Azar Says Federal Law Had Preexisting Conditions Covered Before ACA. Not So Much.

“First off, it’s in statute already in HIPAA that preexisting conditions are covered.”

One of the most popular features of the Affordable Care Act is its guarantee of insurance coverage — at no greater cost — for people with preexisting health conditions.

Thus, even as the Trump administration argues before the Supreme Court that the entire Affordable Care Act should be declared invalid, the president and his administration officials maintain that regardless of what happens to the ACA, they will protect people who have had health problems in the past.

Speaking to a “virtual health summit” sponsored by the political newspaper The Hill, Health and Human Services Secretary Alex Azar answered a question about the case, Texas v. Azar, by pointing out “it’s in statute already in HIPAA that preexisting conditions are covered,” implying that if the ACA were declared unconstitutional, those protections would remain in place for everyone.

Umm … not so much.

When we checked with HHS for more information about Azar’s comment, a spokesperson reiterated the secretary’s statement, adding that Azar was “clear that the story on preexisting conditions doesn’t end with HIPAA” and that affordability is a critical component.

So we investigated.

A Little About HIPAA

The Health Insurance Portability and Accountability Act, a law we have examined before, was passed by a Republican-led Congress and signed by Democratic President Bill Clinton in 1996. It is best known for safeguarding medical privacy and patient access to medical records, even though the privacy provisions were added toward the end of congressional deliberations.

HIPAA’s original purpose was to end what was known as “job lock,” a situation in which people with preexisting conditions were reluctant to leave jobs with health insurance even for other positions with health insurance for fear their conditions would not be covered or they would be subject to long waiting periods for coverage. Both scenarios were common at the time.

HIPAA addressed that problem — as long as people maintained “continuous” coverage, defined as having health insurance for at least 12 months without a break of more than 63 days. People who met that requirement could not have waiting periods or denials of coverage imposed upon their own or a family member’s preexisting condition. HIPAA included protections for people with coverage in the small-group insurance market, which primarily comprises small businesses, by requiring insurers who sold policies in that market to sell to all small groups, regardless of health status, and to cover every eligible member of the groups — again, regardless of health status.

But HIPAA was not designed to comprehensively address the problem of people with preexisting conditions getting and keeping affordable health insurance.

For starters, the protections were only for people who already had job-based insurance, to make it easier for them to move to other job-based insurance. It did nothing for those in the individual insurance market who needed to purchase their own coverage — such as self-employed people and those working for companies that did not offer health insurance.

HIPAA attempted to create a pathway for people transitioning from employer-sponsored to individual coverage. It ensured that, after leaving a job, people who secured insurance through another law, the 1986 Consolidated Omnibus Budget Reconciliation Act, or COBRA, would be eligible to buy a “conversion” plan from their insurer once their previous job-based benefits were exhausted.

However, two giant problems arose. First, COBRA, which allows individuals to continue their employer-provided coverage for up to 18 months if they pay the entire premium themselves (plus a small administrative fee), is prohibitively expensive for most people. In 2019, the average premium for a single worker was $599 per month.

The other problem was that even if a former worker did manage to pay for COBRA coverage until that 18-month period ended, there was no limit on how much insurers could charge for the conversion policies. So, even if they were technically available, they were frequently unaffordable.

There were other problems. COBRA coverage was not available to people who worked for small businesses, or for those who became unemployed because the business they worked for failed and no longer offered insurance to anyone. HIPAA also did not stipulate which benefits had to be offered.

Next, the ACA

The ACA sought to deal with HIPAA’s shortcomings. It required most employers to offer coverage and, for those purchasing their own, it required insurers to provide a comprehensive package of benefits at the same price to all purchasers, regardless of health status.

However, the ACA rewrote the HIPAA provisions regarding preexisting conditions, so if the ACA is struck down by the Supreme Court, it’s not clear whether even HIPAA’s lesser provisions would remain. Experts disagree about this, but there is a possibility that HIPAA’s protections could be swept away along with the ACA.

Later in his answer to the question posed at The Hill’s summit, Azar pointed out that there are significant affordability problems with coverage under the ACA, as well. “So we will work with Congress if the time ever comes, to get real affordable solutions,” he said. That’s true. ACA plans, even with subsidies, can be too expensive for some people, and prohibitive for those who earn just slightly too much to qualify for government help. Earlier this month, Democrats in the House passed a bill to make ACA plans more affordable.

Our Ruling

Azar’s statement suggested that if the Supreme Court rules against the ACA and that sweeping law is nullified, Americans with preexisting conditions would continue to have the protections originally offered under HIPAA.

Though it contains an element of truth, it leaves out critical pieces of information. For instance, the HIPAA protections are not equivalent to those provided by the ACA. First, they are geared toward people who have work-based insurance coverage — as long as that coverage is continuous for at least 12 months with lapses no longer than 63 days. One expert we consulted pointed out that this window could be especially problematic now, during a time of “enormous economic dislocation.”

Additionally, the ACA rewrote the HIPAA provisions regarding preexisting conditions — bringing into question what might become of them, too.

We rate Azar’s claim Mostly False.
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States Allow In-Person Nursing Home Visits As Families Charge Residents Die ‘Of Broken Hearts’

For the most part, visitors are required to stay outside and meet relatives in gardens or on patios where they stay at least 6 feet apart, supervised by a staff member. Appointments are scheduled in advance and masks are mandated. Only one or two visitors are permitted at a time.

Before these get-togethers, visitors get temperature checks and answer screening questions to assess their health. Hugs or other physical contact are not allowed. If residents or staff at a facility develop new cases of COVID-19, visitation is not permitted.

As of July 7, 26 states and the District of Columbia had given the go-ahead to nursing home visits under these circumstances, according to LeadingAge, an association of long-term care providers. Two weeks earlier, the Centers for Medicare & Medicaid Services clarified federal guidance on reopening nursing homes to visitors.

Eighteen states and the District of Columbia were similarly planning to allow visits at assisted living centers.

Visitation policies may change, however, if state officials become concerned about a rise in COVID-19 cases. And individual facilities are not obligated to open up to families, even when a state says they can do so.

Relaxing restrictions is not without risks. Frail older adults in long-term care are exceptionally vulnerable to COVID-19. According to various estimates, 40% to 45% of COVID-related deaths have occurred in these facilities.

But anguished families say loved ones are suffering too much, mentally and physically, after nearly four months in isolation. Since nursing homes and assisted living centers closed to visitors in mid-March, under guidance from federal health authorities, older adults have been mostly confined to their rooms, with minimal human interaction.

The goal was to protect residents from the coronavirus as the pandemic began to escalate. But the virus entered facilities nonetheless as staffers came and went. And now, families argue, the harms of isolation exceed potential benefits.

“My mother stopped eating around the middle of April — now she just picks at her food,” said Marlisa Mills of Asheville, North Carolina. “Every week, she becomes more delusional.” Mill’s mother, 95, has dementia and lives in a nearby nursing home that remains closed to visitors.

Residents “are dying of broken hearts and neglect,” said Lelia Sizemore, whose 84-year-old father’s health deteriorated precipitously after her mother stopped her daily visits to his Dayton, Ohio, nursing home in early March.

Diagnosed with severe dementia, blind and unable to feed himself, Sizemore’s father lost more than 10 pounds in two months and succumbed to respiratory failure on May 24. Even at the end, the nursing home refused her mother’s requests to see him in person.

“I didn’t even get to say goodbye,” sobbed Sizemore, who lives in Oregon and last saw her father in July 2019.

Ohio began allowing visitors at assisted living centers on June 8 and will permit outdoor get-togethers at nursing homes as of July 20.

New Jersey has the second-highest number of COVID deaths in the country. On June 19, the state’s health commissioner announced that all long-term care facilities could accept visitors outdoors — just in time for Father’s Day.

Broadway House for Continuing Care, a Newark facility, quickly notified families and arranged to pitch a tent with chairs and tables underneath in a garden area.

“It’s time to open things up some more: We’ve all been operating under a sense of being under house arrest,” said James Gonzalez, chief executive officer of Broadway House and chair of the board of the Health Care Association of New Jersey.

With weekly tests, 10 residents and 26 staffers at Broadway House have learned they had COVID-19. One resident has died since the outbreak began.

“Are we worried about visitors bringing the virus? Yes, but I think we can manage that,” Gonzalez said. “We’re going to have to take this day by day.”

On Father’s Day, Raul Lugo arrived at Broadway House to visit his grandmother, Rosa Perez, 89, who raised him after his mother died when he was an infant. He had not seen Perez, who had contracted COVID-19 and spent two months in the hospital, since the end of March. Because Perez is frail and it was extremely hot, they met in the facility’s vestibule.

“She told me she missed me and that she loves me. I told her I love her back,” said Lugo, a truck driver. “It was 1,000 times better seeing her in person than talking to her on the phone. You can’t compare it. It was awesome.”

Raul Lugo wanted to hug his grandmother, Rosa Perez, 89, during their in-person visit at her nursing home on June 21. The two had not seen each other for three months.(Courtesy of Damary Lugo)

Complete Care Management, which operates 16 nursing homes in New Jersey, opened all its facilities to visitors within a week of the announcement of the state’s new policy.

Complete Care asks visitors to sign consent forms indicating they understand the risks and will let staffers know if they become ill. No one is allowed to bring food or enter the buildings, even to use the restrooms. For the time being, get-togethers are short – no more than 15 minutes and no more than two visitors at a time.

“Really, the only burdensome part of it is having staff available to bring residents outside, wait with them and bring them back in,” said Efraim Siegfried, Complete Care’s chief executive officer. “If we do everything right, I don’t see a negative outcome. And to see how excited people are, how happy they are, it’s a beautiful thing.”

