The MCH population has unique needs during an emergency, and Missouri has worked to enhance emergency preparedness planning and response activities to assure MCH population needs are considered in state, regional, and local planning. The MCH Director serves as a branch manager and is part of the Planning Team in the DHSS Emergency Response Center (ERC). Many Title V MCH Program team members serve in the DHSS ERC, including serving on the Local Public Health Management team. The State Emergency Operations Plan (SEOP), reviewed annually, considers a variety of vulnerable populations, including at-risk and medically vulnerable women, infants, and children, in planning elements. Missouri actively includes vulnerable populations in exercises and has sponsored multiple statewide conferences focused on emergency planning issues specific to children and families, such as reunification and pediatric medical surge planning. Missouri maintains an interdisciplinary Children and Youth in Disasters (CYD) Subcommittee of the statewide Access and Functional Needs Committee, with six standing work groups addressing needs across the systems where children live and receive care and support and focused on several key aspects of children’s environments including: public health/medical disaster planning; schools; child care; foster care and congregate care; children’s mental health; and emergency services (e.g., sheltering, feeding).

Work began in early 2020 to systematically integrate MCH knowledge, expertise, and populations into our emergency preparedness risk assessment, training, and exercise planning processes, and the state, regional, and local emergency operations plans. Although the COVID-19 pandemic interrupted formal integration of MCH into Emergency Preparedness and Response (EPR) processes, the pandemic presented opportunities to strengthen existing and build new partnerships between Title V, EPR and MCH programs across state agencies, local public health partners, and community organizations. Lessons learned through COVID-19 response will enhance the work started to Build EPR capacity for maternal and infant and increase capacity to adequately assess and respond to MCH needs in a future disaster or public health emergency. Knowledge gained will inform Title V MCH Program participation in future development of EPR training, communication plans and tools/strategies to enhance statewide preparedness for addressing potential short- and long-term impacts of disasters and emerging threats on the MCH population.

Addressing the needs of Missouri's children and youth with special health care needs (CYSHCN) and their families presents unique challenges and requires special considerations in EPR. Missouri is a largely rural state, with greater population concentrations surrounding the larger urban areas. Comprehensively meeting the needs of CYSHCN and their families in rural areas is more difficult due to transportation barriers and limited access to providers with specialized experience in treating complicated health issues. During times of emergency, MCH team members work to ensure CYSHCN and their families continue to receive high quality services in their local communities and have help to identify resources for additional support. Additional information regarding EPR for CYSHCN can be found in the CYSHCN Population Domain narratives.

Missouri has a variety of MCH surveillance systems that have the ability and flexibility to collect timely data during public health emergencies. The following is an overview of the various MCH surveillance systems that have the ability to gather data with respect to emergency preparedness and response among Missouri’s MCH populations:

1. National Vital Statistics System (NVSS) –Birth and death certificate data is compiled by the Missouri vital statistics team in conjunction with CDC NCHS to assign death codes and compile an annual birth file for pregnancy outcomes. The data can also be compiled monthly to provide real time estimates for adverse pregnancy and neonatal outcomes.
2. National Syndromic Surveillance Program (NSSP) – ESSENCE, Missouri’s syndromic surveillance program, collects real time data from hospitals across the state, including information on chief complaint and ER visits. ESSENCE continues to be a critical resource for timely public health action for a range of issues including but not limited to suicide attempts, COVID like illness, opioid overdose visits and ER visits during natural disasters.
3. Pregnancy Risk Assessment Monitoring System (PRAMS) – Missouri PRAMS continues to be a key MCH surveillance system during public health emergencies, such as the COVID-19, H1N1 and opioid epidemics. The program will be adding new questions to the survey to capture data about emergency preparedness activities for families with infants.
4. Behavioral Risk Factor Surveillance System (BRFSS) – The BRFSS is the nation’s premier system of health-related telephone surveys that collect state data about U.S. residents regarding their health-related risk behaviors, chronic health conditions, and use of preventive services. BRFSS is a population-based surveillance system that has the ability to add modules, such as the COVID-19 module, during public health emergencies for assessment of emergency preparedness among all Missourians, including MCH populations.
5. Reportable Disease Data Collection System (EpiTrax) – The EpiTrax system collects and compiles COVID-19 case data on a real time basis, and the data is disseminated to the public on a daily basis through dashboards.
6. Show Me Vax (SMV) Data Application – Show Me Vax collects vaccine data in Missouri. While it is not mandated to report vaccines in Missouri, it is mandatory for providers to report COVID-19 vaccine uptake. COVID-19 vaccine data is available in real time, is compiled on a daily basis and is made available to the public through dashboards.

COVID-19 Response

Throughout the COVID-19 pandemic, the Title V MCH Program was relied on to provide leadership and support in delivering critical MCH services and assisting local communities to respond to emerging threats and needs. Title V coordinated with MCH partners to develop and implement EPR plans to address MCH population needs. Highlights of Title V supported COVID-19 response activities are summarized below.

