In an extraordinary break from the federal government, the public health departments of at least three states and New York City are joining the global alert network of the World Health Organization, spurred by President Donald Trump’s decision to remove the United States from the United Nations agency responsible for coordinating international public health.

So far, the state public health departments in California, Illinois, New York, as well as the public health agency in New York City, have joined the Global Outbreak Alert and Response Network (GOARN), which is part of the World Health Organization (WHO). The U.S. officially left the WHO this past January.

California joined GOARN in January, while Illinois, New York state and New York City joined last month.

GOARN, which includes more than 310 national public health agencies, United Nations agencies, academic institutions, and nongovernmental groups, helps identify and manage infectious disease outbreaks worldwide. Since it was established in 2000, GOARN says it has helped manage more than 175 global health emergencies across 114 countries.

GOARN maintains relationships with some medical and research institutions in the U.S., including the Tulane University School of Public Health and Tropical Medicine in New Orleans and university medical centers in Nebraska and Texas. Until now, however, state public health agencies have not been members, because they relied on the U.S. government’s participation in GOARN for information on global outbreaks.

Dr. Ali Khan, a medical epidemiologist who is the dean of the College of Public Health at the University of Nebraska Medical Center and a former member of the GOARN steering committee, said the COVID-19 pandemic highlighted how “disease has no borders” and the importance of sharing information globally to quash the spread of contagious diseases.

Khan said the Trump administration’s withdrawal from the WHO “throttles the information from WHO to the U.S. government, specifically the [federal Centers for Disease Control and Prevention], and which then flows to states. Those states are now left in a position where they’re joining the GOARN.”

“Let’s be clear, it doesn’t substitute for the U.S. withdrawal from the WHO, but it does allow states to directly get information about what’s going on globally that may impact their own citizens. So it allows them to sort of keep their own radar on when the U.S. has decided to no longer participate in this global information sharing.”

In explaining its decision to withdraw from WHO, the Trump administration said the U.S. had “for decades carried a disproportionate share of the organization’s financial burden.” It insisted the country would “continue to ensure detection and response to infectious disease outbreaks” without being a member of the organization.

“These are the same democrat-led states and cities that imposed unscientific school closures, toddler mask mandates, and vaccine passports during the COVID era,” Andrew Nixon, a spokesperson for the U.S. Department of Health and Human Services, wrote in an email.

“They are the ones who destroyed public trust in public health that we are now restoring. We are working with the White House in a deliberative, interagency process on the path forward for global health and foreign assistance that first and foremost protects Americans.”

Dr. James McDonald, commissioner of the New York State Department of Health, told Stateline that the department’s decision to partner with GOARN was apolitical, and that it makes sense for New York because the state is “the world’s gateway to the country.”

“Everybody comes to the United States. Many come through JFK [John F. Kennedy International Airport], but an outbreak in the Democratic Republic of Congo does matter to me, so learning about it sooner helps protect New Yorkers and also helps protect the United States,” McDonald said.

McDonald added that New York is a part of a new public health consortium of Northeast states — the Northeast Public Health Collaborative — and plans to share any information it gathers from GOARN with fellow members Connecticut, Delaware, Maine, Maryland, Massachusetts, New Jersey, Pennsylvania, Rhode Island, and Vermont. New York City also is a member of the consortium.

“One of the things about scientists and health care providers is we’re used to just sharing information with each other, sharing knowledge. It’s not political,” McDonald said.

Doua Yang, a spokesperson for the California Department of Public Health, said that even before officially joining GOARN in January, the agency had been attending weekly operational calls for several months, and even made a presentation on how it has handled bird flu outbreaks.

“As the fourth-largest economy in the world, California cannot afford to let down its guard, or its people,” Yang wrote in an email. “Participating with GOARN is one step California is taking to maintain uninterrupted communication with WHO and protect the state from potential health threats.”

Stateline reporter Shalina Chatlani can be reached at schatlani@stateline.org.

In Johnson County, Iowa, the number of tuberculosis cases has increased in recent years — and so has the cost of containing it.

The cost of contact tracing and surveillance, traveling each day to patients’ homes to ensure they take their meds or booking hotel rooms to quarantine patients, has surged from $17,000 in 2020 to $65,000 last year.

