22nd Biannual 

CDC/ATSDR Tribal Advisory Committee 

Meeting

Follow-Up Report

August 4–5, 2021
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Table of Contents

Introduction..................................................................................................................................................3

Tribal Public Health Infrastructure ..............................................................................................................3

Resources..................................................................................................................................................3

Training .....................................................................................................................................................6

Public Acknowledgment ...........................................................................................................................7

Funding .....................................................................................................................................................7

Tribal Public Health Data ...........................................................................................................................11

Training ...................................................................................................................................................11

Funding ...................................................................................................................................................12

Technical Assistance ...............................................................................................................................12

Data Accessibility ....................................................................................................................................13

Social Determinants of Health...................................................................................................................14

Missing and Murdered Indigenous Persons..............................................................................................16

Data.........................................................................................................................................................16

Opioid Overdose Prevention .....................................................................................................................17

Resources................................................................................................................................................17

Technical Assistance Guidelines ................................................................................................................18

Communication.......................................................................................................................................18

Tribal Testimony.........................................................................................................................................18

Tribal Consultation..................................................................................................................................18

Appendix.....................................................................................................................................................20

Acronym List ...........................................................................................................................................20
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Introduction 

The 22nd Biannual Centers for Disease Control/Agency for Toxic Substances and Disease Registry 

(CDC/ATSDR) Tribal Advisory Committee (TAC) meeting was held virtually August 4–5, 2021. The primary 

agenda topics were tribal public health infrastructure, tribal public health data, social determinants of 

health (SDOH), Missing and Murdered Indigenous Persons (MMIP), and opioid overdose prevention. In 

addition, CDC/ATSDR Director Dr. Rochelle Walensky provided agency updates and participated in a

facilitated discussion with TAC members.

During the meeting, TAC members provided input and recommendations and requested some areas of 

follow-up to CDC leaders from various centers, institutes, and offices (CIOs). After the meeting, CDC’s 

Office of Tribal Affairs and Strategic Alliances (OTASA) collected, categorized, and tracked follow-up 

items, using the categories “request,” “recommendation,” “issue or concern,” or “question.” The 

applicable CDC CIOs responded to the 29 follow-up items. The requests, recommendations, issues or 

concerns, or questions are included in this report. The report is organized by agenda topic area, with the 

input or questions received in each area followed by responses from applicable CIOs.

For additional information about the meeting, please consult the 22nd Biannual CDC/ATSDR TAC 

Meeting Minutes on the CDC Tribal Health website.

Tribal Public Health Infrastructure 

Resources

Request

TAC members requested that CDC work with tribal health departments, provide resources and examples 

of what tribal nations can do with various-sized health departments, and forecast how many potential

full-time employees (FTEs) would be needed to carry out these efforts and those FTEs’ primary duties. 

Resources could include organizational structure templates, basic tool kits, and more. 

Responses

Center for State, Tribal, Local, and Territorial Support (CSTLTS) – Division of 

Performance Improvement and Field Services (DPIFS)

National Public Health Department Accreditation, Public Health Accreditation Board (PHAB),

and Related Resources 

The National Public Health Performance Standards (NPHPS or the Standards) provide a 

framework to assess capacity and performance of public health systems and public health 

governing bodies. This framework can help identify areas for system improvement, strengthen 

state and local partnerships, and ensure that a strong system is in place for providing the 10 

essential public health services. If you have questions about assessment resources, previous 

versions of the Standards, or CDC’s role in the NPHPS program, email CSTLTSfeedback@cdc.gov.

PHAB’s initial accreditation process assesses a health department’s capacity to carry out the 10

essential public health services, to manage an effective health department, and to maintain 

strong and effective communications with the governing entity. After five years, reaccreditation 
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is necessary for a health department to remain accredited. Reaccreditation focuses on assessing

accredited health departments’ continued improvement and advancement, to determine if they 

are becoming increasingly effective at improving the health of the populations they serve. 

PHAB is a 501(c)(3) organization. The PHAB Standards and Measures document is the official 

blueprint for standards, measures, required documentation, and guidance for PHAB national 

public health department accreditation. Five tribal health departments are now accredited

through PHAB, but even for those not accredited or not seeking to become accredited, the 

standards can still serve as a blueprint for building infrastructure. Reviewing performance 

against the standards can provide valuable insight into gaps and opportunities for 

improvement. In addition, on September 14, 2021, a revised version of the standards was 

released for public review; it included revisions that addressed new attention to health equity, 

connections with foundational capabilities, and additional focus on preparedness and response.

CSTLTS also supports efforts to use the national standards and strengthen performance 

improvement through the National Indian Health Board (NIHB). Visit PHAB, Health Department 

Accreditation, and NIHB to learn more. 

PHAB Accreditation “Pathways Recognition Program”

PHAB, with CSTLTS’s support, is developing a recognition program that may be more suitable for 

smaller health departments, including tribal health departments, than full accreditation. This 

program is still under development; more information is available at Pathways Recognition 

Program. This work has been informed through multiple interactions with individuals in tribal 

public health settings (e.g., tribal-specific open webinar feedback sessions, input from NIHB’s 

Tribal Public Health Accreditation Advisory Board). 

