] to plan and track your list of prioritized goals, objectives, and activities.

View the Guide for Facilitating Conversations with the state HAI/AR programs pdf icon[PDF – 3 Pages] for guidance on engaging your state HAI/AR program and other partners that have a role in HAI/AR across your jurisdiction.

Introduction

View the LHD HAI/AR Strategy One-Pager for a quick reference to the LHD HAI/AR Strategy

Local Health Department Strategy for HAI/AR One-Pager pdf icon[PDF – 1 Page]

Each day, approximately 1 in 31 U.S. hospital patients and 1 in 43 nursing home residents has a healthcare associated infection (HAI). In addition, on any given day, about half of hospital patients and 1 in 12 nursing home residents receive an antimicrobial medication [1]. HAIs can have devastating effects on physical, mental, emotional, and financial health. They cost billions of dollars in added expenses to the healthcare system annually. Research suggests that a growing number of HAIs are caused by pathogens (germs) that are outsmarting the antimicrobial medications typically used to fight them. These are known as antibiotic-resistant germs. Inappropriate or unnecessary use of antimicrobial medications contributes to the development of antibiotic resistance. More than 2.8 million antibiotic-resistant infections occur in the U.S. each year, and more than 35,000 people die as a result, also costing billions annually in healthcare costs [2]. While much progress has been made to reduce the spread of HAI and AR threats, more needs to be done to prevent HAIs and AR in a variety of healthcare and community settings. Local, territorial, and state health departments have a critical role in coordinating, implementing, and leveraging regional HAI/AR prevention and response efforts, including the promotion of antibiotic stewardship. For more information on HAI and AR visit CDC’s Healthcare-Associated Infections page and Antibiotic/Antimicrobial Resistance page.

[1] https://www.cdc.gov/hai/eip/antibiotic-use.html

[2] https://www.cdc.gov/drugresistance/about.html

Strategy Background

CDC’s Division of Healthcare Quality Promotion (DHQP) developed a strategy for local health departments (LHDs). The strategy is being developed to highlight and support the important role that LHDs play in preventing, responding to, and controlling HAI and AR related events. The COVID-19 pandemic has further highlighted the important and unique role of LHDs.

Funding and support to HAI/AR programs, primarily at state health departments, has increased greatly over the last few decades and contributes to HAI/AR capacity building in LHDs. Since 1995, the Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases (ELC) Cooperative Agreement has been critical to U.S. health departments’ ability to combat infectious diseases. ELC currently funds all 50 states, 6 LHDs, and U.S. territories and affiliates.

NACCHO and CDC HAI/AR Capacity Building Projects

With support from CDC, the National Association of City and County Health Officials (NACCHO) also provides funding and support to LHDs for HAI/AR prevention. Visit NACCHO’s Emerging Infectious Disease Grant Dashboardexternal icon to view a map of LHDs that have received funding for HAI/AR prevention and capacity building.

In 2011, NACCHO began funding a small number of LHDs through the HAI/AR demonstration site projectexternal icon to support LHD capacity for HAI prevention and response. The demonstration site project has since funded a total of 9 LHDs. In 2016, NACCHO funded an additional 11 LHDs through the Lessons in Infection Control (LINC)external icon project and 34 LHDs through the Certification in Infection Control (CIC) Scholarship Programexternal icon to improve local capacity and staff education for infection control. The COVID-19 pandemic further highlighted the important role of LHDs in responding to outbreaks and mitigating the spread of infections. To support local efforts to respond to the pandemic, NACCHO and CDC launched Building Local Operational Capacity for COVID-19external icon (BLOC COVID-19) which funded a total of 25 LHDs in 2020 and will provide additional funding to select LHDs in 2022 through Building Local Operational Capacity for COVID-19, Healthcare-Associated Infections, and Antimicrobial Resistance (BLOC COVID-19 +)external icon. Additional COVID-19 investments funded supplements to ELC to respond to the pandemic. These supplements include:

  • CDC’s Project Firstline, which provides infection control training for frontline healthcare and public health personnel.
  • The Coronavirus Aid, Relief and Economic Security (CARES) Act, which establishes and monitors key activities related to COVID-19 in the areas of epidemiology, laboratory, and informatics.
  • Enhancing Detection funding, which supports a broad range of COVID-19/SARS-CoV-2 testing and surveillance activities.
  • The American Rescue Plan (ARP) Act of 2021, which provides supplemental funding for Strengthening HAI/AR Program Capacity (SHARP) to improve infection prevention and control activities across the U.S. public health and healthcare sectors with enhanced guidance for directing support to LHDs.

Visit the ELC HAI/AR Program Funded Activities webpage to learn more about CDC investments to support state, local, and territorial health departments.