That doesn’t include $13,000 spent last year for language translation, as many of the cases were among the local immigrant communities, said Danielle Pettit-Majewski, director of the Johnson County public health department. She said the rise in spending is directly tied to the increase in diagnoses since 2020, with latent infections tripling, from 27 that year to 90 last year.

Last week, the state informed the county that the greater number of cases had made it too costly to help pay for the home visits, forcing the county to pay for them on its own.

“I was kind of dumbfounded,” Pettit-Majewski said. “It was surprising.”

Tuberculosis cases have been rising nationwide since 2021, and in 2024 — the most recent year for which data is available — they reached the highest level since 2011. Thirty-four states and the District of Columbia reported increases in TB case counts and rates from 2023 to 2024, according to the federal Centers for Disease Control and Prevention.

In 2024, there were 10,347 reported cases nationwide, up 8% from the 9,622 cases reported the year before.

The case numbers for 2025 won’t be released until the end of March. But the Trump administration’s immigration crackdown last year might have dissuaded some people from seeking care, perhaps leading to fewer recorded diagnoses, some TB experts say.

Some states, however, are reporting preliminary data to the National Tuberculosis Coalition of America that shows that the number of cases grew from 2024 and 2025 by between 10% and 20%, said Donna Hope Wegener, the coalition’s executive director.

“There are a number of [tuberculosis] program managers that are reporting double-digit increases,” Wegener said, adding that the cost of antibiotics to treat TB is rising. “These back-to-back increases that states are contending with are certainly alarming.”

In San Antonio, Texas, case numbers have been steady, but the local public health department is still struggling to cover treatment costs.

Tommy Camden, health program manager at the City of San Antonio’s tuberculosis clinic, said the city has proposed eliminating a full-time specialist position that assists with TB contact tracing, blood draws and home visits.

Whatever the 2025 numbers show, many public health agencies are struggling to keep up, especially as they also contend with a growing measles outbreak that so far has affected 26 states.

Tuberculosis is a bacterial infection with both active and latent stages. A person with active tuberculosis disease, which can be deadly, can spread the disease. A person with a latent infection can’t, but they can develop the disease at any point.

Consistent, daily antibiotic treatment for four to nine months, with no skipped doses, is crucial to knocking it out. Skipping doses can allow the germs to mutate into drug-resistant TB, which is one reason health agencies spend so much to ensure patients take their medication.

In the U.S., the disease disproportionately affects people born in countries where it’s more common, as well as Hispanic, Black, Asian American, Pacific Islander and Indigenous communities, according to the CDC.

Immigrant communities tend to be disproportionately affected, in part because the disease can spread more easily in multigenerational households and other crowded home and work settings. Poverty, a lack of access to health care because of language, transportation and cultural barriers, and the stigma around the disease also can make those communities more vulnerable, Pettit-Majewski explained.

The California Department of Public Health says the cost of drugs to prevent a latent tuberculosis infection from turning into full-blown disease can be about $857 for what is usually three to four months of treatment. In contrast, diagnosing and treating one infected person who develops active tuberculosis disease can cost about $43,900.

While there is a vaccine for tuberculosis, it isn’t recommended for use in the U.S. because it can cause false positives in TB tests taken by skin sample. The vaccine also isn’t consistently effective against adult pulmonary tuberculosis.

Research has been underway for developing a new vaccine. But the Trump administration’s antipathy toward vaccines of all kinds is dampening investment in new products.

Immigration crackdown

Before the COVID-19 pandemic, tuberculosis was the world’s deadliest infectious disease, killing about 1.5 million people each year, according to the World Health Organization. It remains a leading infectious disease killer globally. Immigrants coming to the U.S. are screened for active TB and connected with treatment, and U.S. residents may be asked about travel abroad during routine checkups.

Many immigrants might be reluctant to seek care amid the Trump administration’s immigration crackdown, said Dr. Michael Lauzardo, a University of Florida associate professor at the division of infectious diseases and global medicine and director of the Florida TB Physicians Network.

“I think the numbers will be lower because people are afraid,” Lauzardo said of the soon-to-be-released 2025 data. “A lot of the people at risk for TB are not seeking care, I suspect.”