Before the pandemic, Patricia Tietjen, 72, visited her husband of 52 years, Robert, who has dementia, every day at Complete Care at Green Acres in Toms River, New Jersey. Though staffers tried to arrange FaceTime visits when the home closed to visitors, “it was hard because he was never awake – he started sleeping all the time – and he can’t speak anymore,” Tietjen said.

Robert became ill with COVID-19 in April. Although he survived that, he recently entered hospice care and Tietjen has twice been let into the facility because he is near the end of his life. “It was extremely emotional,” she said, breaking into tears.

Although federal guidance says visitors should be permitted inside long-term care facilities at the end of life, this is not happening as often as it should, said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, an advocacy group.

She wants family visitation policies to be mandatory, not optional. As it stands, facility administrators retain considerable discretion over when and whether to offer visits because states are issuing recommendations only.

Smetanka’s organization has also begun a campaign, Visitation Saves Lives, calling for one “essential support person” to be named for every nursing home or assisted living resident, not just those who are dying. This person should have the right to go into the facility as long as he or she wears personal protective equipment, follows infection control protocols and interacts only with his or her loved one.

Not doing so is “inhumane and cruel” punishment for more than 2 million people — most of them older adults — living in “solitary confinement conditions,” said Tony Chicotel, a staff attorney at California Advocates for Nursing Home Reform, a campaign partner.
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Colorado, Like Other States, Trims Health Programs Amid Health Crisis

As a teenager, Paulina Castle struggled for years with suicidal thoughts. When her mental health was at its most fragile, she would isolate herself, spending days in her room alone.

“That’s the exact thing that makes you feel significantly worse,” the 26-year-old Denver woman said. “It creates a cycle where you’re constantly getting dug into a deeper hole.”

Part of her recovery involved forcing herself to leave her room to socialize or to exercise outside. But the COVID-19 pandemic has made all of that much harder. Instead of interacting with people on the street in her job as a political canvasser, she is working at home on the phone. And with social distancing rules in place, she has fewer opportunities to meet with friends.

“Since the virus started,” she said, “it’s been a lot easier to fall back into that cycle.”

Between the challenges of the pandemic, the social unrest and the economic crisis, mental health providers are warning that the need for behavioural health services is growing. Yet faced with budgetary shortfalls, Colorado is cutting spending on a number of mental health and substance use treatment programs.

Across the country, the recession has cut state revenues at the same time the pandemic has increased costs, forcing lawmakers into painful decisions about how to balance their budgets. State legislatures have been forced to consider health care cuts and delay new health programs even in the midst of a health care crisis. But many lawmakers and health experts are concerned the cuts needed to balance state budgets now could exacerbate the pandemic and the recession down the line.

“Health care cuts tend to be on the table, and of course, it’s counterproductive,” said Edwin Park, a health policy professor at Georgetown University. When there’s a recession, people lose their jobs and health insurance, he noted, the very moment when people need those health programs the most.

‘Everything Has To Be On The Table’

In Colorado, for example, lawmakers had to fill a $3.3 billion hole in the budget for the fiscal year 2020, which started July 1. That included cuts to a handful of mental health programs, with small overall savings but potentially significant impact on those who relied on them.

They cut $1 million from a program designed to keep people with mental illness out of the hospital and another million from mental health services for juvenile and adult offenders. Lawmakers reduced funding for substance abuse treatment in county jails by $735,000 and eliminated $5 million earmarked for addiction treatment programs in underserved communities. And that’s all on top of a 1% cut to Medicaid community providers who offer health care to the state’s poorest residents.

Some of those cuts were offset by $15.2 million in federal CARES Act funding allocated to behavioural health care programs. But some programs were completely defunded. Cuts were targeted primarily at programs that hadn’t started yet or hadn’t been fully implemented. The rationale: Those cuts wouldn’t have as deep an impact.

Doyle Forrestal, CEO of the Colorado Behavioral Healthcare Council, which represents 23 behavioural health care providers, worries that resources won’t be there for an emerging wave of people who have developed mental health or addiction issues during the pandemic.

“People who are isolated at home are drinking a lot more, maybe having other problems — isolation, economic despair,” she said. “There’s going to be a whole new influx once all of this takes hold.”

State legislators said they tried to avoid cutting programs that would hamper the response to the pandemic or the economic recovery.

“There was a desire on both sides to do everything we could to protect health care spending in Colorado,” said Democratic Rep. Dylan Roberts. “But when you’re looking at across-the-board cuts, everything has to be on the table.”

Every state is facing a similar conundrum. With tax filing deadlines pushed back to July 15, states are unsure how much income tax revenue they will collect.

So in addition to cutting back where possible, states are raiding discretionary funds — Colorado repurposed money from the tobacco settlement and marijuana taxes — to shore up their budgets. States are also tapping rainy day funds, which, according to the National Association of State Budget Officers, grew to record levels after the 2008 recession.

New Policies Delayed

Overall, at least 43 states have made some changes to facilitate access to Medicaid or the Children’s Health Insurance Program as many people have lost their job-based health insurance in the COVID crisis. And in late June, voters in Oklahoma approved expanding Medicaid to more residents. But since the start of the pandemic, states including Kansas and California have put off plans to expand eligibility for Medicaid, which provides health care to low-income people.

“These are symptoms of states that can’t deficit-spend, despite this great need for more coverage,” said Sara Collins, vice president for health care coverage and access at the Commonwealth Fund, an independent health policy research foundation based in New York. “If they spend more in one area, that means cuts in another.”

Paulina Castle uses weekly routines to manage her mental health — made worse from isolation during the coronavirus pandemic. “We need to start treating mental health the same as we do physical health,” she says. “This is an issue we need to stop keeping in the dark.”(Courtesy of Paulina Castle)

Colorado has had an aggressive health agenda in recent years but had to defer plans for a public health insurance option that could have provided a more affordable plan for people buying insurance on their own.

The legislature killed a proposal to create an annual mental health checkup. The measure would have cost the state only $13,000, but Democratic Gov. Jared Polis signaled he wouldn’t sign any bills that included new mandates for insurance companies.

Democratic Rep. Dafna Michaelson Jenet, who sponsored the checkup measure, was disappointed.

“Not every one of us is going to catch COVID, but every single one of us will have a mental health impact,” she said.

Long-Term Implications

Once the economic crisis eases, Roberts said, lawmakers will look to restore funding to some of the programs they cut.

But cuts are often easier to make than to restore — as illustrated by cutbacks made during the 2008 recession, according to Georgetown’s Park.

“Many cuts were never fully restored, even though we were in one of the longest economic expansion periods in our country’s history,” Park said.

He also worries many of the smaller primary care and behavioural health providers, who saw fewer patients come through their doors because of stay-at-home orders during the pandemic, might not survive.

“That means less access to care, including routine care like vaccinations,” he said. “If kids aren’t vaccinated, they may be more vulnerable to flu and measles, making them more vulnerable to COVID-19. That makes it more difficult for a stressed health care system to try to deal with a potential second wave of infections.”

The longer-term mental health toll may be harder to catalogue.

Castle, for one, has focused on establishing routines to help her manage her mental health during the pandemic. Every Wednesday night, she plays games online with her friends. And every Friday night, she and her boyfriend build a fire in the backyard.

“If I know people are expecting me to be somewhere at 6 o’clock, that obligation encourages me to go out,” she explained. “There are days it’s a struggle. I have to focus on baby steps.”

Still, Castle worries about others who may be struggling during the pandemic. She has signed on to work with the Colorado chapter of Young Invincibles, which lobbies for health care, higher education and workforce policies to help young adults. Even as states and the federal government have found the money to help hospitals and doctors treat the physical effects of the COVID pandemic, she doesn’t see the same commitment to treating its mental health toll.

“We need to start treating mental health the same as we do physical health,” she said. This is an issue we need to stop keeping in the dark.”

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Amid Surge, Hospitals Hesitate To Cancel Nonemergency Surgeries

Three months ago, the nation watched as COVID-19 patients overwhelmed New York City’s intensive care units, forcing some of its hospitals to convert cafeterias into wards and pitch tents in parking lots.

Hospitals elsewhere prepped for a similar surge: They cleared beds, stockpiled scarce protective equipment, and — voluntarily or under government orders — temporarily canceled non-emergency surgeries to save space and supplies for coronavirus patients.

In most places, that surge in patients never materialized.

Now, coronavirus cases are skyrocketing nationally and hospitalizations are climbing at an alarming rate. But the response from hospitals is markedly different.

Most hospitals around the country are not canceling elective surgeries — nor are government officials asking them to.

Instead, hospitals say they are more prepared to handle the crush of patients because they have enough protective gear for their workers and know-how to better treat coronavirus patients. They say they will shut down nonessential procedures at hospitals based on local assessments of risk, but not across whole systems or states.

Some hospitals have already done so, including facilities in South Florida, Phoenix and California’s Central Valley. And in a few cases, such as in Texas and Mississippi, government officials have ordered hospitals to suspend elective surgeries.

Hospitals’ decisions to keep operating rooms open are being guided partly by money. Elective surgeries account for a significant portion of hospital revenue, and the American Hospital Association estimates that the country’s hospitals and health care systems lost $202.6 billion between March 1 and June 30.

“What we now realize is that shutting down the entire health care system in anticipation of a surge is not the best option,” said Carmela Coyle, president of the California Hospital Association. “It will bankrupt the health care delivery system.”

The association projects that California hospitals will lose $14.6 billion this year, of which $4.6 billion has so far been reimbursed by the federal government.

But some health care workers fear that continuing elective surgeries amid a surge puts them and their patients at risk. For instance, some nurses are still being asked to reuse protective equipment like N95 masks and gowns, even though hospitals say they have enough gear to perform elective surgeries, said Zenei Cortez, president of the National Nurses United union.

