The U.S. experienced its worst measles outbreak in a quarter-century in 2025, thousands of cases of a disease once considered to be eliminated. Measles vaccination rates are below recommended levels throughout the country. There were more pediatric deaths from flu in 2025 than in any other year in the two decades they have been tracked with the exception of the 2009-2010 avian flu pandemic. Nearly 9 out of 10 of the children who died were not fully vaccinated.
A hantavirus outbreak on a cruise ship carrying American passengers, a surge in Dengue fever cases and the first human death from avian flu are all recent examples of the continually shifting public health landscape.
At the same time, a changing climate is altering the character and frequency of natural disasters that threaten humans and life-sustaining infrastructure alike. Extreme heat causes more fatalities than any other weather event; the U.S. heat wave season is now 46 days longer than it was in the 1960s.
The 2026 Ready or Not report from Trust for America’s Health (TFAH) offers a summary of the challenges public health departments face at this time and an assessment of their readiness to meet them. Using a scorecard based on indicators including workforce resilience, health security surveillance, investments in preparedness and vaccination coverage, it ranked state emergency preparedness in three performance tiers: high, middle and low. These rankings are accompanied by an exhaustive list of state and federal action and policy recommendations.
Key Points:
- Only 20 states scored well enough to be in the “high performance” tier. The authors note that even they show “room for improvement.” Thirteen were ranked as “low performance” due to factors including the state of public health investment, patient safety, avoidable mortality rates and vaccination coverage. (See map for rankings.)
- Federal funding has made up a significant portion of state and local public health budgets in the past. State funding will be more important than ever as federal allocations and grants are cut back.
- Higher rates of illness and death from influenza and measles are associated with lower vaccination rates. The flu vaccination rate during the last flu season was estimated at 44 percent, well short of the 70 percent target. Ninety percent of children under 5 who contracted measles in 2025 were unvaccinated. Recent changes in federal vaccine recommendations have raised concerns in the public health community; the American Public Health Association has said that changes in the childhood schedule put “families at risk.” TFAH recommends congressional oversight of immunization schedules.
- In the face of increasing risks from weather disasters, states should assess their climate vulnerability and make adaptation plans using the Centers for Disease Control and Prevention's Building Resilience Against Climate Effects Framework. TFAH urges that the Department of Health and Human Services have a dedicated office “focused on addressing climate-related health impacts.”