Munira Maalimisaq, a family nurse practitioner in Minneapolis, said such fear has been rampant across immigrant communities in her area. After President Donald Trump was elected, a health care center where she worked had to drop a routine question on patient intake forms that asked where a patient is from, because people were scared to answer it. The question was meant to assess exposure to TB in countries where it’s more common.

“That was a big barrier, because people would just not answer that question, or would not even want to engage and say ‘yes’ or ‘no,’” said Maalimisaq, CEO of a nonprofit health care center in Minneapolis, Inspire Change Clinic.

She said such fear could cause more active cases later on, as people with latent TB may not get diagnosed or get care — increasing the risk that they’ll develop the disease and become contagious.

“The whole thing delays seeking care,” she said. “If I don’t get screened for it, there’s no way that my provider is going to diagnose me.”

In Iowa, Pettit-Majewski said she hopes that Johnson County residents won’t be scared to seek care.

“If you are a Johnson County resident, you are our neighbor, and it is our responsibility to keep you safe and healthy — and we take that very seriously,” said Pettit-Majewski. “We want to make sure that folks are able to get the best care, regardless of immigration status, regardless of where you came from.”

People in detention or correctional facilities also are disproportionately at risk of infection. In recent weeks, two tuberculosis cases cropped up at a U.S. Immigration and Customs Enforcement facility in El Paso, Texas. Last year, California, Alaska and Arizona also saw cases at ICE detention facilities.

ICE didn’t respond to Stateline’s questions about the recent two cases at the El Paso facility. On a recent visit to the detention center, Democratic U.S. Rep. Veronica Escobar, who represents El Paso, said she saw agents go into a community pod, which can hold between 30 to 70 detainees, without protective attire.

“I was about to walk into a pod with the ICE agents, and the security guard said, ‘No, no, ma’am, you don’t want to walk in there. They’ve not been tested for TB yet,’” Escobar told Stateline.

“But I did see contractor staff coming in and out of the pod, and so I asked, ‘Why are they not wearing [personal protective equipment]? Why aren’t they wearing a mask?’ And my concerns were pretty much dismissed, and I was told it’s their choice and they don’t have to if they don’t want to.”

Cuts to public health funding 

Earlier this month, the Trump administration told Congress it intends to rescind $600 million in public health funds to four Democratic-led states: California, Colorado, Illinois and Minnesota. Many of the grants targeted HIV, and some also targeted tuberculosis.

The four states have sued to stop the cuts, arguing that the administration is targeting them with “devastating funding cuts to basic public health infrastructure based on political animus and disagreements about unrelated topics such as federal immigration enforcement.”

A federal judge has temporarily halted the cuts, saying the administration’s statements suggest “hostility to what the federal government calls ‘sanctuary jurisdictions’ or ‘sanctuary cities.’” An agency action, U.S. District Judge Manish S. Shah said, can’t be honored “if it is arbitrary or capricious.”

One of the California grants affected is a grant to the Tuberculosis Elimination Alliance, a partnership of community-based organizations that conduct outreach and education about tuberculosis.

The group received notice Feb. 11 that its grants were ending — putting in jeopardy $100,000 the alliance distributes to groups serving high-risk communities across California, Illinois, Washington state, the District of Columbia and U.S. island territories.

One of the largest tuberculosis outbreaks in recent weeks occurred at a San Francisco Bay Area high school, where latent TB was detected in more than 200 students and staff.

“It’s just such a scary and confusing time for our communities,” said Chibo Shinagawa, associate director of infectious diseases at the Association of Asian Pacific Community Health Organizations, which leads the Tuberculosis Elimination Alliance.

“The instability, the uncertainty right now — it’s such a disruption to public health, to the trust we’ve built in our communities.”

Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.

Nearly a quarter of pregnant women aren’t getting prenatal care in the early stages of pregnancy, according to a new analysis from the U.S. Centers for Disease Control and Prevention.

The share of pregnant women getting prenatal care had been improving: It rose between 2016 and 2021 to a high of more than 78%, but then declined to 75.5% by 2024, wiping out previous gains.

The trend is worrying because getting care early in pregnancy can improve the likelihood of a healthy pregnancy and baby.