“They continue to put us at risk,” Cortez said. “They continue to look at us as if we are disposable material.”

Elective surgeries, generally speaking, are procedures that can be delayed without harming patients, such as knee replacements and cataract surgery.

At least 33 states and the District of Columbia temporarily banned elective surgeries this spring, and most hospitals in states that didn’t ban them, such as Georgia and California, voluntarily suspended them to make sure they had the beds to accommodate a surge of coronavirus patients. The U.S. surgeon general, the Centers for Disease Control and Prevention and the American College of Surgeons also recommended health care facilities suspend nonemergency surgeries.

The suspension was always intended to be temporary, said Dr. David Hoyt, executive director of the American College of Surgeons. “When this all started, it was simply a matter of overwhelming the system,” he said.

Today, case counts are soaring after many states loosened stay-at-home orders and Americans flocked to restaurants, bars and backyards and met up with friends and family for graduation parties and Memorial Day celebrations.

Nationally, confirmed cases of COVID-19 have topped 3 million. In California, cases are spiking, with a 52% jump in the average number of daily cases over the past 14 days, compared with the two previous weeks. Hospitalizations have gone up 44%.

Governors, county supervisors and city councils have responded by requiring people to wear masks, shutting down bars and restaurants — again — and closing beaches on the July Fourth holiday weekend.

But by and large, government leaders are not calling on hospitals to proactively scale back elective surgeries in preparation for a surge.

“Our hospitals are telling us they feel very strongly and competent they can manage their resources,” said Holly Ward, director of marketing and communications at the Arizona Hospital and Healthcare Association. If they feel the situation warrants it, “they on their own will delay surgeries.”

In some states, like Colorado, public health orders that allowed hospitals to resume nonemergency surgeries in the spring required hospitals to have a stockpile of protective equipment and extra beds that could be used to treat an influx of COVID-19 patients.

States also set up overflow sites should hospitals run out of room. In Maryland, for example, the state is using the Baltimore Convention Center as a field hospital. The state of California last week reactivated four “alternative care sites” — including a hospital that was on the verge of closure in the San Francisco Bay Area — to take COVID-19 patients should hospitals fill up.

But the decision to reduce elective surgeries in California will not come from the state. It will be made by counties in consultation with hospitals, said Rodger Butler, a spokesperson for the California Health and Human Services Agency.

The question is whether hospitals have systems in place to meet a surge in COVID-19 patients when it occurs, said Glenn Melnick, a professor of health economics at the University of Southern California.

“To some extent, elective care is good care,” Melnick said “They’re providing needed services. They are keeping the system going. They are providing employment and income.”

In Los Angeles County, more than 2,000 COVID patients are currently hospitalized, according to county data. While that number is projected to go up by a couple of hundred people over the next few weeks, hospitals believe they can accommodate them, said county Health Services Director Christina Ghaly. In the meantime, hospitals are preparing to bring on additional staff members if needed and informing patients who have scheduled surgeries that they could be delayed.

“There’s more patients with COVID in the hospitals than there has been at any point previously in Los Angeles County during the pandemic,” Ghaly said. “Hospitals are more prepared now for handling that volume of patients than they were previously.”

While hospitals have not stopped elective surgeries, many have not ramped up to the full schedule they had before COVID-19. And they say they are picking and choosing surgeries based on what’s happening in their area.

“We were all things COVID when it was just starting,” said Joshua Adler, executive vice president for physician services at UCSF Health. “We didn’t know what we were facing.”

But after a couple of months of treating patients, hospitals have learned how to resupply units, how to transfer patients, how to simultaneously care for other patients and how to improve testing, Adler said.

At Scripps Health in San Diego, which has taken more than 230 patients from hard-hit Imperial County to the east, its hospitals have scaled back how many transfers they will accept as confirmed COVID-19 cases rise in their own community, said Chris Van Gorder, president and CEO of Scripps Health.

A command center set up by the hospital system reviews patient counts and medical supplies and coordinates with county health officials to study how the virus is spreading. Only patients who need urgent surgeries are being scheduled, Van Gorder said.

“We’re only allowing our doctors to schedule cases two weeks out,” Van Gorder said. “If we see a sudden spike, we have to delay.”

In California’s Central Valley and in Phoenix, where cases and hospitalizations are surging, Mercy hospitals have suspended elective surgeries to focus resources on COVID-19 patients.

But the other hospitals in the CommonSpirit Health system, which has 137 hospitals in 21 states, are not ending elective surgeries — as they did in the spring — and are treating patients with needs other than COVID, said Marvin O’Quinn, the system’s president and chief operating officer.

“In many cases their health deteriorated because they didn’t get care that they needed,” said O’Quinn, whose hospitals lost close to a $1 billion in two months. “It’s not only a disservice to the hospital to not do those cases; it’s a disservice to the community.”

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In Texas, Individual Freedoms Clash With Efforts To Slow The Surge Of COVID Cases

HOUSTON — The Fourth of July was a little different this year here in Texas’ biggest city. Parades were canceled and some of the region’s beaches were closed. At the city’s biggest fireworks show, “Freedom Over Texas,” fireworks were shot higher in the air to make it easier to watch from a distance. Other fireworks displays encouraged people to stay in their cars.

After weeks of surging COVID-19 cases and dire warnings that Houston’s massive medical infrastructure would not be able to keep pace, Republican Gov. Greg Abbott issued an executive order on July 2 requiring Texans to wear masks in public, after previously reversing course on the state’s reopening by again closing bars and reducing restaurant capacity.

While most Houstonians appear to be taking heed, not everyone is on board. Small protests against the orders occurred over the holiday weekend. Lawsuits have been filed. At least one Houston-area law enforcement agency said it would not enforce the mask requirement. The State Republican Executive Committee plans to hold its mid-July convention downtown, drawing an expected 6,000 people from around the state.

Democratic Mayor Sylvester Turner said he and other local leaders sent a letter to GOP leaders asking them to convert the convention into a virtual event. But the party remains steadfast.

“There simply is no substitute for the in-person debate we value so strongly,” Texas GOP Chairman James Dickey said, adding that the party committee explicitly affirmed it would not voluntarily cancel the convention. He said there would be thermal scanners, social distancing, deep cleaning between meetings, hand sanitizer and thousands of donated masks available for those in attendance.

“My sincerest sympathies go out to anyone who is affected by any severe disease, including this one,” he said. “But on a per capita basis, Harris County, and Texas in general, are both dramatically better than most of the states in the United States.”

However, confirmed cases in Houston’s surrounding county, Harris, more than doubled in a month to reach more than 37,000 positive cases as of July 6. Hospitals in the Texas Medical Center had 2,261 COVID-positive patients that day in intensive care or medical-surgical units, up from 1,747 the week before, according to the center’s tracking website. All told, the nine-county Houston region has had more than 52,000 confirmed cases and 572 deaths.

The Texas Medical Center has predicted that unless the spread of the virus is mitigated, Houston hospitals could exceed existing capacity by mid-July. A federal assessment team came to Houston to determine how the federal government can help the city respond to the current surge.

Local officials had tried to protect Houston. Early in the pandemic, Harris County Judge Lina Hidalgo, a Democrat who serves as the county’s top elected leader, implemented business closures and stay-at-home and masking orders. But Lt. Gov. Dan Patrick and U.S. Rep. Dan Crenshaw, both Republicans, called them an “overreach” that “could lead to unjust tyranny.” On April 27, Abbott overruled the county guidance, and announced plans to reopen businesses and relax social distancing guidelines.

For those who live in Houston, it’s all meant lots of confusion.

“This whole thing has been a messaging nightmare from the beginning,” said Joe Garcia, 50, who works in data management. “When a flood happens, when a hurricane happens, nobody cares what side you’re on — blue, red, whatever else — all you know is it’s a disaster and everybody comes in and helps. That’s just the way things are. This wasn’t treated as a disaster.”

Public discourse about the pandemic has been disheartening, said Norma Ybarbo, 55, who avoids leaving home beyond socially distant visits with her father and attending a lightly populated early morning mass. She said the political arguments and conflicting communication from the Texas Medical Center in June about hospital capacity have made an already stressful situation worse.

“It’s worrisome, for sure,” Ybarbo said. “It’s really hard to determine what is right and what is true.”

Marine veteran S.D. Panter, 44, said it all has deepened his concern about bias in doctors and politicians who are advocating for businesses to be shut down. Panter, who doesn’t deny the virus is troublesome, said he prefers to do his own research because, for him, the dire picture being painted by those in the spotlight doesn’t make sense. He does wear a mask in public, even though he is not sure it is necessary.

“There’s just so much information. Just let me make my own decision, my own informed decision,” said Panter, who helps his parents and his wife’s parents stay socially isolated. “The older population should probably stay indoors, and let’s protect them the best we can.”

The state’s reopening this spring coincided with Mother’s Day, graduations, Memorial Day and Black Lives Matter protests. Once Texans were released from pandemic-induced restrictions, many happily took advantage of the chance to socialize.

Alyssa Guerra, 27, who lost her job when the store she managed closed, said she now knows people who have contracted the virus, and a few who have become sick or lost loved ones. She has friends who went to bars and social events, without masks, when the state reopened. She went out to eat once, but felt so uncomfortable she hasn’t done it since.

“It’s affecting us in greater numbers now because of the selfish decisions we are making,” said Guerra. “At some point, yes, we are going to have to start living our lives again, but we did it so quickly this time that people just had no care in the world.”

While the number of confirmed COVID-19 infections is rising in all age groups here, those seeing the most rapid growth in positive tests and hospitalizations are 20 to 40 years old. Dr. David Persse, public health authority with the Houston Health Department, said recently that 15% of COVID patients being admitted to the hospital are younger than 50, and 30% are younger than 60.

