Hawaii, last year ranked the healthiest state in the nation, has scored below average in a report measuring public health preparedness — or the ability to respond to natural disasters, disease outbreaks and other public health crises.

While Hawaii improved slightly over last year’s rating, the state continues to lag behind most states in the 2017 National Health Security Preparedness Index.

The annual assessment of the nation’s day-to-day preparedness for managing local health emergencies gave Hawaii a 6.4 on a 10-point scale, compared with 6.8 for the United States as a whole, according to results released Thursday by the Robert Wood Johnson Foundation.

Like Hawaii, the nation’s overall preparedness improved slightly over last year, though regional disparities persist, with generally lower scores in the Deep South and the Mountain West, where some face elevated disaster risk and have a disproportionate number of low- income residents.

In arriving at an overall health security score, the index analyzes 139 measures ranging from hazard planning in public schools, flu vaccination rates, monitoring food and water safety, and numbers of paramedics and hospitals to laboratory capacity to test for certain viruses and contaminants.

With the measures grouped in six general categories, Hawaii failed to meet the national average in five of the six, with the state falling especially short in two areas:

>> Incident and information management, or its ability to mobilize and manage resources during a health incident (6.8 compared with the national average of 8.2).

>> Community planning and engagement, or how communities mobilize to work together during times of crisis (4.8 compared with the national average of 5.8).

The one area in which Hawaii exceeded the national average was health security surveillance, or the state’s ability to collect and analyze data to identify possible threats before they arise.

Some examples of the measures Hawaii faltered on include not being a member of the Water Information and Analysis Center — a national organization that 90 percent of states belong to for sharing information about water threats — and for not having a climate change and adaption plan. (Hawaii is working on one.)

Other examples of measures affecting Hawaii’s score are its rate of volunteerism — 21 percent compared with 30 percent nationally — and declining participation in Hawaii’s federally funded health care preparedness coalitions.

Isolation factor

Glen P. Mays, a University of Kentucky public health professor and one of the report’s authors, said Hawaii’s score is hurt, in part, because the population is spread out across islands and because the state is isolated from the mainland.

“Hawaii doesn’t have the benefit of being able to rely on a neighboring jurisdiction. For example, in Kentucky there are trauma centers located just across the border in Cincinnati, Ohio,” he said.

Hawaii was at the national average four years ago when the index was started by the U.S. Centers for Disease Control and Prevention, but apparently lost capability between 2013 and 2014.

“The good news is that Hawaii is trending upward,” Mays said. “The question is, Can we accelerate progress?”

Dr. Sarah Park, the state Department of Health’s Disease Outbreak Control Division chief, said the index is a shared responsibility between government and society, with the measures compiled from many sources across diverse sectors, including emergency management, education, hospitals and others.

“While we cannot speak to areas outside our purview, we can say with assurance the department is working continuously to improve overall public health resilience and preparedness levels of our state,” Park said.

But state Sen. Josh Green (D, Kona-Kau) said he wasn’t surprised by Hawaii’s subpar score. He said that while state health officials do good work on basic health issues, the department has fallen short responding to disease outbreaks in the past two to three years.

Green, a physician, said that during the recent dengue fever outbreak, the department didn’t mobilize enough people immediately out of an excess of caution to protect tourism, and that it took six months for the governor to make an emergency proclamation.

“The department needs to be more aggressive to actually deal with disease outbreaks,” he said. “In rural areas the department has fallen short. On the neighbor islands we feel we are often neglected until the people of Oahu get afraid.”

Call for investment

However, Park responded that even the CDC commended the department for its “quick and appropriate response” despite its reduced vector surveillance and response capacity, which is now being rebuilt, and an understaffed communications capacity.

Karl Kim, executive director of the University of Hawaii’s National Disaster Preparedness Training Center, said the results are a wake-up call for Hawaii to invest in public health and health security.

The state should do a better job of addressing a key underlying cause of the low score: growing disparities in health care access for certain economic and ethnic groups, he said.

Kim said Hawaii needs to try harder in this area because the islands are vulnerable due to isolation and exposed to health risks associated with the large number of tourists who flock to the state each year.

Green added, “The long-term threat of infectious disease is more serious than terrorism, and we would be wise to spend more attention and resources in this area.”