The decrease in early prenatal care held true for nearly all race and ethnic groups, but the drops were sharpest for Native Hawaiian and Other Pacific Islanders, Black women and American Indian and Alaska Native women.

By 2024, less than half of Native Hawaiian and Other Pacific Islander mothers received prenatal care in their first trimester — the first three months of pregnancy.

Anne Markus, a professor at George Washington University’s Milken Institute School of Public Health, said that because the statistically significant decline began around 2021, two events could explain some of the decrease: the COVID pandemic, with its associated stay-at-home orders, and the U.S. Supreme Court’s Dobbs decision in 2022 that dismantled the constitutional right to abortion.

“Both disproportionately affected, and continue to affect, communities of color, and the decline in early entry into prenatal care has been disproportionately bigger for racial and ethnic minorities since 2021,” said Markus, whose work focuses on public policy and access to health care. She was not involved in the analysis.

A lack of early prenatal care has also been disproportionately seen in “very young women who are more likely to have a pregnancy that they do not want,” Markus said. “The Dobbs decision and the fear and uncertainty it generated could be particularly relevant in explaining this disproportionate effect observed in the data.”

The share of women getting late care — beginning in the seventh month of pregnancy or later — or no care at all increased in more than half of states from 2021-2024. Utah saw the biggest rise in late or no care, followed by Massachusetts and Rhode Island. The number of Utah women getting late or no prenatal care jumped 54%, up to nearly 6% of women.

More than 1 in 10 women had late or no prenatal care by 2024 in Florida, Georgia, Hawaii, New Mexico and Texas.

“Geographic and financial barriers to accessing care are often behind late entry to recommended care, including prenatal care,” Markus said.

Late or no prenatal care decreased in six states: Arkansas, New Hampshire, South Carolina, Tennessee, West Virginia and Wisconsin.

The CDC compiled the report based on information from birth certificates, and includes information for all births that occurred in the United States.

Stateline reporter Anna Claire Vollers can be reached at avollers@stateline.org.

WASHINGTON — President Donald Trump and his top environmental policy officer finalized a move Thursday to undo an Environmental Protection Agency regulation that laid the foundation for federal rules governing emissions of the greenhouse gases that cause climate change.

At a White House event, Trump and EPA Administrator Lee Zeldin said they were officially rolling back the “endangerment finding” that labeled greenhouse gases a threat to public health and provided a framework for the EPA to regulate emissions. 

The 2009 finding, established under President Barack Obama, called climate change a danger to human health and therefore gave the EPA power to regulate greenhouse gases, such as carbon dioxide from cars and trucks. 

Such regulations created a challenge for automakers and other industries, which dragged down the entire economy, according to Trump, administration officials and allies in Congress. 

Democrats and their allies in environmental and climate activism, though, consider the measure a crucial tool to address climate change and protect human health.

Undoing the finding will remove the economy-wide uncertainty, Trump argued. 

“That is why, effective immediately, we are repealing the ridiculous endangerment finding and terminating all additional green emission standards imposed unnecessarily on vehicle models and engines between 2012 and 2027 and beyond,” he said Thursday. 

Affordability argument

In its initial notice last year that it would repeal the endangerment finding, the EPA said it did not have the authority to regulate vehicle emissions.

With household costs, including transportation, expected to be a major theme in the fall’s midterm campaigns to determine control of Congress, members of both parties have framed it as an economic issue.

“This will be the largest deregulatory action in American history, and it will save the American people $1.3 trillion in crushing regulations,” White House press secretary Karoline Leavitt said at Tuesday’s press briefing.

Some Democrats and climate activists argue the rollback will hurt the country’s nascent renewable energy sector, driving up the cost of home heating, electricity and other common expenses.

Senate Minority Leader Chuck Schumer, D-N.Y., and Sen. Sheldon Whitehouse, D-R.I., issued a lengthy joint statement slamming the announcement.

“The Trump EPA has fully abandoned its duty to protect the American people from greenhouse gas pollution and climate change.  This shameful abdication — an economic, moral, and political failure — will harm Americans’ health, homes, and economic well-being. It ignores scientific fact and common-sense observations to serve big political donors,” the senators said.

“This sham decision initially relied on a now thoroughly disgraced and abandoned ‘report’ by known climate deniers. Zeldin stuck to this charade anyway, undaunted by half a century of actual evidence, showing the fix was in from the beginning,” they continued.