Cross-Jurisdictional Sharing (CJS) Opportunities

Ultimately, tribes may be interested in exploring CJS opportunities (ranging from more flexible 

sharing of staff and services to more formal regionalization efforts). CDC is interested in this 

issue and has engaged with organizations like the Center for Sharing Public Health Services and 

the Public Health National Center for Innovation (PHNCI) on this topic. The Center for Sharing 

Public Health Services has a variety of case studies (including some in tribal locations) and a tool 

(COMPASS) to guide CJS-related decision making and implementation activities. More 

information is available at Center for Sharing Public Health Services and the CSTLTS CrossJurisdictional Sharing of Public Health Services websites.

Staffing Up Project

During phase 1 of the Staffing Up: Determining Public Health Workforce Levels Needed to Serve 

the Nation project, which de Beaumont Foundation supported and PHNCI coordinated, findings 

and estimates about needed state and local public health workforce levels were developed. The 

final report was released in October 2021. Development of the national estimate relied on 

modeling existing expenditure and staffing data for a sample of local and state health 

departments. A partnership between PHNCI, de Beaumont Foundation, and CSTLTS will support 

additional data collection, analysis, and modeling efforts. These efforts will guide development 

of a public health workforce calculator that will allow health departments to determine the 

number and type of staff needed to provide sufficient levels of public health services. CSTLTS is

interested in developing estimates for tribal and territorial settings as the project advances. 
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CSTLTS – Office of Tribal Affairs and Strategic Alliances (OTASA)

Public Health in Indian Country Capacity Scan (PHICCS)

PHICCS is a national scan that NIHB conducted, in part with CDC funding. CDC funded an initial

one-year project to determine the feasibility of a public health capacity scan, and that project

resulted in the 2010 Tribal Public Health Profile: Exploring Public Health Capacity in Indian

Country report. NIHB was funded to develop the public health scan of Indian Country,

identifying strengths and challenges facing communities. The second iteration, called the Public

Health in Indian Country Capacity Scan (PHICCS I), was conducted during November 2018–

August 2019 and resulted in the 2019 PHICCS report, an official report that provides specific,

succinct survey information that can be used for advancing tribal public health priorities. The

2019 report can help tribal health organizations identify public health needs, successes,

strategies, challenges, and limitations in areas that include clinical care, health promotion,

workforce retention, and data use and assessment for decision making.

NIHB is currently seeking feedback and guidance from tribal leaders on the planning and

instrument development of the 2022 Public Health in Indian Country Capacity Scan (PHICCS II).

NIHB held an open comment period (October 1–29, 2021) and hosted a webinar on October 19

titled “Drumming Up Interest for PHICCS II Webinar.” More information is available on NIHB’s

PHICCS II web page.

Pilot Project to Build Sustainable Public Health Capacity in Tribal Nations and Organizations

for COVID-19

In September 2021, CDC funded the National Network of Public Health Institutes (NNPHI) to

develop and implement a virtual learning cohort of American Indian/Alaska Native (AI/AN)

public health champions. Currently in the planning phase, this project will increase tribes’ and

tribal organizations’ ability to respond to future public health crises by 1) identifying public

health champions, not currently in a leadership position, who are working within a tribal

department of health (DOH) or in Indian Health Service/tribal/urban (I/T/U) healthcare facilities

serving AI/AN communities; 2) creating a virtual learning consortium for tribal DOH and I/T/U

public health champions to access public health training modules; 3) hosting a virtual forum for

members of the learning consortium to learn from each other and replicate best practices

across tribal communities; 4) spreading awareness about CDC training and employment

opportunities to diversify the CDC workforce.

National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) –

Division of Population Health (DPH), Healthy Tribes Program

In FY 2019 under the Tribal Public Health Capacity Building and Quality Improvement Umbrella 

Cooperative Agreement (OT18-1803), a project was awarded to Northwest Portland Area Indian 

Health Board (NPAIHB) to increase tribal epidemiology centers’ (TECs’) capacity to support tribes 

in achieving public health accreditation. This project included inventory of existing tribal 

resources for public health accreditation and subawards to tribes to pursue accreditation 

standards.
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Request

TAC members requested that CDC provide best practices and educational packets about the 10 essential 

public health services.

Response

CSTLTS – DPFIS

Revised Essential Public Health Services (EPHS) framework – The revised EPHS framework and 

tools provide additional information to consider about the public health responsibilities. CDC 

was a stakeholder in this effort, but it was a collaboratively driven process and included 

significant input from the field and from public health organizations at all levels. The revision 

builds on the long-standing EPHS framework, but the framework now centers on equity and 

incorporates other important considerations for current and future public health practice. If 

certain materials of interest are not available, contact CSTLTS at CSTLTSfeedback@cdc.gov, and 

CSTLTS can determine opportunities to fill the gaps.

Request

TAC requested CDC provide examples or templates of public health codes related to development of 

tribal health departments. 