Piloting and implementation of the HAI/AR LHD strategy is not tied to specific funding at this time but is intended to complement and support these investments and provide a framework for HAI/AR activities in local jurisdictions of all levels.

CDC’s Vision for Enhancing Local HAI/AR Capacity:

Goal 1: Grow Networks & Collaboration. Goal 2: Build Operational Capacity. Goal 3: Expand Programmatic Activities.

Figure 1: LHD HAI/AR Strategic Goals

CDC’s vision is to strengthen LHD capacity to respond to, control, and prevent HAI/AR across all healthcare settings and in the community by supporting enhanced coordination between state and local partners and by promoting local public health, healthcare, and community partner networks. We can achieve this vision together with collaboration between local, state, and federal public health entities, and partners. This strategy aims to strengthen LHDs by focusing on three main goals:

  1. Growing strong partner networks;
  2. Building internal operational capacity; and
  3. Expanding the scope of programmatic activities to effectively address HAI/AR in their jurisdictions.

See Figure 1 and Table 1 for the strategic goals and objectives to help LHDs and their partners realize this vision.

What is the Strategy?

The strategy includes recommended goals, objectives, and activities based on an assessment of the key roles that LHDs could play in the response, control, and prevention of HAI/AR. The strategic goals and objectives are meant to be a guide to help LHDs plan and implement the HAI/AR activities appropriate for their jurisdiction. The strategy is intended to demonstrate how LHDs are part of the network of HAI/AR prevention activities and the ways these programs can contribute to the overall landscape of HAI/AR work. It is not intended for locals (or states) to be required to use the strategy; however, it is offered as a useful tool for developing and strengthening LHDs in HAI/AR prevention and response.

Creating the Strategy

To create the strategy, CDC first reviewed relevant research, such as NACCHO’s Profile of LHDs pdf icon[PDF – 147 Pages]external icon, to better understand the various types of LHDs and their current role in HAI/AR work. CDC then conducted a series of landscape assessments on various topics to further explore the varying capacity of LHDs. Topics for these data-driven reviews included governance structures, size of populations served, partner networks, emergency preparedness and response, and health equity. Findings from these data driven reviews were used to provide recommendations for informing the goals, objectives, and activities within the strategy. CDC reviewed these findings and discussion questions with key stakeholders throughout development of the strategy. CDC worked in close collaboration with NACCHO to develop the strategy and received input from CDC staff with previous experience working in LHDs. CDC interviewed a total of eight LHDs and two state health departments representing a variety of population sizes served and governance structures to review and provide input on the goals, objectives, and activities within the strategy. The strategic goals and objectives were shared with state health departments. CDC will continue to incorporate feedback from state and LHDs while the strategy is in an interim format through a pilot period.

Who Can Use this Strategy?

The strategy is designed to support public health professionals who are planning, leading, or coordinating HAI/AR activities at the local level.  The specific users may vary depending on structures within states. For example, this strategy could be used by LHDs, or by local health jurisdictions, districts, or units who have responsibility for HAI/AR prevention, control, and response [3]. For convenience, throughout this document we will refer to any local health entities within a state, as LHDs. While the strategy is intended for use at local levels, to successfully investigate, prevent, and monitor HAIs and AR, LHDs should communicate the use of the strategy with their state HAI/AR programs to ensure maximum understanding and alignment of efforts. Outbreaks and antibiotic-resistant germs do not recognize jurisdictional boundaries. A local case can quickly have much broader implications as patients, residents and healthcare staff move between healthcare facilities and in the community. State and LHDs may also leverage the Success Framework for HAI/AR Partner Networks for recommendations on building and enhancing their partner networks.

When Should the Strategy be Used?

The strategy can be used when LHDs are ready to examine and strengthen their HAI/AR capabilities. The strategy can be revisited annually in close collaboration with key partners, such as the state HAI/AR program.

Roles of Local Public Health

Why LHDs?
The strategy focused on LHDs because they…

  • Are the frontline of public health
  • Connect federal, state, and local partners
  • Are well-positioned to educate and convene healthcare facilities
  • Play a vital role in infection prevention, control, and response
  • Often have authority for public health action and policies
  • Have unique relationships to local healthcare facilities and partners
  • Have knowledge of the local culture

LHDs play important roles in the prevention and control of HAI/AR in their jurisdictions. The particular HAI/AR activities that are conducted by LHDs vary widely and depend on many factors such as staff capacity and expertise, governance structures and public health authorities, prevalence of emerging HAI/AR diseases, types and organization of healthcare facilities in the jurisdiction, population demographics, local relationships, and nature of collaborations with the state HAI/AR program. While the specific activities and responsibilities of LHDs will vary, the unique roles and assets of LHDs make them critical players in the prevention and control of HAI/AR infections. LHDs can build relationships in their local communities and may be well-positioned to understand and respond to the health needs of their communities.  There is much to be learned and many best practices to be shared from LHDs working in HAI/AR.  To learn more about the role of LHDs in addressing HAIs, watch this Addressing Healthcare-Associated Infections: The Role of Local Health Departments Videoexternal icon.