Money and fossil fuels

The move outraged Democrats and climate activists when Zeldin first proposed it last summer. Climate activists say undoing the finding undercuts the federal government’s ability to address an issue critical to the United States and the entire world.

In a Tuesday floor speech, Schumer blasted the rollback as a giveaway to fossil fuel companies, leaders of which contributed to Trump’s 2024 campaign.

“Remember: In the spring of 2024, Donald Trump invited top oil executives to Mar-a-Lago and told them, if you raise me a billion dollars to get me elected, I will cut regulations so you can make more money,” Schumer said. “That devil’s bargain is now coming true. I never thought it would be this way in America, in this bald disgusting way that so hurts people’s health, but there it is.”

Democratic attorneys general and environmental groups are likely to sue over the rollback.

At least one lawsuit, from the Environmental Defense Fund, was promised Thursday afternoon.

“EDF will challenge this decision in court, where evidence matters, and keep working with everyone who wants to build a better, safer and more prosperous future,” Fred Krupp, EDF president, said in a statement Thursday. 

Washington state Attorney General Nick Brown, a Democrat, said last year he would “consider all options if EPA continues down this cynical path.”

Ashley Murray contributed to this report.

A sign at a University of Utah health clinic warns visitors about the spread of measles. Under the Trump administration, federal health officials have cut back the number of recommended vaccines, and more states are offering exemptions for parents who don't want to vaccinate children entering public schools. (Photo by McKenzie Romero/Utah News Dispatch)

States that were leaders in childhood vaccination before the pandemic are among those losing ground as exemptions and unfounded skepticism take hold, encouraged by the Trump administration’s stance under U.S. Health and Human Services Secretary Robert F. Kennedy Jr.

Expanded exemptions for parents are likely to drop both Mississippi and West Virginia from the top national rankings they held before the pandemic, according to a Stateline analysis of federal data. Other states like Florida, Idaho, Louisiana and Montana also are pushing the envelope on vaccine choice.

At least 33 states were below herd immunity in the 2024-25 school year, compared with 28 states before the pandemic in 2018-2019, the analysis found. Herd immunity refers to the percentage of people who must be vaccinated or otherwise immune from an infectious disease to limit its spread.

Research shows that in the case of measles — a highly contagious disease — states need to maintain at least 95% vaccination rates to protect people who can’t get vaccinated. Other diseases have similar herd immunity rates. People who can’t be vaccinated might include infants too young to receive certain vaccines and those with underlying health conditions.

Misinformation and expressions of distrust from influential leaders have an effect on parents, doctors say, as do new state exemptions making it easier for families to avoid the vaccines.

Some people who never questioned vaccines before notice a national debate and get confused, said Dr. Patricia Tibbs, a pediatrician in rural Mississippi and president of the Mississippi chapter of the American Academy of Pediatrics. New religious exemptions may already be fueling an increase in pertussis, also known as whooping cough, in Mississippi, she said.

“If they hear something about it in the news, then it must be right, they think,” Tibbs said. “We’re just following the guidelines and informing patients that this is a scientific discussion. Nothing has changed about the science. But people who don’t know science are making decisions.”

Under Kennedy’s leadership, federal support for vaccination has continued to slide, and many states have joined a movement to set their own course by following more science-based recommendations from doctors. On Jan. 26 the Governors Public Health Alliance, a group of 15 Democratic governors, endorsed child and adolescent vaccination standards from the American Academy of Pediatrics rather than the federal government.

Federal health officials in Trump’s administration have cut back the number of recommended vaccines. The chair of a vaccine advisory committee, pediatric cardiologist Kirk Milhoan, suggested in a Jan. 22 podcast that individual freedom was more important than protecting community health with vaccines, even for measles and polio.

New leading states

Before the pandemic, Mississippi and West Virginia had the highest kindergarten vaccination rates in the nation, according to the Stateline analysis. About 99% of kindergartners in each state had their required vaccinations before entering public schools in the 2018-2019 school year.

In the latest statistics for the 2024-25 year, Connecticut gained the No. 1 spot, followed by New York and Maine. Those states have reined in exemptions to school vaccine requirements, while Mississippi and West Virginia have begun to allow more exemptions.