Response

CSTLTS – Public Health Law Program (PHLP)

PHLP has acknowledged this request. Currently, CDC does not have specific coding templates

but will explore potential opportunities for developing or sharing resources.

Training

Request

TAC members mentioned difficulties related to locating, funding, and scheduling public health training 

opportunities and resources and asked what types of resources are available for public health training 

and workforce development of tribal health departments.

Response

CSTLTS 

CDC TRAIN offers access to thousands of trainings and courses. Visit CDC Learning Connection to 

find public health training opportunities from CDC, other federal agencies, and federally funded 

partners. 

Several training and leadership development resources, including information about the 

National Leadership Academy for Public Health, are available on CSTLTS’s Training & 

Professional Development web page.

CSTLTS offers a variety of training programs focused on performance improvement and public 

health infrastructure. The Public Health Improvement Training (PHIT) is an annual opportunity

for interactive learning and skill building. It includes some content specially geared for tribal 

participants. Other programs, such as the Strategic Scholars Program, can offer opportunities for 
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skill-specific trainings for tribal health department teams. More information is on CSTLTS’s

Supporting the Performance Improvement Workforce web page.

OTASA’s biweekly newsletter highlights training opportunities and resources. Email 

tribalsupport@cdc.gov to sign up for this newsletter.

Public Acknowledgment

Recommendation 

TAC members recommended that CDC publicly acknowledge its support for the importance of and the 

development of tribal public health infrastructure. TAC members also said this infrastructure can be an 

effective public health force for all citizens in the area whether they are part of a tribe or not. Suggested 

examples included—

• Offering examples of what tribal public health infrastructure looks like 

• Publishing a position paper on the importance of exercising public health authority as a tribal 

nation

• Developing a video on the importance of tribal public health infrastructure and describes the 

support CDC offers to tribes

Response 

CSTLTS – OTASA

NIHB and CDC have partnered to develop trainings and resources, including the NIHB Working 

with Tribes Training, Public Health Training for tribal leaders and TAC members, and Public 

Health 101—Foundations of Public Health in Indian Country. CDC will work closely with the TAC 

to identify additional opportunities to promote the importance of and development of tribal

public health infrastructure. 

Funding

Recommendation

TAC members recommended that CDC consult with tribal public health professionals to help ensure 

tribal public health infrastructure is included in funding opportunity development and design. 

Response

CSTLTS

CSTLTS acknowledges this recommendation and will share it with other CIOs for consideration 

as they develop future funding opportunities.

Recommendation

CDC should fund tribes for systems and workforce development initiatives that build tribes’ capacity for

data collection, analysis, and governance.

Responses

NCCDPHP – DPH, Healthy Tribes Program
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CDC’s Healthy Tribes Program is committed to strengthening the tribal public health capacity 

and infrastructure needed to prevent disease and promote the health and well-being of AI/AN 

communities. Through the Tribal Epidemiology Centers Public Health Infrastructure (TECPHI) 

Program, CDC funds 12 TECs to increase their capacity—and the capacity of the tribes and urban 

Indian organizations (UIO) they support—to deliver the essential public health services by 

building data infrastructure and workforce development and establishing partnerships.

In the final year of the five-year cooperative agreement, TECs created data-sharing platforms to 

support tribal data collection capacity and governance and to support tribal access to federal, 

state, and local tribal data; administered student internship programs to support workforce 

development; supported more than 70 subawards to fund tribally identified public health 

projects, including data collection (e.g., Behavioral Risk Factor Surveillance System), adverse 

childhood experiences, and community health assessments; initiated data governance and 

accreditation activities; and established a Tribal Data Users group.

To further development of tribal public health infrastructure, CDC’s Healthy Tribes Program 

recently forecasted a new five-year funding opportunity for TECPHI. The goal of the program is 

to expand the public health infrastructure and capacity of the TECs, and the tribes and UIOs they 

support, in meeting national public health accreditation standards and the 10 essential public 

health services. The intent is to identify and address underlying determinants of health, reduce 

persistent health disparities, and improve the overall health and well-being of AI/AN 

populations.

In addition, the Healthy Tribes Program supports development of tribes’ public health 

infrastructure by funding three projects through the Tribal Public Health Capacity Building and 

Quality Improvement Umbrella Cooperative Agreement (OT18-1803):

• FY 2018 – Increasing Tribal Public Health Leadership and Capacity. Awarded $750,000 to 

Cherokee Nation. Activities included subawards to Choctaw and Chickasaw Tribes and 

supported a contract with Seven Directions Indigenous Public Health Institute and Red 

Star to develop a webinar series, Establishing Tribal Public Health Governance –

Becoming Ka Ma Ma (Becoming Butterfly).

• FY 2019 – Increasing TEC Capacity to Support Tribes in Achieving Public Health 

Accreditation. Awarded to NPAIHB. Included inventory of existing tribal resources for 

public health accreditation and subawards to tribes to pursue accreditation standards.