[3] ELC funded cities should first follow the ELC guidance but may consider use of this framework for self-assessment or strategic planning, if desired.

Table 1: Strategic Goals and Objectives for LHDs

Goal 1: Grow and expand networks across state, regional, and local levels through increased LHD communication and collaboration within the public health sector and among public-private sector partners.

Goal 1: Grow and expand networks across state, regional, and local levels through increased LHD communication and collaboration within the public health sector and among public-private sector partners.

  • Objective 1.1: Engage with the state HAI/AR program to determine priorities, state and local roles and responsibilities when working together, and to maintain coordination between the LHD and the state.
  • Objective 1.2: Grow and sustain relationships between healthcare and public health at the local level tailored to meet the LHD’s, healthcare facilities’, and providers’ needs.
  • Objective 1.3: Engage public health, healthcare, academic, and community partners in growing the partnership network to prevent HAI/AR in all patient populations within the local jurisdiction.
  • Objective 1.1: Engage with the state HAI/AR program to determine priorities, state and local roles and responsibilities when working together, and to maintain coordination between the LHD and the state.
  • Objective 1.2: Grow and sustain relationships between healthcare and public health at the local level tailored to meet the LHD’s, healthcare facilities’, and providers’ needs.
  • Objective 1.3: Engage public health, healthcare, academic, and community partners in growing the partnership network to prevent HAI/AR in all patient populations within the local jurisdiction.

Goal 2: Build LHD operational capacity to conduct and promote sustainable HAI/AR infection prevention and control activities.

Goal 2: Build LHD operational capacity to conduct and promote sustainable HAI/AR infection prevention and control activities.

  • Objective 2.1: Increase local public health staff capacity, expertise, and confidence to conduct HAI/AR activities, in alignment with the overall state HAI/AR program strategy.
  • Objective 2.2: Increase local public health awareness of the latest HAI/AR guidance, data, programs, and policies that impact their community.
  • Objective 2.3: Increase interjurisdictional infrastructure and sustainability of local HAI/AR infection prevention and control activities, in alignment with the overall state or regional strategy.
  • Objective 2.4: Develop and/or update local healthcare preparedness and response plans to have capacity for responding to emerging HAI/AR threats and outbreaks.
  • Objective 2.1: Increase local public health staff capacity, expertise, and confidence to conduct HAI/AR activities, in alignment with the overall state HAI/AR program strategy.
  • Objective 2.2: Increase local public health awareness of the latest HAI/AR guidance, data, programs, and policies that impact their community.
  • Objective 2.3: Increase interjurisdictional infrastructure and sustainability of local HAI/AR infection prevention and control activities, in alignment with the overall state or regional strategy.
  • Objective 2.4: Develop and/or update local healthcare preparedness and response plans to have capacity for responding to emerging HAI/AR threats and outbreaks.

Goal 3: Expand LHD HAI/AR infection prevention, outbreak response, and stewardship activities using data for action and prioritizing activities that increase impact on health equity.

Goal 3: Expand LHD HAI/AR infection prevention, outbreak response, and stewardship activities using data for action and prioritizing activities that increase impact on health equity.

  • Objective 3.1: Implement HAI/AR outbreak and response strategies using data to identify appropriate participation in local, regional, and state-wide approaches.
  • Objective 3.2: Implement infection prevention activities using available data to tailor and focus efforts.
  • Objective 3.3: Implement antibiotic stewardship activities using data to tailor and focus efforts.
  • Objective 3.4: Support HAI/AR activities that promote health equity and are aligned with state health equity priorities.
  • Objective 3.1: Implement HAI/AR outbreak and response strategies using data to identify appropriate participation in local, regional, and state-wide approaches.
  • Objective 3.2: Implement infection prevention activities using available data to tailor and focus efforts.
  • Objective 3.3: Implement antibiotic stewardship activities using data to tailor and focus efforts.
  • Objective 3.4: Support HAI/AR activities that promote health equity and are aligned with state health equity priorities.

How to Use the Strategy

Visit the Framework for Implementing the LHD HAI/AR Strategy webpage for instructions on using the strategy. We recommend considering the following steps when a LHD is ready to assess and strengthen HAI/AR capacity.

