Background
In January 2026, NACCHO convened a listening session with health departments that have responded to STI, HIV, and/or hepatitis B or C outbreaks that have occurred in the United States since 2021. Fifty-two health department staff participated, most representing local health departments (LHDs), along with a smaller number of tribal health department staff and state health department disease intervention specialists (DIS).
Participants shared how outbreaks are identified and declared, what outbreak dynamics look like on the ground, how response roles are coordinated across agencies, and what policy and system-level factors either support or hinder effective response.
How Outbreaks Are Detected and Declared
Participants shared that frontline staff—including DIS, public health nurses, clinicians, and epidemiologists—often noticed increases in cases before trends were apparent in routine surveillance data. In other situations, state health departments alerted LHDs to emerging clusters identified through surveillance analyses. There was no single, standardized approach to confirming or declaring an outbreak. Some jurisdictions relied on formal statistical thresholds or predefined protocols, while others used more contextual indicators, such as shared risk factors, geographic clustering, or overlapping networks of concern. Participants noted that when clear state or local outbreak frameworks existed, they were extremely helpful in guiding enhanced monitoring and response efforts. While some LHDs technically have the authority to declare outbreaks, declarations were most often made collaboratively with state health departments rather than independently.
One challenge rose above all others: timely access to data. Many LHDs described delays in receiving surveillance data from their state health departments, which limited their ability to detect outbreaks early. Participants also emphasized the importance of access to data from neighboring jurisdictions, especially given the frequency of outbreaks among transient populations. Limited access to testing and treatment data outside of LHD-run clinics further slowed detection and response.
Outbreak Dynamics
LHDs emphasized that STI, HIV, and hepatitis B/C outbreaks are often syndemic in nature, with co-infection common and shared risk factors emerging among cases. These patterns were often identified through DIS interviews, with several LHDs describing enhanced interviews and partner services as case counts began to rise. One participant noted that risk factors were sometimes more clearly understood through informal community engagement than in formal clinical settings or structured interviews. Partnerships with tribal health entities, community-based organizations, and other service providers were critical for understanding transmission dynamics and tailoring response strategies.
Response Roles and Coordination
While state health departments often played a central role in outbreak detection and declaration, response efforts were frequently implemented by local health departments. States commonly supported LHDs by providing technical assistance, medications and testing supplies, surge staffing (including DIS), and data or analytic support.
The division of responsibilities for case investigation and partner services varied by jurisdiction. LHDs often led community outreach efforts and expanded clinical services, including community-based testing and treatment. Across the board, participants highlighted strong community partnerships as a key factor in successful outbreak response.
Ongoing Challenges
In addition to data access issues, participants described a range of operational challenges that complicated response efforts. These included workforce strain and staff turnover, limited flexibility across systems, and medication shortages (i.e., Bicillin) which made treatment and follow-up more difficult.
Looking Ahead
Overall, the listening session reinforced several core themes: the importance of strong state–local collaboration, timely and transparent data sharing, clear outbreak response policies and plans, and community-centered approaches. Participants also noted that STI, HIV, and hepatitis B/C outbreaks are often syndemic nature, and that coordinated, cross-program, and cross-sector responses can strengthen preparedness and response efforts moving forward.