West Virginia didn’t report vaccinations to the federal Centers for Disease Control and Prevention for the 2024-25 school year. The state department of health told Stateline the data wouldn’t be available until later this year.

But the state is likely to be pushed out of the top 10. Republican Gov. Patrick Morrisey issued an executive order a year ago giving parents the right to ask for religious exemptions. To date, the state has approved 693 such requests for the current school year, spokesperson Gailyn Markham wrote in an email. That alone is enough to shift the state’s ranking significantly.

Stateline computed an average of required kindergarten vaccination rates to compare states. The analysis uses 2018-19 as a pre-pandemic baseline because a large number of states did not report the information in 2019-20 in the chaos that followed the early COVID-19 spikes and school closings.

A January study published by JAMA Pediatrics found increased vaccination rates among kindergartners in states that had repealed nonmedical exemptions, suggesting the repeals “played a role in maintaining vaccination coverage in repeal states during a period of heightened vaccine hesitancy.”

Requirements and exemptions

All 50 states and the District of Columbia require students to have certain vaccines before attending public school. They also all allow exemptions for children who cannot receive vaccinations for medical reasons, and most states allow nonmedical exemptions, often for religious or sometimes personal reasons. But Florida Republican Gov. Ron DeSantis’ administration has proposed dropping all requirements, and Idaho enacted a 2025 law allowing vaccination exemptions for any reason. Idaho had the lowest rate of kindergarten vaccination, about 80% in the 2024-25 school year before the law took effect in July last year.

Louisiana in 2024 enacted a law dropping COVID-19 vaccine requirements for public schools, and the state has opted to halt publicity about flu vaccination and end public vaccine clinics.

A Florida bill that progressed out of committee in January would maintain school vaccine requirements but expand exemptions to include “conscience” as well as medical and religious reasons.

Dr. Jennifer Takagishi, a Tampa pediatrician and vice president of the Florida chapter of the American Academy of Pediatrics, said the organization opposes both the DeSantis administration proposal to revoke vaccine requirements and the bill that would expand exemptions. Florida’s kindergarten vaccination rate fell from 94% before the pandemic to about 90% in 2024-25, according to the Stateline analysis.

“They’re ignoring the 90% of their constituents who want vaccines and want to stay safe,” said Takagishi. “The legislators are listening to the louder voice of those who want to oppose vaccines instead of the majority. We also know that there are teachers in the school system and school nurses who are fighting this because it puts them at risk.”

All states except Montana report kindergarten vaccine statistics to the federal government. Montana enacted a 2021 law making vaccine status private and unavailable for statistical reports, over the objections of medical experts. The law also made medical exemptions easier for families who think their children have been injured by vaccines.

Dr. Lauren Wilson, a pediatrician and then-vice president of the Montana chapter of the American Association of Pediatrics, said in a hearing that the law would make “vaccination information unavailable for responding to and mitigating public health emergencies.”

“Vaccines have saved millions of lives. I personally have seen cases of tetanus, pertussis, measles and meningitis and the tragedies that these mean for families,” Wilson said in her testimony.

A 2023 court order forced Mississippi to accept religious exemptions. West Virginia allows religious exemptions following the governor’s order last year.

Tibbs, who practices pediatrics in rural Jones County, Mississippi, said she has been seeing more pertussis than usual, and thinks vaccine exemptions could be a factor.

In Mississippi, which reported 394 religious exemptions for the 2024-25 school year, overall rates remained high enough that year, at about 97.8%, to ensure “herd immunity” in most cases.

Mississippi has granted 617 religious vaccination exemptions for kindergartners this school year, about 1.8% of the class, according to Amanda Netadj, immunizations director for the state health department. About 96.3% of kindergartners have all required vaccinations this year.

But the state’s whooping cough cases last year were the highest they’d been in at least decade, and in September health officials announced an infant had died of the disease — the state’s first whooping cough death in 13 years.

“We do have a lot of people getting the religious exemption,” Tibbs said. ”But still, on any given day, the majority of my patients will still get their vaccines. We are keeping our fingers crossed that the numbers stay high enough.”

Stateline reporter Tim Henderson can be reached at thenderson@stateline.org.