• FY 2021 – Building the Tribal Public Health Workforce Through Student 

Engagement awarded to Chickasaw Nation and NPAIHB. Improving Tribal Data Sharing 

Capacity awarded to NPAIHB and Southern Plains Tribal Health Board.

NCCDPHP – Division of Reproductive Health (DRH)

CDC’s partnership with NIHB focuses on the foundations necessary for implementing tribally

lead maternal mortality review committees (MMRCs) that respect Native culture, consider 

Native context and social determinants of health, and result in meaningful and effective 

prevention strategies for Native communities to reduce maternal mortality. Alongside the focus 

on maternal mortality, this project supports assessment of infrastructure among and between 

tribes for data collection, analysis, sharing, and governance. Understanding the strengths and 

opportunities for data governance both within and across tribes is a foundational input to the 

logic model of tribally lead maternal mortality review committees that NIHB developed with 
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input from many tribal stakeholders. With funding from CDC, NIHB is currently requesting 

proposals for grants to support Indian Health Board areas and tribes to conduct selfassessments, based on the logic model, for implementing tribally lead MMRCs. Post-assessment, 

NIHB will provide technical assistance to Indian Health Board areas and tribes to build on 

existing infrastructure.

CDC supports Sudden Unexpected Infant Death (SUID) and Sudden Death in the Young (SDY) 

monitoring programs in 22 states and jurisdictions through the SUID/SDY Case Registry. To 

strengthen tribal capacity, infrastructure, and training to conduct child death reviews, CDC is 

currently funding the Michigan Public Health Institute (MPHI) to build the capacity of the Navajo 

Nation to improve population-based surveillance of SUIDs and related prevention efforts. The 

Navajo Nation identified this as a need in earlier work with MPHI. In collaboration with Navajo 

leaders, MPHI mapped the Navajo Nation infant fatality case review process. MPHI will also host

an in-person training (when travel is allowable) for Navajo tribal representatives, state and 

federal law enforcement, and Navajo leaders, to support their efforts to navigate the 

complicated issues and improve data collection.

Recommendation

TAC members have recommended that the Good Health and Wellness in Indian Country (GHWIC)

initiative be funded $32 million in FY 2023.

Response

NCCDPHP – DPH, Healthy Tribes Program

Increased funding for GHWIC would further CDC’s current investment in chronic disease

prevention and health promotion for AI/AN communities. CDC would continue to fund tribes in 

implementing evidence-based, culturally adapted strategies to prevent and control chronic 

disease risk factors and conditions by—

• Supporting a coordinated and holistic approach to healthy living and chronic disease 

prevention

• Reinforcing the work already underway in Indian Country to make healthy choices 

easier for AI/AN people

• Continuing to support culturally appropriate, effective public health approaches

• Working with more tribes to extend the program’s reach and impact through tribal 

organizations

CDC will continue to administer the program and deliver high quality technical and scientific 

support, including applying flexibility in CDC support of culturally appropriate approaches in 

alignment with federal appropriation standards.

Recommendation 

TAC members recommended additional supplemental funding of the 1803 Tribal Public Health Capacity 

Building and Quality Improvement Cooperative Agreement. The 1803 cooperative agreement should 

have two tracks, one specifically for tribes to allow them to develop their own public health capacity, 

including tribal health departments, and another track for TECs and tribal organizations to support tribal 

public health infrastructure. CDC should provide both tracks with ongoing training to help applicants 

apply successfully for the cooperative agreement.
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Response

CSTLTS

CSTLTS will consider this recommendation when developing the next tribal public health 

capacity cooperative agreement.

Recommendation

In response to CDC’s question of what funding for public health infrastructure looks like, TAC members 

recommended direct funding to help establish health departments in tribal communities. Startup 

funding for infrastructure should include operational costs, FTEs, or funding to contract to outside 

experts to assist tribal nations.

Response

CSTLTS

The suggested funding options are allowable expenses in the current CSTLTS funding 

mechanisms. CSTLTS will take these recommendations into account when developing future 

funding mechanisms. 

Recommendation

The TAC recommends $1 billion to fund a CDC Tribal Public Health Emergency Fund that would be

established through the Secretary of the Department of Health and Human Services (HHS) and that

tribes would be able to access directly for tribally declared public health emergencies.

Response

CSTLTS 

CDC is committed to advancing tribal health in partnership with tribal nations, tribal 

organizations, urban Indian health organizations, and other partners. Given CDC’s current 

congressional authorities and funding directives, the agency cannot implement this 

recommendation now. CDC will continue to work to identify and maximize funding 

opportunities for tribal nations and organizations to support tribal public health priorities and 

emerging needs.

Recommendations 

TAC members reiterated the recommendation that funding be provided directly to tribal nations and not 

pass-through other organizations or states. Comments speaking to this recommendation included—

• To truly understand tribal sovereignty, states should not pass funding through to tribal nations 

like has been traditionally done.

• To develop a workforce plan for a tribal public health department is significant. When talking 

about cooperative agreements or direct funding, instead of flowing through other agencies as 

pass-through from the state or other national agencies, there could be a direct appropriation 

through a cooperative agreement specifically for workforce development.