That could explain lower rates of death now than earlier in the pandemic, said Dr. Angela Shippy, chief medical and quality officer at Memorial Hermann Health System. Another reason for the lower death rates could be that providers have learned more effective treatments for the virus, using different respiratory and drug therapies to avoid intensive care units and intubation.

Still, Houston’s hospitals are being challenged by the rapid spike in COVID patients as a whole. Without taking steps to slow the spread of the virus, hospitals could become unable to manage the load. That has been the message from hospitals — including in multiple full-page ads in the Houston Chronicle advising people to stay home or wear a mask in public.

“We still have the ability to grow capacity, but there will come a limit to how much capacity you can grow,” said Roberta Schwartz, executive vice president, chief innovation officer and CEO of Houston Methodist Hospital.

The area’s public hospitals, which had been steadily handling COVID cases since March, have been transferring adult patients the past several weeks to private hospitals, including Texas Children’s Hospital, which had 29 COVID patients as of July 6. Houston Fire Chief Sam Peña said it has been taking an hour, in some cases, to transfer patients from ambulances to some emergency rooms — which Schwartz said have been “inundated.”

The fire and police departments have large numbers of staff in quarantine. Hospitals report staffers are testing positive, which they attribute to contracting the virus outside the hospital. Some area hospitals are bringing in traveling nurses to help.

“We encourage everyone to do their part and always wear a mask when leaving home, wash your hands often and maintain social distance,” Mark A. Wallace, president and CEO of Texas Children’s Hospital, said in an emailed statement. “This is the best way to protect yourself, your loved ones and our health care workers.”
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What Seniors Should Know Before Going Ahead With Elective Procedures

For months, Patricia Merryweather-Arges, a health care expert, has fielded questions about the coronavirus pandemic from fellow Rotary Club members in the Midwest.

Recently people have wondered “Is it safe for me to go see my doctor? Should I keep that appointment with my dentist? What about that knee replacement I put on hold: Should I go ahead with that?”

These are pressing concerns as hospitals, outpatient clinics and physicians’ practices have started providing elective medical procedures — services that had been suspended for several months.

Late last month, KFF reported that 48% of adults had skipped or postponed medical care because of the pandemic. Physicians are deeply concerned about the consequences, especially for people with serious illnesses or chronic medical conditions.

To feel comfortable, patients need to take stock of the precautions providers are taking. This is especially true for older adults, who are particularly vulnerable to COVID-19. Here are suggestions that can help people think through concerns and decide whether to seek elective care:

Before you go in. Give yourself at least a week to learn about your medical provider’s preparations. “You want to know in advance what’s expected of you and what you can expect from your providers,” said Lisa McGiffert, co-founder of the Patient Safety Action Network.

Merryweather-Arges’ organization, Project Patient Care, has developed a guide with recommended questions. Among them: Will I be screened for COVID-19 upon arrival? Do I need to wear a mask and gloves? Are there any restrictions on what I can bring (a laptop, books, a change of clothing)? Are the areas I’ll visit cleaned and disinfected between patients?

Also ask whether patients known to have COVID are treated in the same areas you’ll use. Will the medical staffers who interact with you also see these patients?

If you’re getting care in a hospital, will you be tested for COVID-19 before your procedure? Is the staff being tested and, if so, under what circumstances?

Hospitals, medical clinics and physicians are offering this kind of information to varying degrees. In the New York City metropolitan area, Mount Sinai Health System has launched a comprehensive “Safety Hub” on its website featuring extensive information and videos.

Mount Sinai also encourages physicians to reach out to patients with messages tailored to their conditions. People “want to hear directly from their providers,” said Karen Wish, the system’s chief marketing officer.

Don’t hesitate to press for more details, said Dr. Allen Kachalia, senior vice president of patient safety and quality at Johns Hopkins Medicine: “Where people get in trouble is when they’re afraid to bring their concerns forward.”

Seeking care. Wendy Hayum-Gross, 57, a counselor who lives in Naperville, Illinois, had been waiting since mid-March to get blood tests that would help doctors diagnose the underlying cause of a new condition, a goiter. A few weeks ago, she decided it was time.

The hospital lab she went to, operated by Edward-Elmhurst Health, told Hayum-Gross to wear a mask and gave her a number to call when she arrived in the parking lot. Outside the front door, she was met by a staffer who took her temperature, asked several screening questions and gave her hand sanitizer.

“Once I passed that, a phlebotomist met me on the other side of the door and took me to a chair that was still wet with disinfectant. She wore a mask and gloves, and there was no one else around,” Hayum-Gross said. “When I saw the precautions they had put in place and the almost military precision with which they were carrying them out, I felt much better.”

Marjorie Helsel DeWert, 67, of Athens, Ohio, was similarly impressed when she visited her dentist recently and noticed circular yellow signs on the floor of the office, spaced 6 feet apart, indicating where people should stand. Staffers had even put pens used to fill out paperwork in individual containers and arranged to disinfect them after use.

DeWert, a learning scientist, came up with a patient safety checklist and distributed it to family and friends. Among her questions: Can necessary forms be completed online before a medical visit? Can I wait in the car outside until called? What kind of personal protective equipment is the staff using? And is the staff being checked for symptoms daily?

Bringing a caregiver. Some medical centers are allowing caregivers to accompany patients; others are not. Be sure to ask what policies are in place.

If you feel your presence is necessary — for instance, if you want to be there for a relative who is frail or cognitively compromised — be firm but also respectful, said Ilene Corina, president of the Pulse Center for Patient Safety Education & Advocacy.

Be prepared to wear a gown, gloves and mask. “You’re not there for yourself: You’re there to support the health care team and the patient,” said Corina, whose organization offers training to caregivers.

In Orland Park, Illinois, debi Ross, an interior designer, and her sister live with her 101-year-old mother. Eight years ago, when her mother had a tumor removed from her colon, Ross and her sister wiped down every electric socket, cord, surface and door handle in her mother’s hospital room.

“Unless Mom absolutely needs [medical] care, we’re not going to take her anywhere,” Ross said. “But I assure you, if she does have to go see somebody, we’re going to clean that place down from top to bottom, I don’t care what anybody says.”

If you are not allowed into a medical facility, get a phone number for the physician caring for a loved one and make sure they have your number as well, Merryweather-Arges said. Ask that you be contacted immediately if there are any complications.

Afterward. Patients leaving hospitals are fearful these days that they may have become infected with COVID-19, unwittingly. Ask your physician or a nurse what equipment you’ll need to monitor yourself. Will a pulse oximeter and a thermometer be necessary? Will you need masks and gloves at home if someone is coming in to help you out with the transition? Can someone provide that equipment?

“Family caregivers need instructions that are clear,” said Martin Hatlie, chief executive of Project Patient Care. “They need to know who to call 24/7 if they have a question. And they need clear guidance about infection control in the home.”

If home care is being ordered, ask the agency whether they have trained staff to recognize COVID symptoms. And have home care workers been tested for COVID-19 or had symptoms?

If follow-up care is being provided via telehealth, make sure the setup works before your loved one comes home. Ask your physician’s office what kind of equipment you will need, which service they use (Zoom? Skype?) and whether you can arrange a test in advance.

Finally, as you resume activities, help protect others against COVID-19 as well as yourself. When you go out into the world again, “mask up, socially distance and wash your hands,” said Kachalia of Johns Hopkins. “And if you’re sick or have symptoms, by all means, let your doctor’s office know before you come in for a checkup.”
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Statement of the twenty-fifth polio IHR Emergency Committee

The twenty-fifth meeting of the Emergency Committee under the International Health Regulations (2005) (IHR) on the international spread of poliovirus was convened and opened by the Director General on 23 June 2020 with committee members attending via teleconference, supported by the WHO Secretariat.  Dr Tedros in his opening remarks said that while there has been amazing progress on wild poliovirus in Africa, there is still much more work to do to end transmission in Pakistan and Afghanistan. Similarly, the significantly greater than expected number of circulating vaccine derived polio virus type-2 (cVDPV2) outbreaks are another major challenge.  The COVID-19 pandemic has had a significant impact on public health programs, including polio eradication.  As a result, the risk of the international spread of polio is likely to have increased considerably.  At the same time, the polio infrastructure that has been developped in Pakistan and Afghanistan has been used to assist with the tracking and tracing as part of the COVID-19 pandemic response.
He also remarked that the novel oral polio vaccine type-2, which will be made available under the Emergency Use Listing procedure (EUL), is expected to be an important new tool to stop the vicious cycle of using monovalent Sabin OPV2 to combat outbreaks, but in turn seeding new outbreaks of cVDPV2.  Dr Tedros thanked the committee for their commitment and said he looked forward to receiving their advice.
The Emergency Committee reviewed the data on wild poliovirus (WPV1) and circulating vaccine derived polioviruses (cVDPV).  The WHO Secretariat presented a report of progress for affected IHR States Parties subject to Temporary Recommendations.  The following IHR States Parties provided an update at the teleconference on the current situation and the implementation of the WHO Temporary Recommendations since the Committee last met on 26 March 2020: Afghanistan, Burkina Faso, Mali and Pakistan.   In order to ease the burden on affected  State Parties in the exceptional situation following the determination of the COVID-19 outbreak as a Public Health Emergency of International Concern (PHEIC) on 30 January 2020, the following invited State Parties were asked to present their reports electronically only instead of attending via teleconference: Chad, Cote d’Ivoire, Ethiopia, Ghana, Malaysia, Niger, Nigeria, Philippines, Philippines, and Togo.  All these States Parties have previously attended teleconferences of the committee to present their statements.