• A majority of program staff supported by Title V funding provided ongoing assistance with state COVID-19 pandemic response efforts such as: participating in operational briefings with state and local leaders and partners; manning the DHSS ERC and the state emergency operations center; conducting data entry and processing; working the EpiTrax Help Desk; test result notifications/sorting; case investigations/contact tracing; training; community testing and vaccination administration; community education and engagement; provision of accurate and reliable information to partners, health care providers, parent networks, etc.; partnerships with other state agencies, medical providers, and health care organizations to help educate the MCH population about COVID-19; support for local emergency preparedness efforts to represent the needs of the MCH population; and MCH epidemiology support, including setting up and maintaining public facing COVID-19 dashboards.
• SHCN team members collaborated with MO HealthNet on Medicaid waivers and state plan amendments and provided one-on-one education with families and providers on COVID-19 precautions, testing sites, vaccinations, resources, etc.
• The Women’s Health Initiative Program provided weekly women’s health listserve updates and technical assistance to subcontractors on best practices for virtual engagement and transitioning their work to virtual settings.
• The State School Nurse Consultant provided ongoing support and guidance to schools and school nurses, including hosting virtual learning opportunities for school nurses to assist with implementing on-site COVID testing and best practices in schools, developing guidance for schools, participating on the Hub team for the COVID and Kids ECHO, and responding to requests for guidance and best practices on pivoting from in-person to virtual or “front porch” school nursing.
• At the request of the Association of State and Territorial Dental Directors, the Office of Dental Health contributed to the creation of a toolkit for schools on how to respond to the pandemic and manage, coordinate and provide a school-based preventive oral health services program.
• Title V funded local implementing agencies (LIAs) transitioned to providing virtual or tele-home visiting (HV) services, engaging families in HV services within the limits of stay at home orders and social distancing recommendations. LIAs supported HV families in the following ways:
  • Healthy Families America (HFA) LIAs used local diaper banks for supplies and referred families to local resources for support. Staff helped families complete forms for utility assistance. Diaper and wipes were delivered through no contact delivery at family homes, with additional community resource information included. Resources were also texted to families.
  • Nurse Family Partnership (NFP) LIAs stayed connected with clients through tele-visits to provide services and ensure families had access to available community resources. Collaboration between agencies was particularly apparent in the St. Louis region where weekly virtual webinars were sponsored by Generate Health to allow presentations by community resource agencies, sharing their contact information to agencies serving families. Diapers and wipes were distributed to enrolled moms by either no contact home drop-off or by pick up by the families.
  • Information was sent out in the private DHSS HV Weekly Update email to LIAs regarding free data and minutes from SafeLink Wireless for families receiving unemployment benefits.
  • NFP’s national office partnered with Verizon cellular to provide free cell phones with four months of data service for LIAs to order and distribute to clients to access resources, including healthcare providers and crisis hotlines. DHSS Title V and MIECHV grant supported NFP LIAs obtained and distributed over 60 free cell phones.
  • Webinars and additional resources for building protective factors were shared with LIAs, offering updated information specific to supporting families virtually during the COVID-19 pandemic.
  • The Title V supported NFP agency is based within the Southeast Health Hospital healthcare system, allowing NHVs the ability to assist pregnant and new moms in establishing and maintaining relationships with healthcare providers for preventive and routine healthcare for their children. When well-child visits were canceled due to COVID-19 restrictions, NHVs followed up with new moms to assure visits occurred when re-scheduling was possible. Completion of routine well-child visits is a DHSS Home Visiting Program performance measure.

The local public health system was significantly impacted by the COVID-19 pandemic, and regular day-to-day local public health agency (LPHA) operations were drastically decreased, and in some cases completely halted, to maximize local response capacity. In an effort to support the continually evolving needs of the LPHAs as they anticipated and responded to the significant impact of COVID-19 in their local communities, flexibilities in the expenditure of Title V funds through the MCH Services contract were allowed to support implementation of approved science-based approaches to respond to COVID-19 and address related MCH population needs. Expenditures were in accordance with state fiscal policies and regulations for MCH block grant funds and all other contract funding provisions. Local approaches and responses included: epidemiological activities related to outbreak investigation; educating public health partners, community agencies, medical providers, health care organizations, and the MCH population about COVID-19; working with local, regional, and/or state public health partners to assure the needs of the MCH population are prioritized and addressed appropriately; building infrastructure capacity to support COVID-19 response, including testing, case investigation and/or monitoring, vaccination, and related health services; provision of accurate information and community status updates; and community-wide educational communication and media campaigns.

The School Health Program (SHP) participated in coordinated COVID-19 response efforts to communicate practice recommendations and resource options. The SHP leveraged the established frameworks of Show-Me ECHO (Extension for Community Healthcare Outcomes) to partner with the subject matter experts to develop and setup didactic learning opportunities for school nurses on COVID-19 and general infection control practices, as well as other prevalent chronic conditions including Autism, Asthma, and Trauma-Informed care. The SHP sponsored a series of focus group conversations with key stakeholders in school nursing across Missouri to identify successes, challenges, needs and barriers from the COVID-19 response in the school setting. From this work, the SHP also collected recommendations for improving response plans for infectious disease management among communities and partners to maintain student wellness and family health. The focus groups were followed by a series of interviews with agencies working with school health staff.

There has been a significant turnover of public health nurses in all settings, including local and state public health and school nursing. Title V MCH continues to work with state and Department leadership to address gaps in this critical public health profession to ensure capacity to adequately assess and respond to MCH population and program needs in future disasters or public health emergencies.

The COVID-19 pandemic highlighted and exacerbated systematic inequalities affecting vulnerable populations, especially communities of color. Related emerging needs in MCH such as: disruptions to routine maternal, infant, child, and adolescent health care, including routine scheduled immunizations; reductions in breastfeeding prevalence; shortages in child care providers; decreased access to infant formula and food; increased homelessness; and increased mental health needs, substance use and suicide, just to name a few, further elevated the importance of prioritizing the MCH population in EPR planning and activities. Along with continuation, evaluation and expansion of telehealth models, leveraging new and expanded partnerships, and enhancing MCH data collection, analysis, and observation capacity, these are some of the new MCH challenges to be addressed and opportunities to be explored.