• Something along the lines of NNPHI funding for tribes specifically. It focused on building 

infrastructure. Tribal nations need funding for building infrastructure at a community level.

• We request tribal set-asides for AI/AN programs and services.

• CDC must ensure direct funding to tribal governments for AI/AN communities. Tribes should not 

have to access funds through state block grants.
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Response

CSTLTS 

CDC programs continue to work directly with the CDC/ATSDR TAC and tribal nations to get tribal 

input into CDC program and resource development through TAC meetings and listening sessions 

at national tribal meetings. Visit CDC Tribal Funding Profiles to find more information about 

tribal-specific funding information.

CDC currently has four funding mechanisms exclusive to tribal nations and tribal organizations: 

1) Good Health and Wellness in Indian Country, 2) Tribal Epidemiology Centers Public Health 

Infrastructure, 3) Tribal Practices for Wellness in Indian Country, and 4) Tribal Public Health 

Capacity Building and Quality Improvement Umbrella Cooperative Agreement. CDC created 

these programs as a direct result of input received from the TAC and other tribal 

recommendations for mechanisms with tribal eligibility only and for mechanisms that allow for 

culturally appropriate activities.

• The Tribal Public Health Capacity Building and Quality Improvement Umbrella 

Cooperative Agreement enables any CDC program to fund collaborations with tribal 

nations and regional tribally designated organizations to improve the tribal public 

health system.

• CDC used several of these mechanisms to provide tribal nations and tribal 

organizations with the first funding to address the opioid epidemic in Indian Country

and for COVID-19 response efforts.

NIHB and the National Council of Urban Indian Health are funded through CDC’s national 

partnership umbrella cooperative agreement, Strengthening Public Health Systems and Services 

Through National Partnerships to Improve and Protect the Nation’s Health. Any CDC program 

can fund these national partners to provide technical assistance to tribal nations and tribal 

organizations, and these partners can subaward funding to other tribal entities, as appropriate 

to the work. 

Tribal Public Health Data 

Training

Request

TAC members requested trainings on use of national datasets at the tribal level for exchange of tribal 

information to allow effective work with state and local health jurisdiction partners.

Response

Center for Surveillance, Epidemiology, and Laboratory Services (CSELS)

Trainings on a variety of topics are available for free on CDC TRAIN. In addition, CDC launched an 

upskilling program in 2020, the Data Science Team Training, that provides more structured dataoriented training to state, tribal, territorial, and local teams. The inaugural cohort included a 

team from the Urban Indian Health Institute. CDC is continuing to assess data science training 

needs and will have technical assistance available to help tribes assess unique needs.
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Funding

Question

Is there language that prohibits funding tribes directly for data infrastructure? 

Response

CSELS

No, legislative language for data modernization funding does not prohibit use of the funds for 

supporting tribal jurisdictions. In general, eligibility depends on the scope of the grant authority, 

programmatic intent, and the available appropriation for any funding. These factors have to be 

evaluated before making an award. 

Question

Are states given money through the existing funding mechanisms to work with tribal organizations or 

tribes?

Response

CSELS

States do receive funding to advance data modernization, and they are encouraged to engage 

partners and interested parties; however, there are no requirements naming specific entities.

States are not given money through the OT18-1803 cooperative agreement and the data 

projects within that agreement.

Technical Assistance

Request

TAC members requested assistance with developing outcome measures specific to tribal populations. It 

is difficult to find benchmarks for tribal populations because most data are state data. Tribal health 

departments have to build datasets from the ground up to develop their own outcome measures.

Response

CSELS

CDC has several mechanisms to provide technical assistance for data modernization. Tribes can 

email edx@cdc.gov to determine whether their needs are within scope of available services.

CSTLTS – PHLP

CSTLTS/PHLP funded a tribal data-sharing project in partnership with the Northwest Tribal 

Epidemiology Center (NWTEC) and the National Association of County and City Health Officials. 

The project ended on September 30, 2021. Through this project, CDC supported creation of a 

website, documents, and resources that will facilitate data sharing and help create relationships 

between tribes and health departments. The NWTEC identified a workgroup of tribal and health 

department data-sharing experts to identify strategies and resources to effectively share data, 

build relationships, and promote effective data-sharing agreements. The workgroup 

collaborated for nearly nine months to develop the resources.
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The NativeDATA Data Sharing Resource for Native Peoples and Organizations website is the 

main hub for accessing the results of these efforts. This website contains information and tools 

supporting identified areas of activity related to data sharing, including goal definition, 

relationship building, and data and approval gathering. In addition, this website will have a 

resource section containing documents, trainings, and videos; inspirational stories about data 

sharing from individuals working in the field; and an option to contact and ask questions of the 

website administrators, NPAIHB.

Recommendation

There cannot be a one-size-fits-all approach. Every tribal nation will have different needs. A collective 

individualized needs assessment for tribal nations would be beneficial. CDC should partner with tribes to 

develop a plan to assist tribes to identify public health needs through assessments.