Wild poliovirus

The global situation remains of great concern with the increased number of WPV1 cases that started in 2019 continuing in 2020.  This year there have been 70 WPV1 cases as at 16 June 2020, compared to 57 for the same period in 2019, with no significant success yet in reversing this upward trend.
In Pakistan transmission continues to be widespread, as indicated by both acute flaccid paralysis (AFP) surveillance and environmental sampling. WPV1 transmission continues to be widespread, with southern Khyber Pakhtunkhwa becoming a new WPV1 reservoir, and some areas such as Karachi and the Quetta block having uninterrupted transmission.  There has also been expansion of WPV1 to previously polio free areas in Sindh and Punjab.
In Afghanistan, the security situation remains very challenging.  Inaccessibility and missed children particularly in the Southern Region have led to a large cohort of susceptible children in this part of Afghanistan.  The risk of a major upsurge of cases is growing, with other parts of the country that have been free of WPV1 for some time now at risk of outbreaks. The number of provinces reporting WPV1 has increased from three in 2019 to 11 in 2020.  This would again increase the risk of international spread.
The  Committee noted that based on results from sequencing of WPV1, there were recent instances of international spread of viruses from Pakistan to Afghanistan and from Afghanistan to Pakistan.  The ongoing frequency of WPV1 international spread between the two countries and the increased vulnerability in other countries where routine immunization and polio prevention activities have both been adversely affected by the COVID-19 pandemic are two major factors that suggest the risk of international spread may be at the highest level since 2014.  While border closures and lockdowns may mitigate the risk in the short term while in force, this would be outweighed in the longer term by falling population immunity through disruption of vaccination and the resumption of normal population movements.
The Committee noted that at its meeting 15 – 17 June, the African Regional Certification Commission had accepted the evidence presented by Nigeria that it was now free of WPV1 infection, and commended this achievement by the Government of Nigeria and its partners.

Vaccine derived poliovirus (VDPV)

The multiple cirulating VDPV (cVDPV) outbreaks in four WHO regions (African, Eastern Mediterranean, South-east Asian and Western Pacific Regions) are very concerning, with one new country reporting an outbreak since the last meeting (Mali).  Unlike historical experience, international spread of cVDPV2 has become quite common, with recent spread from Chad and CAR to Cameroon; Nigeria, Togo and Ghana to Cote d’Ivoire; Nigeria to Benin, Ghana to Burkina Faso, Nigeria to Mali, Togo to Niger, Ghana and Benin to Togo, Angola to DR Congo, and Pakistan to Afghanistan.  In addition, a new local emergence attributable to mOPV2 use has recently occurred in Ethiopia.
In 2020, West Africa and Ethiopia are experiencing high levels of transmission of cVDPV2, and due to the pandemic, outbreak response has been significantly hampered, with many areas that have reported cases recently not having had an immunization response.  The Committee repeated its strong support for the development and proposed Emergency Use Listing of the novel OPV2 vaccine which should become available mid-2020, and which it is hoped will result in no or very little seeding of further outbreaks.

Impact of COVID-19

The Committee noted that in many polio infected countries, the COVID-19 pandemic has disrupted polio surveillance to a varying extent, sometimes significantly, resulting in an unusual degree of uncertainty regarding the current true polio epidemiology.  All of the countries reported postponements of immunization responses to cases, further increasing risk.  In addition, routine immunisation has also been adversely affected by the pandemic in many countries.  There is evidence that in some polio infected countries, the pandemic may yet to have peaked.  As international travel begins to return, there is unknown risk of exportation of polioviruses.  There are many other challenges ahead, such as the effect of COVID-19 on community trust and support for immunization, the possibility of other epidemics such as measles, the risks to front-line workers and how these can be managed, and the risk of immunization activities being associated with COVID-19 outbreaks, either truly or spuriously.
On a positive note, the contribution of polio infrastructure, such as the National Emergency Operation Centre in Pakistan, to pandemic control efforts was significant.  Going forward, the committee noted the opportunity to link polio eradication and pandemic response in positive ways.

Conclusion

The Committee unanimously agreed that the risk of international spread of poliovirus remains a Public Health Emergency of International Concern (PHEIC) and recommended the extension of Temporary Recommendations for a further three months.  However noting that many international borders are closed to prevent  international spread of COVID-19, State Parties may not currently be able to enforce the Temporary Recommendations in all places. The Committee strongly urges countries subject to these recommendations to maintain a high state of readiness to implement them as soon as possible ensuring the continued safety of travelers as well as health professionals.  The Committee recognizes the concerns regarding the lengthy duration of the polio PHEIC, but concludes that the current situation is extraordinary, with clear ongoing and increasing risk of international spread and ongoing need for coordinated international response. The Committee considered the following factors in reaching this conclusion:
  • Rising risk of WPV1 international spread: The progress made in recent years appears to have reversed, with the Committee’s assessment that the risk of international spread is at the highest point since 2014 when the PHEIC was declared. This risk assessment is based on the following:

 

  • the ongoing WPV1 exportation from Pakistan to Afghanistan, and from Afghanistan to Pakistan;
  • ongoing rise in the number of WPV1 cases and positive environmental samples in both Pakistan and
    Afghanistan with formerly polio free areas within the countries reporting cases in 2020;
  • the quickly increasing cohort of inaccessible unvaccinated children in Afghanistan, with the risk of a major
    outbreak imminent if nothing is done to access them;
  • the urgent need to overhaul the leadership and strategy of the program in Pakistan, which although already commenced, is likely take some time to lead to more effective control of transmission and ultimately eradication;
  • increasing community and individual resistance to the polio program.

 

  • Rising risk of cVDPV international spread: The clearly documented increased spread in recent months of cVDPV2 demonstrate the unusual nature of the current situation, as international spread of cVDPV in the past has been very infrequent.  The number of new emergences of cVDPV2 in Africa raises further concern.  The risk of new outbreaks in new countries is considered very high.
  • COVID-19:  This unprecedented pandemic is likely to continue to substantially negatively impact the polio eradication program and outbreak control efforts.  The need to take extra precautions to prevent COVID-19 transmission will probably have an impact on vaccination coverage, and also hamper polio surveillance activities leading to increased risk of missed transmission.
  • Falling PV2 immunity:  Global population mucosal immunity to type 2 polioviruses (PV2) continues to fall, as the cohort of children born after OPV2 withdrawal grows, exacerbated by poor coverage with IPV particularly in some of the cVDPV infected countries.
  • Multiple outbreaks: The evolving and unusual epidemiology resulting in rapid emergence and evolution of cVDPV2 strains is extraordinary and not yet fully understood and represents an additional risk that is yet to be quantified.
  • Weak routine immunization: Many countries have weak immunization systems that can be further impacted by various humanitarian emergencies including COVID19, and the number of countries in which immunization systems have been weakened or disrupted by conflict and complex emergencies poses a growing risk, leaving populations in these fragile states vulnerable to outbreaks of polio.
  • Lack of access: Inaccessibility continues to be a major risk, particularly in several countries currently infected with WPV or cVDPV, i.e. Afghanistan, Nigeria, Niger, Somalia and Myanmar, which all have sizable populations that have been unreached with polio vaccine for prolonged periods.
  • Population movement: While border closures may have mitigated the short term risk, conversely the risk once borders begin to be re-opened is likely to be higher.

 

 

 

 

Risk categories

The Committee provided the Director-General with the following advice aimed at reducing the risk of international spread of WPV1 and cVDPVs, based on the risk stratification as follows:
  • States infected with WPV1, cVDPV1 or cVDPV3, with potential risk of international spread.
  • States infected with cVDPV2, with potential risk of international spread.
  • States no longer infected by WPV1 or cVDPV, but which remain vulnerable to re-infection by WPV or cVDPV.
Criteria to assess States as no longer infected by WPV1 or cVDPV:
  • Poliovirus Case: 12 months after the onset date of the most recent case PLUS one month to account for case detection, investigation, laboratory testing and reporting period OR when all reported AFP cases with onset within 12 months of last case have been tested for polio and excluded for WPV1 or cVDPV, and environmental or other samples collected within 12 months of the last case have also tested negative, whichever is the longer.
  • Environmental or other isolation of WPV1 or cVDPV (no poliovirus case): 12 months after collection of the most recent positive environmental or other sample (such as from a healthy child) PLUS one month to account for the laboratory testing and reporting period
  • These criteria may be varied for the endemic countries, where more rigorous assessment is needed in reference to surveillance gaps (e.g. Borno State, Nigeria)
Once a country meets these criteria as no longer infected, the country will be considered vulnerable for a further 12 months.  After this period, the country will no longer be subject to Temporary Recommendations, unless the Committee has concerns based on the final report.

