The Florida Department of Health (Department) received accreditation status as an integrated public health system from the Public Health Accreditation Board (PHAB) in 2 phases: the State Health Office received accreditation in June 2014 and the 67 county health departments received accreditation in March 2016 (Table). The accreditation process validated the Department's existing work in addressing the 10 Essential Public Health Services, identified opportunities for improvement, and highlighted areas of excellence that support the Department's mission to protect, promote, and improve the health of all people in Florida through integrated state, county, and community efforts. This achievement demonstrates the passion and commitment of 15 000 public health professionals and numerous community partners to improving public health.
The Department has dedicated resources to quality improvement for more than 3 decades; however, 6 weeks after PHAB awarded accreditation to the Department as an integrated public health system in March 2016, the World Health Organization declared the Zika outbreak in the Americas a Public Health Emergency of International Concern. Even in that short time, integrated public health accreditation, along with the other components of the Department's performance management system, allowed the Department to address this public health emergency, especially in Miami-Dade County, where the impact of Zika was significant. This case report describes the local response in Miami-Dade County and supporting statewide efforts.
To oversee statewide Zika mitigation and response efforts, the Department deployed the incident command system structure to execute the Zika strategic response plan, including reporting and documenting throughout the entire response period. The Zika Incident Management Team response plan included elements related to, or addressing, real-time disease and environmental surveillance with rapid analysis and reporting; prioritized testing of susceptible populations, such as pregnant women; mosquito control and surveillance; community engagement and response coordination, including public outreach and education campaigns; and distribution of mosquito repellent. Per an executive order signed by Governor Rick Scott, the Department sought to address stakeholder concerns regarding outbreak control measures—including issuing travel advisories, defining geographical areas of local transmission, and aerial spraying of certain pesticides—by conducting tabletop meetings with local officials and holding public town hall meetings.
PHAB accreditation bolstered the Department's efforts and actions when Florida became the first state in the nation to report a locally acquired Zika infection; for example, the standards and measures in PHAB Domain 2: Investigate Health Problems and Environmental Public Health Hazards to Protect the Community ensured that the Department was well prepared to respond. As it was preparing for accreditation, the Department assessed the systems and processes that support the PHAB Standards and Measures within each accreditation domain. The assessment involved identifying potential sources of evidence demonstrating that the Department met the standards; it also identified gaps and weaknesses that the Department would need to address. This process assisted the Department in developing, strengthening, and implementing integrated surveillance systems at all levels and in integrating vector management, risk communication, and community engagement. It also validated that the Department had strong standardized internal training and processes for epidemiology, environmental health, and emergency preparedness staff, which was critical during the formation of strike teams comprising staff from Central Office and county health departments who were deployed to Miami-Dade County. In addition, it ensured that the Department maintained long-term relationships that had been established with community partners through its ongoing Community Health Improvement Plan activities in Miami-Dade County and that were vital in helping the Department access hard-to-reach and underserved communities to provide health information and testing.
As with many emerging health threats, innovation or new collaboration is often inspired. Although established partnerships existed with hospitals and private laboratories, new approaches to routine processes became important throughout the Zika response. While the Department had already expanded the capacity of state laboratories for Zika testing, testing demands were not fully met, particularly in Miami-Dade County. Thus, the Department collaborated with a commercial vendor and 3 main local hospitals to process the high volume of Zika tests. The vendor agreed to accept all laboratory requisitions for asymptomatic pregnant women from the 3 hospitals and provide access to the test results through the vendor portal. Because symptomatic pregnant women were considered to be at higher risk for infection, hospitals continued to send these laboratory requisitions to the state laboratories. As a result of the shared capacity, the Department and its partners were able to provide all testing as needed.
In addition, the Department leveraged its relationship with the Healthcare Preparedness Coalition in Miami-Dade County, whose members include local acute care hospitals, emergency management, emergency medical services, long-term care providers, and ambulatory care organizations. This collaboration enhanced the Department's ability to directly learn from the community, address concerns, and provide guidance using established, strong channels of communication. Open dialogue allowed less experienced members to gain knowledge and support from more experienced peers, resulting in a more effective response. The Department also engaged other response partners that played important roles in the Zika response, such as mosquito control boards, county extension offices, tourist development councils, and airport and port authorities.
When Florida became the first state in the nation to report a locally acquired Zika infection, the Zika virus and its complications represented a novel public health threat that required the Department to develop and coordinate a unique and integrated strategy. As an integrated accredited public health system, the Department worked closely with its county health departments to execute Zika strategic response plan objectives, which included detection, prevention, care and support, and research. In addition, accreditation provided the Department with a framework for consistent and coordinated response and messaging to successfully stop local transmission, share best practices, map processes for linking pregnant women and infants to care, and increase preparation for a more robust response to other vector-borne diseases.
To share Florida's experience responding to this public health threat, Department staff have been asked to speak on the Zika response at national conferences and events hosted by the Association of State and Territorial Health Officers, Centers for Disease Control and Prevention (CDC), Council of State and Territorial Epidemiologists, United South and Eastern Tribes, Inc, and the Department of Health and Human Services' Assistant Secretary for Preparedness and Response. The Department also continues to advance the scientific basis for Zika laboratory testing and disease/outbreak surveillance and control through timely and impactful publications in peer-reviewed scientific literature,1–7 such as the CDC's Morbidity and Mortality Weekly Report. In addition, the Department will continue efforts to improve collaboration with American Indian populations. Initial strategies have included deployment of 200 Zika kits to the Miccosukee Tribe of Florida and 1000 kits to the Seminole Tribe of Florida.
While the Department identified areas for improvement, the overall success of its integrated statewide and local response to Zika more broadly bolstered the Department's public health platform; it elevated the importance of investing in public health to state and local policy makers, as well as residents, and instilled a shared sense of organizational accomplishment and pride among the Department's workforce, from the frontline workers to the executive leadership team. Meeting the standards and measures necessary to attain PHAB accreditation supported and ensured the Department's success. Furthermore, by continuing to focus on collaborative partnerships and consistent growth in performance management important for maintaining PHAB accreditation, the Department will continue to pursue its mission to protect, promote, and improve the health of all people in Florida through integrated state, county, and community efforts.
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virus infection—50 states and District of Columbia, January-December, 2016. MMWR Morb Mortal Wkly Rep. 2017;66(24):636–643.
2. Grubaugh ND, Ladner JT, Kraemer MUG, et al Genomic epidemiology reveals multiple introductions of Zika
virus into the United States. Nature. 2017;546:401–405.
3. Reynolds MR, Jones AM, Petersen EE, et al Vital Signs: update on Zika
virus-associated birth defects and evaluation of all US infants with congenital Zika
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4. Honein MA, Dawson AL, Petersen EE, et al Birth defects among fetuses and infants of US women with evidence of possible Zika
virus infection during pregnancy. JAMA. 2017;317(1):59–68.
5. Likos A, Griffin I, Bingham AM, et al Local mosquito-borne transmission of Zika
and Broward Counties, Florida, June-August 2016. MMWR Morb Mortal Wkly Rep. 2016;65(38):1032–1038.
6. Meaney-Delman D, Oduyebo T, Polen K, et al Prolonged detection of Zika
virus RNA in pregnant women. Obstet Gynecol. 2016;128(4):724–730.
7. Bingham AM, Cone M, Mock V, et al Comparison of test results for Zika
virus RNA in urine, serum, and saliva, specimens from persons with travel-associated Zika
virus disease—Florida 2016. MMWR Morb Mortal Wkly Rep. 2016;65. doi:http://dx.doi.org/10.15585/mmwr.mm6518e2