Response

CSELS

CDC is currently developing an assessment tool intended to help state, territorial, local, and 

tribal jurisdictions assess health information and workforce capabilities and needs. In addition, 

CDC is making available contracted technical assistance to support these jurisdictions in 

conducting the assessment and to help translate findings into a data modernization and 

workforce plan. Requests for assistance can be made via EDX@cdc.gov.

Data Accessibility

Question

The Tribal Health Data Improvement Act of 2021 was introduced in Congress and seeks to reaffirm tribal 

public health authority and tribal nations’ ability to access public health data. It requires CDC to take 

certain actions to address the availability of AI/AN data. Is that all happening through the TECs? We have 

tribes that are their own public health authority—are they getting COVID-19 data and all other data they 

need?

Response

CSELS

With any data sharing or access provision, CDC needs to examine the data and any statutory or 

legal protections that might apply to it. Because each data system is unique in terms of data 

ownership, applicable laws and policies, sharing agreements, and content—and because CDC is 

not the data owner in many cases—CDC must work with state health departments to identify 

the best process to share data with the federally recognized tribes on a system-by-system basis. 

Given these challenges, CDC encourages federally recognized tribes to coordinate with the 

respective state health departments for non-COVID-19 surveillance data specific to their 

populations. 

CDC has also made available several national public use datasets, such as the COVID-19 Case 

Surveillance Public Use Dataset with Geography, which has 19 elements for all COVID-19 cases 

shared with CDC and includes demographics, geography (county and state of residence), any 

exposure history, disease severity indicators and outcomes, and presence of any underlying 

medical conditions and risk behaviors.
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Request 

NWTEC should be able to access all national datasets. Specifically, NWTEC has been unable to access the 

National Death Index (NDI) (and National Death Index linked to National Hospital Care Survey), National 

EMS Information System, and the Medicare/Medicaid claim data from the Centers for Medicare and 

Medicaid Services. The National Death Index has a lengthy access process and a substantive cost for the 

TEC.

Response

National Center for Health Statistics (NCHS)

NCHS is not currently aware of any issues regarding NWTEC’s access to NCHS data.

The NDI dataset, with direct personal identifiers, cannot be provided directly to a researcher for 

analysis. The NDI data linked to the National Hospital Care Survey are available only via the 

Research Data Centers pending a proposal review, and they require a fee.

The National Vital Statistics System (NVSS) mortality statistical files available for download on 

the NCHS website do not contain personal identifiers or geographic information and are freely 

available online. NVSS restricted-use mortality files that contain geographic detail are also free

to researchers but require a brief proposal review process. 

Social Determinants of Health 

Issue/Concern

Lack of clean water and housing is a large issue. Elders need homes to live in, and some elders do not 

have adequate resources to live independently, including basic resources like housing and water.

Response

NCCDPHP

CDC does not currently work on housing for AI/AN elders. We recommend contacting the US 

Department of Housing and Urban Development’s Office of Native American Programs or the 

Administration for Community Living’s Office for American Indian, Alaska Natives, and Native 

Hawaiian Programs. 

Infrastructure Task Force Memorandum of Understanding (MOU) on Safe Drinking Water and 

Basic Sanitation in American Indian and Alaska Native Communities: COVID-19 outbreaks in 

tribal communities identified the need for improving sanitary infrastructure and promoting 

sustainable practices to support safe drinking water and basic sanitation, including wastewater 

and solid waste. CDC’s National Center for Environmental Health (NCEH) and the other agencies 

on the Infrastructure Task Force will provide tribal consultation, technical assistance programs, 

and operator training opportunities to help tribes provide or sustain improved access to safe 

drinking water and basic sanitation for their people. Joining NCEH on the MOU are the following 

agencies to help guide tribal water, wastewater, and solid waste infrastructure work: 

Department of Agriculture, Department of Health and Human Services, Department of Housing 

and Urban Development, Department of Interior, and Environmental Protection Agency. 
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Navajo Nation COVID-19 Water Access Mission: At the request of the Navajo Nation, the NCEH 

Division of Environmental Health Science and Practice (DEHSP) deployed a team to support 

water access issues on the Navajo Nation from April 25 through May 25, 2020. This first team 

identified homes without access to piped water and recommended a targeted water haul 

program focused on those at highest risk for COVID-19. On May 22, 2020, the Navajo Nation 

Office of the President requested continued water access planning support from CDC. A second 

field team went to Gallup, New Mexico, from June 15 through July 4, 2020, to provide technical 

assistance for targeted water home delivery and water storage practices and facilities at Navajo 

homesites. The team provided draft recommendations to Navajo Nation leaders for their 

consideration. NCEH/DEHSP continues to provide technical assistance to the Navajo Nation and

Indian Health Service (IHS) as needed. 

Navajo COVID-19 Home Water and Wastewater Improvements Mission: In September 2020, the 

NCEH/DEHSP deployed a staff member to work with an IHS team in Arizona. Through October 

2020, this team member worked with IHS and used home location information provided by the 

Navajo Area to complete site layout system designs detailing the location of proposed water 

cisterns and onsite wastewater disposal systems for 280 homes on the Navajo Nation. The 

team’s work also included field assessments, soil analysis, site designs, and work order drafts for 

follow-on construction to be completed for individual water and wastewater facilities.