TEMPORARY RECOMMENDATIONS

States infected with WPV1, cVDPV1 or cVDPV3 with potential risk of international spread 

WPV1
Afghanistan     (most recent detection 27 May 2020)
Pakistan           (most recent detection 8 June 2020)
cVDPV1
Malaysia          (most recent detection 12 February 2020)
Myanmar        (most recent detection 9 August 2019)
Philippines      (most recent detection 28 November 2019)

These countries should:

  • Officially declare, if not already done, at the level of head of state or government, that the interruption of poliovirus transmission is a national public health emergency and implement all required measures to support polio eradication; where such declaration has already been made, this emergency status should be maintained as long as the response is required.
  • Ensure that all residents and long­term visitors (i.e. > four weeks) of all ages, receive a dose of bivalent oral poliovirus vaccine (bOPV) or inactivated poliovirus vaccine (IPV) between four weeks and 12 months prior to international travel.
  • Ensure that those undertaking urgent travel (i.e. within four weeks), who have not received a dose of bOPV or IPV in the previous four weeks to 12 months, receive a dose of polio vaccine at least by the time of departure as this will still provide benefit, particularly for frequent travelers.
  • Ensure that such travelers are provided with an International Certificate of Vaccination or Prophylaxis in the form specified in Annex 6 of the IHR to record their polio vaccination and serve as proof of vaccination.
  • Restrict at the point of departure the international travel of any resident lacking documentation of appropriate polio vaccination. These recommendations apply to international travelers from all points of departure, irrespective of the means of conveyance (e.g. road, air, sea).
  • Further intensify cross­ border efforts by significantly improving coordination at the national, regional and local levels to substantially increase vaccination coverage of travelers crossing the border and of high risk cross ­border populations. Improved coordination of cross ­border efforts should include closer supervision and monitoring of the quality of vaccination at border transit points, as well as tracking of the proportion of travelers that are identified as unvaccinated after they have crossed the border.
  • Further intensify efforts to increase routine immunization coverage, including sharing coverage data, as high routine immunization coverage is an essential element of the polio eradication strategy, particularly as the world moves closer to eradication.
  • Maintain these measures until the following criteria have been met: (i) at least six months have passed without new infections and (ii) there is documentation of full application of high quality eradication activities in all infected and high risk areas; in the absence of such documentation these measures should be maintained until the state meets the above assessment criteria for being no longer infected.
  • Provide to the Director-General a regular report on the implementation of the Temporary Recommendations on international travel.

 

States infected with cVDPV2s, with potential or demonstrated risk of international spread

Afghanistan       (most recent detection 15 May 2020)
Angola                (most recent detection 9 February 2020)
Benin                  (most recent detection 16 January 2020)
Burkina Faso     (most recent detection 30 March 2020)
Cameroon         (most recent detection 5 May 2020)
Central African Republic  (most recent detection 5 February 2020)
Chad                  (most recent detection 9 May 2020)
Cote d’Ivoire     (most recent detection 9 May 2020)
Democratic Republic of the Congo    (most recent detection 8 February 2020)
Ethiopia            (most recent detection 16 March 2020)
Ghana               (most recent detection 11 March 2020)
Malaysia           (most recent detection 22 January 2020)
Mali                   (most recent detection 6 February 2020)
Niger                 (most recent detection15 March 2020)
Nigeria              (most recent detection 1 January 2020)
Pakistan            (most recent detection 2 May 2020)
Philippines       (most recent detection 16 January 2020)
Somalia            (most recent detection 8 May 2020)
Togo                  (most recent detection 3 May 2020)
Zambia             (most recent detection 25 November 2019)

These countries should:

  • Officially declare, if not already done, at the level of head of state or government, that the interruption of poliovirus transmission is a national public health emergency and implement all required measures to support polio eradication; where such declaration has already been made, this emergency status should be maintained.
  • Noting the existence of a separate mechanism for responding to type 2 poliovirus infections, consider requesting vaccines from the global mOPV2 stockpile based on the recommendations of the Advisory Group on mOPV2.
  • Encourage residents and long­term visitors to receive a dose of IPV four weeks to 12 months prior to international travel; those undertaking urgent travel (i.e. within four weeks) should be encouraged to receive a dose at least by the time of departure.
  • Ensure that travelers who receive such vaccination have access to an appropriate document to record their polio vaccination status.
  • Intensify regional cooperation and cross border coordination to enhance surveillance for prompt detection of poliovirus, and vaccinate refugees, travelers and cross border populations, according to the advice of the Advisory Group.
  • Further intensify efforts to increase routine immunization coverage, including sharing coverage data, as high routine immunization coverage is an essential element of the polio eradication strategy, particularly as the world moves closer to eradication.
  • Maintain these measures until the following criteria have been met: (i) at least six months have passed without the detection of circulation of VDPV2 in the country from any source, and (ii) there is documentation of full application of high quality eradication activities in all infected and high risk areas; in the absence of such documentation these measures should be maintained until the state meets the criteria of a ‘state no longer infected’.
  • At the end of 12 months without evidence of transmission, provide a report to the Director-General on measures taken to implement the Temporary Recommendations.

 

 

States no longer infected by WPV1 or cVDPV, but which remain vulnerable to re-infection by WPV or cVDPV

WPV1

  • none

 

cVDPV
  • Mozambique cVDPV2 (most recent detection 17 December 2018)
  • PNG cVDPV1 (most recent detection 6 November 2018)
  • Indonesia cVDPV1 (most recent detection 13 February 2019)
  • China (most recent detection 25 April 2019)

These countries should:

  • Urgently strengthen routine immunization to boost population immunity.
  • Enhance surveillance quality, including considering introducing supplementary methods such as environmental surveillance, to reduce the risk of undetected WPV1 and cVDPV transmission, particularly among high risk mobile and vulnerable populations.
  • Intensify efforts to ensure vaccination of mobile and cross ­border populations, Internally Displaced Persons, refugees and other vulnerable groups.
  • Enhance regional cooperation and cross border coordination to ensure prompt detection of WPV1 and cVDPV, and vaccination of high risk population groups.
  • Maintain these measures with documentation of full application of high quality surveillance and vaccination activities.
  • At the end of 12 months without evidence of reintroduction of WPV1 or new emergence and circulation of cVDPV, provide a report to the Director-General on measures taken to implement the Temporary Recommendations.

Additional considerations

Impact of COVID-19 on the polio program:
  • The committee urges all countries, but particularly those at high risk of polio, to maintain a high level of polio surveillance throughout the ongoing pandemic, noting that the postponement of polio immunization campaigns whether preventive or in response to outbreaks may lead to an increase in polio transmission including international spread.  There may be opportunities to strengthen polio and COVID-19 surveillance synergistically.
  • Secondly, outbreak affected countries should resume immunization response campaigns as soon as feasibly possible.  The planning and implementation of the response should employ a flexible approach whereby some activities are put on hold as the transmission of COVID-19 intensifies and then resumed as the COVID-19 transmission reverses back from community transmission to the interruption of COVID-19 transmission.  Critically, campaigns should be planned and implemented in such a way that they protect front line polio workers and also the communities they serve so that COVID-19 transmission is not increased.  This includes ensuring teams have access to appropriate personal protective equipment, teams are selected so that high risk workers are not put on the front-line, and that the risks related to the pandemic are factored into the selection and planning of areas targeted by polio campaigns.
  • Given the risk of international spread, countries need to ensure that they are ready to use appropriate polio vaccines, as recommended by the Strategic Advisory Group of Experts on Immunization, in response to new outbreaks.
  • The committee urged countries to maximize the use of polio assets to synergistically address the COVID19 pandemic, noting that polio affected countries may be vulnerable to poorer outcomes in the pandemic due to health care system fragility and poorer health status of the population generally.  
  • Lastly the pandemic should serve as a reminder to high risk countries with poor immunization coverage that infectious disease outbreaks can lead to social and economic disruption as well as straining the health care system, and countries can increase their population resilience and recovery through prioiritising  robust immunization programmes. This is relevant not only to polio, but to all other vaccine preventable diseases particularly measles.  In particular, countries whether eligible for Gavi support or not should plan to implement a second dose of IPV now being introduced to protect children from paralytic polio.
    Based on the current situation regarding WPV1 and cVDPV, and the reports provided by affected countries, the Director-General accepted the Committee’s assessment and on 3 July 2020 determined that the situation relating to poliovirus continues to constitute a PHEIC, with respect to WPV1 and cVDPV.  The Director-General endorsed the Committee’s recommendations for countries meeting the definition for ‘States infected with WPV1, cVDPV1 or cVDPV3 with potential risk for international spread’, ‘States infected with cVDPV2 with potential risk for international spread’ and for ‘States no longer infected by WPV1 or cVDPV, but which remain vulnerable to re-infection by WPV or cVDPV’ and extended the Temporary Recommendations under the IHR to reduce the risk of the international spread of poliovirus, effective 3 July 2020.

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Introductory meeting of WHO’s Strategic and Technical Advisory Group for Tuberculosis

An introductory meeting of WHO’s Strategic and Technical Advisory Group for Tuberculosis (STAG-TB) was held on 24-25 June 2020. STAG-TB, which is comprised of 15 eminent experts from ministries of health, national TB programmes, academic and research institutions, civil society organizations, and communities and patients affected by TB. The group is led by Dr Ariel Pablos-Méndez as Chair,  and provides strategic advice to WHO’s Director-General and the Global TB Programme on its TB response.

In his keynote address, WHO Director General Dr Tedros emphasized the important strategic role of STAG-TB in efforts to end TB especially in light of the current COVID-19 pandemic. He said, “Even at this difficult time, with COVID-19 threatening the world, WHO remains committed to meet the TB targets and driving high-level action and investment. Commitments must be kept to address all communicable disease threats, and reach the triple billion targets, despite the COVID-19 crisis. Doing so offers hope to end avoidable death and suffering for millions of people worldwide at risk from preventable and treatable diseases like TB.”

The meeting was opened by Dr Ren Minghui, WHO Assistant Director-General, Universal Health Coverage, Communicable and Noncommunicable Diseases Division. The first day focused on briefings from the WHO Global TB Programme secretariat on ongoing WHO efforts towards ending TB, preparations underway for the development of the 2020 progress report of the UN Secretary General on TB, and the impact of the COVID-19 pandemic on the TB response. The second day included a special session of STAG-TB members with WHO Director-General Dr Tedros Adhanom Ghebreyesus. Key partners – Stop TB Partnership, Global Fund and UNITAID also participated in this session.

Dr Ariel Pablos-Méndez, STAG-TB Chair highlighted the group’s commitment to guide WHO’s TB response. He emphasized, “We need to leverage existing synergies between TB and universal health coverage to save lives. This is especially critical in this time of crisis. STAG-TB is dedicated to providing strategic direction that will guide WHO in supporting countries to accelerate progress and investment to reach targets set by the UN High-level Meeting on TB.”

