Hawaii is ranked among the seven states least-prepared for a public health emergency, according to the 10th annual report titled, “Ready or Not? Protecting the Public from Diseases, Disasters and Bioterrorism.”

The report found significant progress toward improving public health preparedness over the past 10 years, but also found persistent gaps in the country’s ability to respond to health emergencies ranging from bioterrorist threats, to serious disease outbreaks, to extreme weather events.

The study assigned points for state readiness to a maximum possible 10 points, and Hawaii earned four points, putting it in the bottom seven along with Colorado, Georgia, Nevada and New Jersey, while Nos. 6 and 7 Kansas and Montana earned only three points each.

The report was prepared by the Trust for America’s Health and the Robert Wood Johnson Foundation.