NCEH/DEHSP continues to provide technical assistance to the Navajo Nation and IHS as needed.

Recommendation

SDOH unique to AI/AN people must be acknowledged and better understood. CDC should work with 

tribes to better understand SDOH in Indian Country and incorporate the tribal perspective and needs in 

any efforts to address SDOH. 

Response from

NCCDPHP – DPH, Healthy Tribes Program

DPH’s Healthy Tribes Program recently forecasted a new funding opportunity for Tribal Practices 

for Wellness in Indian Country that will focus on addressing SDOH through revitalization of 

traditional practices, connecting with culture, and an increased sense of belonging. Tribal 

partners will create their own definition of cultural connectedness that is representative of their 

perspective, needs, and culture. Tribal partners will have access to evaluation experts, including 

indigenous evaluation experts, to support creation of evaluation measures for their definition of 

cultural connectedness. 

Recommendation

Any efforts to invest in SDOH must also engage tribes and tribal public health experts. 

Response

NCCDPHP – DPH, Healthy Tribes Program

The Healthy Tribes Program and DPH welcome the opportunity to meet with tribes and tribal 

public health experts to better understand the tribal perspective on addressing SDOH. DPH’s 

Healthy Tribes Program will engage and consult with tribes, tribal public health leaders, and 

indigenous evaluation experts to understand, identify, and develop indigenous program 

strategies that affect the SDOH, particularly through the lens of traditional practices and culture. 
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In FY 2021, CDC announced funding to support up to 20 jurisdictions to develop or enhance 

plans to address SDOH. Cherokee Nation is an awarded recipient under this program. 

Response

NCCDPHP – Division of Diabetes Translation (DDT)

DDT is actively engaging with tribes and tribal public health experts to understand their 

perspectives and unique SDOH.

The Native Diabetes Wellness Program website highlights DDT’s work in wellness and type 2 

diabetes prevention among AI/AN people and core principles for the work—including tribal 

consultation and respecting traditional ecological knowledge.

DDT is developing three culturally relevant video public service announcements (PSAs) to share 

vibrant stories of Native participants enrolled in the National Diabetes Prevention Program

(DPP) type 2 diabetes prevention program. The PSAs highlight critical elements of success 

identified by coaches and participants, including community values of generosity and sharing, 

social support, and community engagement in increasing access to traditional foods. The video 

series will be available on CDC’s YouTube channel to view, download, post, and disseminate.

DDT is in the process of developing a cultural adaptation of the National DPP PreventT2 

curriculum for AI/AN people. DDT aims to listen to input and gain understanding to adopt a 

deeper, culture-centered approach within the context of community-based participatory 

research. The narratives will respectfully acknowledge and honor the history and strengths of 

AI/AN communities. The curriculum will include SDOH over generations as well as cultural 

values, such as generosity, sharing, trust, community support, and traditional health knowledge 

(including traditional foods). Individual programs will be able to further tailor the curriculum 

modules with their own stories, photos, recipes, messages of support and encouragement, and 

narratives.

Missing and Murdered Indigenous Persons 

Data

Question

What is CDC doing to develop data collection for MMIP? How is the NCHS involved?

Responses

National Center for Injury Prevention and Control (NCIPC)

There are ongoing surveillance efforts for violent deaths (e.g., homicide) through the National

Violent Death Reporting System, as well as ongoing efforts to analyze data and disseminate 

results via scientific publications and updated communication products.

There are also discussions to increase AI/AN sampling in other surveillance studies (e.g.,

National Intimate Partner and Sexual Violence Survey) that may give information about the risk 

for MMIP.
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NCHS

NCHS does not collect any information directly related to MMIP, nor is NCHS involved with any 

broader effort at CDC to collect these data. NCHS collects only what it can glean from death 

certificates. For example, there are death records for all registered deaths with AI/AN reported 

as the race of the decedent (understanding that AI/AN race is substantially underreported). This 

includes homicides.

Opioid Overdose Prevention 

Resources

Request

The TAC requested community advocacy materials specific for tribal communities and tribal providers to 

address the high rates of fentanyl use.

Response

NCIPC

Although NCIPC does not have materials specific to tribal communities and providers, the 

following helpful resources can be used to communicate about and address high rates of 

fentanyl use:

▪ Rx Awareness Campaign Resources

▪ Stop Overdose

▪ Overdose Resource Exchange

In addition, NCIPC’s Rx Awareness Campaign includes ads that focus on audiences heavily 

affected by the opioid overdose epidemic, including AI/AN communities.

Request

The TAC requests that CDC follow up with NPAIHB on the resolution around the Narcan shortage in the 

Northwest.