Dr Tereza Kasaeva, Director of WHO’s Global TB Programme appreciated the role of STAG-TB, she said, “The STAG-TB provides a critical contribution to WHO, and the world, in combatting TB. We look forward to receiving strategic advice from STAG-TB during this, and coming, years on how the world can meet commitments to end the TB epidemic especially in the face of new threats”.

The next meeting of the STAG-TB will be held in November 2020.
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60 Minutes promotes one hospital’s “promise of plasma”

I’m a bit late on this with only a few excuses.  The birth of a new grandson.  Computer problems.  Living in the Minneapolis area and being focused on the death of George Floyd and the ensuing protests.

But this is worth addressing, even though a little late.

CBS 60 Minutes broadcast a story it called, “The Promise of Plasma,” about a trial of convalescent plasma at just one medical center in New Jersey.

You’re going to hear a lot about convalescent plasma because the approach makes intuitive sense.  But science needs to prove that things work. Intuition is not sufficient.  And the 60 Minutes story did a pretty weak job of establishing the difference. (The Mayo Clinic explains convalescent plasma on its website.)

Here are some of the things that could have been improved in the 60 Minutes story.

  • There are many clinical trials of convalescent plasma all over the US and all over the world.  CBS referred to tests at “numerous hospitals” – which is a bit of an understatement.  And the only one mentioned, the only one profiled by CBS, was one in New Jersey, which CBS notes is “just a 30-minute drive from midtown Manhattan,” where 60 Minutes is based.  Perhaps that’s why CBS chose to shine its light only on one hospital.
  • The tone of the piece was highly promotional.  It referred to the hospital’s “breakneck battle” and “all out battle.” The segment’s title – “The promise of plasma” – is alluring alliteration. But “promising” was one of the words patients have told me they don’t need to hear in medical news stories.
  • The only data – the only evidence – provided by 60 Minutes was what this one hospital told them:  “So far, 31 of the 46 patients who received plasma in this study appear to have recovered more quickly than those who didn’t.”  There are many holes in that statement and many questions left unanswered by CBS.  And no data from all of the other clinical trials around the globe were presented.
  • There was also no independent perspective in the story.  All of the input came from one hospital and one research team.  Nothing from anyone at any of the other clinical trial sites, no comment from the National Institutes of Health or the Food and Drug Administration. It was wonderful PR for the New Jersey hospital.  It was not the best journalism for 60 Minutes viewers.
  • Often it is what journalists allow interviewees to say – unchallenged – that is most concerning.  That happened with this 60 Minutes story.

CBS quoted a researcher who is helping to lead the New Jersey hospital’s convalescent plasma trial.  This is how the story ended.

CBS’ Bill Whitaker: Based on what you have seen so far, what does your gut tell you?

David Perlin, researcher: My gut says that this is going to work. The initial response of the patients is incredibly encouraging. But as a scientist, I’m trained to be cautious. And so right now this is our best approach, we are going to take it, we’ll be aggressive with it but we’ll see how patients respond.

Benjamin Mazer, MD, a physician who is very active on social media, tweeted:

Another physician joined Mazer with pointed skepticism:

So, even though researcher Perlin made an attempt to remind himself to be cautious, he went ahead and called the experiment “our best approach.”  Well you can’t say that it’s the best approach because you don’t know that. That is why you’re doing the trial.  And CBS should have addressed that.  They didn’t, and that’s the take home message they ended with.

An RN/paramedic on Twitter reflected on the impact of stories like this on viewers:

We have criticized 60 Minutes in the past.  Just two examples:

60 Minutes piece on Kanzius cancer cure not worth 60 seconds

CBS proclaims ‘cancer breakthrough’ – doesn’t explain what FDA means by that term

As always, when we criticize, we try to do so constructively, pointing to ways in which a story could have been improved – often with little effort. We hope 60 Minutes pays attention.
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Hollowed-Out Public Health System Faces More Cuts Amid Virus

The U.S. public health system has been starved for decades and lacks the resources to confront the worst health crisis in a century.

Marshaled against a virus that has sickened at least 2.6 million in the U.S., killed more than 126,000 people and cost tens of millions of jobs and $3 trillion in federal rescue money, state and local government health workers on the ground are sometimes paid so little that they qualify for public aid.

They track the coronavirus on paper records shared via fax. Working seven-day weeks for months on end, they fear pay freezes, public backlash and even losing their jobs.

Since 2010, spending for state public health departments has dropped by 16% per capita and spending for local health departments has fallen by 18%, according to a KHN and Associated Press analysis of government spending on public health. At least 38,000 state and local public health jobs have disappeared since the 2008 recession, leaving a skeletal workforce for what was once viewed as one of the world’s top public health systems.

KHN and AP interviewed more than 150 public health workers, policymakers and experts, analyzed spending records from hundreds of state and local health departments, and surveyed statehouses. On every level, the investigation found, the system is underfunded and under threat, unable to protect the nation’s health.

Dr. Robert Redfield, the director of the Centers for Disease Control and Prevention, said in an interview in April that his “biggest regret” was “that our nation failed over decades to effectively invest in public health.”

So when this outbreak arrived — and when, according to public health experts, the federal government bungled its response — hollowed-out state and local health departments were ill-equipped to step into the breach.

Over time, their work had received so little support that they found themselves without direction, disrespected, ignored, even vilified. The desperate struggle against COVID-19 became increasingly politicized and grew more difficult.

States, cities and counties in dire straits have begun laying off and furloughing members of already limited staffs, and even more devastation looms, as states reopen and cases surge. Historically, even when money pours in following crises such as Zika and H1N1, it disappears after the emergency subsides. Officials fear the same thing is happening now.

“We don’t say to the fire department, ‘Oh, I’m sorry. There were no fires last year, so we’re going to take 30% of your budget away.’ That would be crazy, right?” said Dr. Gianfranco Pezzino, the health officer in Shawnee County, Kansas. “But we do that with public health, day in and day out.”

Ohio’s Toledo-Lucas County Health Department spent $17 million, or $40 per person, in 2017.

Jennifer Gottschalk, 42, works for the county as an environmental health supervisor. When the coronavirus struck, the county’s department was so short-staffed that her duties included overseeing campground and pool inspections, rodent control and sewage programs, while also supervising outbreak preparedness for a community of more than 425,000 people.

When Gottschalk and five colleagues fell ill with COVID-19, she found herself fielding calls about a COVID-19 case from her hospital bed, then working through her home isolation. She stopped only when her coughing was too severe to talk on calls.

“You have to do what you have to do to get the job done,” Gottschalk said.

Now, after months of working with hardly a day off, she said the job is wearing on her. So many lab reports on coronavirus cases came in, the office fax machine broke. She faces a backlash from the community over coronavirus restrictions and there are countless angry phone calls.

Things could get worse; possible county budget cuts loom.

But Toledo-Lucas is no outlier. Public health ranks low on the nation’s financial priority list. Nearly two-thirds of Americans live in counties that spend more than twice as much on policing as they spend on non-hospital health care, which includes public health.

Jennifer Gottschalk, environmental health supervisor of the Toledo-Lucas County Health Department, works in her office in Toledo, Ohio. “Being yelled at by residents for almost two hours straight last week on regulations I cannot control left me feeling completely burned out,” she said in mid-June.(AP Photo/Paul Sancya)

More than three-quarters of Americans live in states that spend less than $100 per person annually on public health. Spending ranges from $32 in Louisiana to $263 in Delaware, according to data provided to KHN and AP by the State Health Expenditure Dataset project.

That money represents less than 1.5% of most states’ total spending, with half of it passed down to local health departments.

The share of spending devoted to public health belies its multidimensional role. Agencies are legally bound to provide a broad range of services, from vaccinations and restaurant inspections to protection against infectious disease. Distinct from the medical care system geared toward individuals, the public health system focuses on the health of communities at large.

“Public health loves to say: When we do our job, nothing happens. But that’s not really a great badge,” said Scott Becker, chief executive officer of the Association of Public Health Laboratories. “We test 97% of America’s babies for metabolic or other disorders. We do water testing. You like to swim in the lake and you don’t like poop in there? Think of us.”

But the public doesn’t see the disasters they thwart. And it’s easy to neglect the invisible.

We don’t say to the fire department, ‘Oh, I’m sorry. There were no fires last year, so we’re going to take 30% of your budget away.’ That would be crazy, right? But we do that with public health, day in and day out.

Dr. Gianfranco Pezzino, health officer in Shawnee County, Kansas

A History of Deprivation

The local health department was a well-known place in the 1950s and 1960s, when Harris Pastides, president emeritus of the University of South Carolina, was growing up in New York City.

“My mom took me for my vaccines. We would get our injections there for free. We would get our polio sugar cubes there for free,” said Pastides, an epidemiologist. “In those days, the health departments had a highly visible role in disease prevention.”

The United States’ decentralized public health system, which matches federal funding and expertise with local funding, knowledge, and delivery, was long the envy of the world, said Saad Omer, director of the Yale Institute for Global Health.

“A lot of what we’re seeing right now could be traced back to the chronic funding shortages,” Omer said. “The way we starve our public health system, the way we have tried to do public health outcomes on the cheap in this country.”

A stack of paperwork detailing positive COVID-19 test results sits in a box at the Toledo-Lucas County Health Department offices. Since 2010, spending for state public health departments has dropped by 16% per capita and spending for local health departments has fallen by 18%, according to an analysis of government spending on public health by KHN and The Associated Press.(AP Photo/Paul Sancya)

In Scott County, Indiana, when preparedness coordinator Patti Hall began working at the health department 34 years ago, it ran a children’s clinic and a home health agency with several nurses and aides. But over time, the children’s clinic lost funding and closed. Medicare changes paved the way for private services to replace the home health agency. Department staff dwindled in the 1990s and early 2000s. The county was severely outgunned when rampant opioid use and needle sharing sparked an outbreak of HIV in 2015.

