A vial of injectable steroids from the New England Compounding Center is displayed at the Tennessee Department of Health. (AP)

At the first sign of a meningitis outbreak last week, the Tennessee Department of Health sprang into action. It set up emergency operation centers across the state, where officials could collaborate on their response, and set up a toll-free phone line that residents can call with suspected cases.

"In a public health emergency, the state health department is usually a lot of the boots on the ground," said Jim Blumenstock, chief program officer for public health practice for the Association of State and Territorial Health Officials. "State and local health departments are reaching out and literally touching, by voice contact or sending visiting nurses, thousands. 

Come next year, Tennessee is slated to have fewer funds for emergency responses to public health outbreaks like this. The Center for Disease Control is among the federal agency that faces budget cuts  under the sequestration that Congress passed last year. It provides about half of all funding for local and state public health work.

If the sequester cuts take effect, Blumenstock's colleagues at the Association of State and Territorial Health Officials estimate that state public health budgets could see their federal funding cut between 8 percent and 11 percent.

Federal funds can make up more than half of a state public health department's budget.

"Approximately 60 percent of our agency's revenue is derived from federal funding," said Terry Cline, commissioner of the Oklahoma State Department of Health. "Across-the-board reductions in federal public health programs could cripple or eliminate necessary public health functions in Oklahoma."

Public health departments have already seen budgets shrink in recent years, as states  cut back during the recession. Across the country, local and state health departments have shed 52,200 jobs since 2009.

Federal grants to the state for emergency preparedness also have declined by 19 percent over the past decade, from $940 million in 2002 to $758 last year.

The worry, among public health groups, is what happens if federal cuts get layered on top of local scale backs.

"We've seen state public health workforce numbers going down due to the regular budget cuts," said Amanda Jezek, government relations director for the Infectious Diseases Society of America. "Fiscal year 2011 was a difficult year. We look at sequestration across the board, and it's not as though the agency can put one cut here and another cut there. Everything gets cut, from the ability to do surveillance to respond."

Sen. Tom Harkin (D-Iowa) put out a report this summer, on behalf of the Senate Appropriations Subcommittee on Labor, Health and Human Services, detailing the impact of the cuts on public health programs. He estimated that public health emergency preparedness grants - used by states to respond to 7,845 public health emergencies since 2005 - would lose $48 million in funding. In 2012, those programs were funded at $619 million.

The program that certifies and inspects health and longterm care facilities would lose $26 million. 

Public health departments do much of the work in responding to public health emergencies, such as the current meningitis outbreak. Blumenstock says it would be typical, in a situation like this, for public health workers to go clinic to clinic to make sure doctors were purging the troublesome medication.

"They're the ones in the field, making sure that the recall is actually happening," he said.

The possibility of a shortfall in funding for dealing with public health emergencies isn't exactly a new one for state governments. Many found themselves in a similar situation in 2009, just as states were beginning to cut back funds.

Shortly afterwards, the H1N1 pandemic hit.

Health and Human Services does have a Public Health Emergency Fund - meant for use in situations just like this one - but, as Congressional Research Service analyst Sarah Lister notes, it has been left empty for years.

 "Massachusetts was one of the early states effected in the Northeast," recalls Paul Jarris, executive director of the Association of State and Territorial Health Officials. "They were about to send staff home without pay. They just didn't have the money."

Congress ultimately approved an emergency appropriation of $2 billion to fight the H1N1 flu and produce more vaccinations against it. 

Jarris also points to the West Nile Virus, which has seen public health resources shrink - even though it just had its most deadly summer

"That tends to be the history of public health," he says. "When it's out of sight, it's out of mind. If we remove the capacity of public health to inspect facilities, there's no doubt in my mind that people will suffer."