Response

NCIPC – Division of Overdose Prevention (DOP)

DOP coordinated with CSTLTS to be connected to NPAIHB. After the initial connection, DOP will 

complete the conversation with NPAIHB.
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Technical Assistance Guidelines 

Communication

Request

The TAC is asking for a comfortable relationship, so if the TAC delegate would like to call on their 

authorized representative to clarify something or to call on a technical advisor, then there is less rigidity 

and formality so that the group can continue the topic and streamline for ease of flow. The TAC 

understands the rules of the Federal Advisory Committee Act (FACA) exemption but would like a more 

comfortable environment by which TAC members can all participate, and technical advisors can add 

comments quickly. The Secretary’s Tribal Advisory Committee (STAC) does this process very well. 

Response

CSTLTS – OTASA

CDC will explore the STAC process for inclusion of technical advisor participation and will work 

to support these considerations within the rules of the FACA exemption.

Request

The TAC reiterates the requirement to ensure TAC inclusion, as well as tribal consultation, in developing 

guidelines or in integrating tribal public health priorities across the agencies. For example, NCEH 

presented at the April 14, 2021, Subcommittee meeting, highlighting the Environmental Tribal Public 

Health Think Tank, which is funded by CDC via the American Public Health Association (APHA) to identify 

areas of interest and provide feedback on CDC environmental health initiatives affecting tribes. The TAC 

expressed concerns that this body does not represent all tribes and should not replace engagement with 

the TAC or formal consultation.

Response

CSTLTS – OTASA

CDC, through OTASA, is working to increase opportunities for more robust and meaningful 

engagement with both the TAC and through formal tribal consultation. The concerns regarding 

the Environmental Think Tank have been provided to and acknowledged by NCEH, and the

center will take these concerns under consideration for any future think tank membership. 

Tribal Testimony 

Tribal Consultation

Recommendation

When CDC creates guidelines with the TAC, tribal consultation must still be conducted. Consultation 

with the CDC TAC does not supplant tribal consultation. It is important that the agency seek input from 

all tribal leaders, across Indian Country, on issues affecting Indian Country. The TAC hopes the recent 

tribal consultation addresses some of these challenges and that CDC leaders are accountable to the 

requests tribal leaders shared, in addition to any further testimony provided via email.
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Response

CSTLTS – OTASA

CDC is working to identify ways to increase opportunities for robust and meaningful 

engagement through tribal consultation with tribal leaders across Indian Country. We are 

committed to increasing our accountability by providing timely feedback about the outcomes of 

tribal consultation.

Recommendation

We recommend that CDC use a Dear Tribal Leader Letter (DTLL) for any tribal consultation official 

notification and widely broadcast the DTLL to the TAC listserv and any other tribal listserv CDC 

maintains.

Response

CSTLTS – OTASA

CDC is committed to providing a Dear Tribal Leader Letter for any tribal consultation and 

increasing the dissemination of this letter through a wide broadcast to the TAC listserv and 

other tribal listservs that CDC maintains.
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Appendix 

Acronym List

ACEs Adverse Childhood Experiences

AI/AN American Indian/Alaska Native

ATSDR Agency for Toxic Substances and Disease Registry

CDC Centers for Disease Control and Prevention

CHA Community Health Assessment

CIOs Centers, Institutes, and Offices

CJS Cross-Jurisdictional Sharing 

COVID-19 2019 Novel Coronavirus Disease

CSELS Center for Surveillance, Epidemiology, and Laboratory Services

CSTLTS Center for State, Tribal, Local, and Territorial Support

DPIFS Division of Performance Improvement and Field Services

DPH Division of Population Health

EPHS Essential Public Health Services

FACA Federal Advisory Committee Act

FDA Food and Drug Administration

FTE Full-Time Employee

GHWIC Good Health and Wellness in Indian Country

HHS United States Department of Health and Human Services

IHS Indian Health Service

MMIP Missing and Murdered Indigenous Persons

MMRC Maternal mortality review committee

MOU Memorandum of Understanding

NCCDPHP National Center for Chronic Disease Prevention and Health Promotion

NCEH National Center for Environmental Health

NCHS National Center for Health Statistics

NCIPC National Center for Injury Prevention and Control

NDI National Death Index

NIHB National Indian Health Board

NNPHI National Network of Public Health Institutes 

NOFO Notice of Funding Opportunity

NPAIHB Northwest Portland Area Indian Health Board

NVSS National Vital Statistics System

NWTEC Northwest Tribal Epidemiology Center

OD Office of the Director

OLJ Operation Lady Justice

OTASA Office of Tribal Affairs and Strategic Alliances

PHAB Public Health Accreditation Board

PHICCS Public Health in Indian Country Capacity Scan

PHNCI Public Health National Center for Innovation

SDOH Social Determinants of Health

SDY Sudden Death in the Young

SPTHB Southern Plains Tribal Health Board

STAC HHS Secretary Tribal Advisory Committee

SUID Sudden Unexpected Infant Death

TAC Tribal Advisory Committee
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TEC Tribal Epidemiology Center

TECPHI Tribal Epidemiology Centers for Public Health Infrastructure

TPWIC Tribal Practices for Wellness in Indian Country