Shifting surveillance: the federalization of healthcare-associated infection reporting in the U.S.

OBJECTIVES: To analyze state healthcare-associated infection (HAI) laws and examine the transition from state-driven surveillance to regulatory frameworks substantially shaped by federal policy. METHODS: We conducted a systematic public health law review of statutes, administrative regulations, and policies governing HAI surveillance across 50 U.S. states and the District of Columbia as of March 1, 2024. We analyzed the HAI surveillance framework in each jurisdiction to assess the federal influence. To supplement the legal review and clarify state-specific reporting requirements, we administered a survey to state HAI program coordinators. RESULTS: As of March 2024, 38 jurisdictions (74.5%) mandate HAI reporting. Early laws were primarily state-driven, while later enactments increasingly incorporated federal standards. Among jurisdictions with HAI reporting laws, 23 (60.5%) reference or incorporate Centers for Medicare & Medicaid Services (CMS) mandates into the state law, enabling sharing of federally reported data. Overall, 41 states (80.4%) modified reporting requirements in response to CMS mandates; nearly all jurisdictions with HAI reporting laws (97.4%) adopt other forms of federal policies. CONCLUSIONS: The majority of states have adopted HAI legislation, with state-level reporting laws and policies demonstrating continuous development from 2002 to 2024. Early HAI surveillance efforts, while guided by emerging federal government influences, were primarily based on state policy. However, since 2009, new state laws and policies have increasingly adopted federal policies. Over time, state reliance on federal standards has created a policy shift: state HAI reporting frameworks have expanded and adapted to federal policy, creating a legal environment marked by growing federal-state integration.