  1. Become familiar with the strategy goals, objectives, and activities
  2. Assess current capacity
  3. Develop an action plan

Importance of Coordinating with the State HAI/AR Program

Successful HAI/AR prevention and response requires coordination and collaboration between LHDs and state HAI/AR programs. HAIs do not recognize jurisdictional boundaries and a local case can quickly have much broader implications as patients and healthcare staff move between facilities and in the community. Through the Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases (ELC) cooperative agreement, CDC funds 64 jurisdictions (50 states, 6 large cities, and 8 territory health departments) to detect, prevent, and respond to the growing threats posed by infectious diseases. As part of ELC, all states have an HAI/AR program that is responsible for developing state level HAI/AR priorities and plans. Each state also has an HAI/AR Advisory Committee charged with making recommendations to the state on the prevention of HAIs. LHDs are encouraged to learn about the work of the HAI/AR Advisory Committees in their states and potentially get involved in the committee or its subcommittees. To learn about your state’s HAI/AR plan and to contact your state HAI/AR coordinator, visit the State-based HAI Prevention Activities webpage. To help guide conversations with states, CDC developed a Guide for Facilitating Conversations with state HAI/AR programs pdf icon[PDF – 3 Pages]. This guide will serve as a tool for engaging your state HAI/AR program or other partners that have a role in HAI/AR across your jurisdiction.

To further understand the scope of HAI/AR work at the local level and determine unique roles and responsibilities in the state and local context, we recommend initiating a conversation with the state HAI/AR program. The Success Framework for HAI/AR Partner Networks can be used as a resource for navigating these conversations. For a more in depth analysis of local HAI/AR activities, LHDs can consider using the Success Framework as a supplemental resource to guide discussions and planning with partners.

LHD HAI/AR Activities

The strategy uses three levels of activities for each objective.

  • Level 1 activities form the foundational components for each objective and may be more suited for LHDs with little to no experience leading HAI/AR activities.
  • Level 2 activities build upon level 1 and may be more suited for LHDs with previous experience leading HAI/AR activities.
  • Level 3 activities build upon levels 1 and 2 and may be more suited for LHDs with extensive experience leading HAI/AR activities.

Read through the goals, objectives, and activities. Click on each level to see a list of recommended activities.

These objectives and activities are inherently interrelated and while activities have been separated out across objective areas, there may be overlap between activities and in some cases, replication of types of activities across different goal areas.  When creating an action plan, activities can be viewed as supporting multiple objective or goals.

Goal 1: Grow and expand networks across state, regional, and local levels through increased LHD communication and collaboration within the public health sector and among public-private sector partners.

Networks represent effective and sustainable communication and collaboration between partners working to advance HAI/AR activities.

Select the Open All or Close All buttons to view or close the full list of activities.

Objective 1.1: Engage with the State HAI/AR program to determine priorities, state and local roles and responsibilities when working together, and to maintain coordination between the LHD and the state.
Not sure where to start?

Be sure you can say “yes” to all level one activities before moving on.

Objective 1.2: Grow and sustain relationships between healthcare and public health at the local level tailored to meet the LHD’s, healthcare facilities’, and providers’ needs.
Objective 1.3: Engage public health, healthcare, academic, and community partners in growing the partnership network to prevent HAI/AR in all patient populations within the local jurisdiction.

Goal 2: Build LHD operational capacity to conduct and promote sustainable HAI/AR infection prevention and control activities.

Select the Open All or Close All buttons to view or close the full list of activities.

Objective 2.1: Increase local public health staff capacity, expertise, and confidence to conduct HAI/AR activities, in alignment with the overall state HAI/AR program strategy.
Not sure where to start?

Be sure you can say “yes” to all level one activities before moving on.

Objective 2.2: Increase local public health awareness of the latest HAI/AR guidance, data, programs, and policies that impact your community.
Objective 2.3: Increase interjurisdictional infrastructure and sustainability of local HAI/AR infection prevention and control activities, in alignment with the overall state or regional strategy (see also Goal 1, objective 1.3).
Objective 2.4: Develop and/or update local healthcare preparedness and response plans to have capacity for responding to healthcare outbreaks.

Goal 3: Expand LHD HAI/AR infection prevention, outbreak response, and stewardship activities using data for action and prioritizing activities that increase impact on health equity.

Select the Open All or Close All buttons to view or close the full list of activities.

Objective 3.1: Implement HAI/AR outbreak and response strategies using data to identify appropriate participation in local, regional, and state-wide approaches.
Not sure where to start?

Be sure you can say “yes” to all level one activities before moving on.

Objective 3.2: Implement infection prevention activities using available data to tailor and focus efforts.
Objective 3.3: Implement antibiotic stewardship activities using data to tailor and focus efforts.
Objective 3.4: Support HAI/AR activities that promote health equity and are aligned with state health equity priorities.

Visit the Framework for Implementing the LHD HAI/AR Strategy webpage page for instructions on how to use this strategy to assess health department capacity and create a customized action plan.