Besides just five full-time and one part-time county public health positions, there was only one doctor in the outbreak’s epicenter of Austin. Indiana’s then-Gov. Mike Pence, now leading the nation’s coronavirus response as vice president, waited 29 days after the outbreak was announced to sign an executive order allowing syringe exchanges. At the time, a state official said that only five people from agencies across Indiana were available to help with HIV testing in the county.

The HIV outbreak exploded into the worst ever to hit rural America, infecting more than 230 people.

At times, the federal government has promised to support local public health efforts, to help prevent similar calamities. But those promises were ephemeral.

Two large sources of money established after Sept. 11, 2001 — the Public Health Emergency Preparedness program and the Hospital Preparedness Program — were gradually chipped away.

The Affordable Care Act established the Prevention and Public Health Fund, which was supposed to reach $2 billion annually by 2015. The Obama administration and Congress raided it to pay for other priorities, including a payroll tax cut. The Trump administration is pushing to repeal the ACA, which would eliminate the fund, said Carolyn Mullen, senior vice president of government affairs and public relations at the Association of State and Territorial Health Officials.

Former Iowa Sen. Tom Harkin, a Democrat who championed the fund, said he was furious when the Obama White House took billions from it, breaking what he said was an agreement.

“I haven’t spoken to Barack Obama since,” Harkin said.

If the fund had remained untouched, an additional $12.4 billion would eventually have flowed to local and state health departments.

But local and state leaders also did not prioritize public health over the years.

In Florida, for example, 2% of state spending goes to public health. Spending by local health departments in the state fell 39%, from a high of $57 in inflation-adjusted dollars per person in the late 1990s to $35 per person last year.

In North Carolina, Wake County’s public health workforce dropped from 882 in 2007 to 614 a decade later, even as the population grew by 30%.

In Detroit, the health department had 700 employees in 2009, then was effectively disbanded during the city’s bankruptcy proceedings. It’s been built back up, but today still has only 200 workers for 670,000 residents.

Many departments rely heavily on disease-specific grant funding, creating unstable and temporary positions. The CDC’s core budget, some of which goes to state and local health departments, has essentially remained flat for a decade. Federal money currently accounts for 27% of local public health spending.

Years of such financial pressure increasingly pushed workers in this predominantly female workforce toward retirement or the private sector and kept potential new hires away.

More than a fifth of public health workers in local or regional departments outside big cities earned $35,000 or less a year in 2017, as did 9% in big-city departments, according to research by the Association of State and Territorial Health Officials and the de Beaumont Foundation.

Maria Fernanda works on COVID contact tracing at the Florida Department of Health in Miami-Dade County in Doral, Florida, in May. In state after state, local health departments charged with doing the detective work of running down the contacts of coronavirus patients are falling well short of the number of people needed to do the job.(AP Photo/Lynne Sladky)

Even before the pandemic, nearly half of public health workers planned to retire or leave their organizations for other reasons in the next five years. Poor pay topped the list of reasons.

Armed with a freshly minted bachelor’s degree, Julia Crittendon took a job two years ago as a disease intervention specialist with Kentucky’s state health department. She spent her days gathering detailed information about people’s sexual partners to fight the spread of HIV and syphilis. She tracked down phone numbers and drove hours to pick up reluctant clients.

The mother of three loved the work but made so little money that she qualified for Medicaid, the federal-state insurance program for America’s poorest. Seeing no opportunity to advance, she left.

“We’re like the redheaded stepchildren, the forgotten ones,” said Crittendon, 46.

Public health loves to say: When we do our job, nothing happens. But that’s not really a great badge. We test 97% of America’s babies for metabolic or other disorders. We do the water testing. You like to swim in the lake and you don’t like poop in there? Think of us.

Scott Becker, chief executive officer of the Association of Public Health Laboratories

Such low pay is endemic, with some employees qualifying for the nutrition program for new moms and babies that they administer. People with the training for many public health jobs, which can include a bachelor’s or master’s degree, can make much more money in the private health care sector, robbing the public departments of promising recruits.

Dr. Tom Frieden, a former CDC director, said the agency “intentionally underpaid people” in a training program that sent early-career professionals to state and local public health departments to build the workforce.

“If we paid them at the very lowest level at the federal scale,” he said in an interview, “they would have to take a 10-20% pay cut to continue on at the local health department.”

As low pay sapped the workforce, budget cuts sapped services.

In Alaska, the Division of Public Health’s spending dropped 9% from 2014 to 2018 and staffing fell by 82 positions in a decade to 426. Tim Struna, chief of public health nursing in Alaska, said declines in oil prices in the mid-2010s led the state to make cuts to public health nursing services. They eliminated well-child exams for children over 6, scaled back searches for the partners of people with certain sexually transmitted infections and limited reproductive health services to people 29 and younger.

Living through an endless stream of such cuts and their aftermath, those workers on the ground grew increasingly worried about mustering the “surge capacity” to expand beyond their daily responsibilities to handle inevitable emergencies.

When the fiercest of enemies showed up in the U.S. this year, the depleted public health army struggled to hold it back.

A Decimated Surge Capacity

As the public health director for the Kentucky River District Health Department in rural Appalachia, Scott Lockard is battling the pandemic with 3G cell service, paper records and one-third of the employees the department had 20 years ago.

He redeployed his nurse administrator to work round-the-clock on contact tracing, alongside the department’s school nurse and the tuberculosis and breastfeeding coordinator. His home health nurse, who typically visits older patients, now works on preparedness plans. But residents aren’t making it easy on them.

“They’re not wearing masks, and they’re throwing social distancing to the wind,” Lockard said in mid-June, as cases surged. “We’re paying for it.”

In Virginia’s Fairfax County, COVID-19 testing was available at no cost and without a doctor’s order. Officials had planned on testing about 1,000 people from 10 a.m. to 6 p.m. on May 23, as hundreds lined up in cars and on foot at this site in Annandale.(AP Photo/Jacquelyn Martin)

Even with more staff since the HIV outbreak, Indiana’s Scott County Health Department employees worked evenings, weekends and holidays to deal with the pandemic, including outbreaks at a food packing company and a label manufacturer. Indiana spends $37 a person on public health.

“When you get home, the phone never stops, the emails and texts never stop,” said Hall, the preparedness coordinator.

All the while, she and her colleagues worry about keeping HIV under control and preventing drug overdoses from rising. Other health problems don’t just disappear because there is a pandemic.

“We’ve been used to being able to ‘MacGyver’ everything on a normal day, and this is not a normal day,” said Amanda Mehl, the public health administrator for Boone County, Illinois, citing a TV show.

Pezzino, whose department in Kansas serves Topeka and Shawnee County, said he had been trying to hire an epidemiologist, who would study, track and analyze data on health issues, since he came to the department 14 years ago. Finally, less than three years ago, they hired one. She just left, and he thinks it will be nearly impossible to find another.

While epidemiologists are nearly universal in departments serving large populations, hardly any departments serving smaller populations have one. Only 28% of local health departments have an epidemiologist or statistician.

Strapped departments are now forced to spend money on contact tracers, masks and gloves to keep their workers safe and to do basic outreach.

Melanie Hutton, administrator for the Cooper County Public Health Center in rural Missouri, pointed out the local ambulance department got $18,000, and the fire and police departments got masks to fight COVID-19.

“For us, not a nickel, not a face mask,” she said. “We got [5] gallons of homemade hand sanitizer made by the prisoners.”

Public health workers are leaving in droves. At least 34 state and local public health leaders have announced their resignations, retired or been fired in 17 states since April, a KHN-AP review found. Others face threats and armed demonstrators.

Ohio’s Gottschalk said the backlash has been overwhelming.

“Being yelled at by residents for almost two hours straight last week on regulations I cannot control left me feeling completely burned out,” she said in mid-June.

Jennifer Gottschalk underwent a test for COVID-19 in a Toledo, Ohio, hospital on March 24. As the environmental health supervisor for the Toledo-Lucas County Health Department, she fielded calls about COVID-19 cases from a hospital bed while fighting the disease herself. She then worked throughout her home isolation, stopping only when her coughing was too severe to talk.(Jennifer Gottschalk via AP)

Gottschalk walks down a hallway of the department’s offices in Toledo, Ohio, on June 24. When the coronavirus pandemic struck earlier in the year, the county’s department was so short-staffed that her duties included overseeing campground and pool inspections, rodent control and sewage programs, while also supervising outbreak preparedness for a community of more than 425,000 people.(AP Photo/Paul Sancya)

Many are putting their health at risk. In Prince George’s County, Maryland, public health worker Chantee Mack died after, family and co-workers believe, she and several colleagues contracted the disease in the office.

A Difficult Road Ahead

Pence, in an op-ed in The Wall Street Journal on June 16, said the public health system was “far stronger” than it was when the coronavirus hit.

It’s true that the federal government this year has allocated billions for public health in response to the pandemic, according to the Association of State and Territorial Health Officials. That includes more than $13 billion to state and local health departments, for activities including contact tracing, infection control and technology upgrades.

A KHN-AP review found that some state and local governments are also pledging more money for public health. Alabama’s budget for next year, for example, includes $35 million more for public health than it did this year.

But overall, spending is about to be slashed again as the boom-bust cycle continues.

Roland Mack holds a poster with pictures and messages made by family members in memory of his sister, Chantee Mack, in District Heights, Maryland, on June 19. The Prince George’s County, Maryland, public health worker died of COVID-19 after, family and co-workers believe, she and several colleagues contracted the disease in their office.(AP Photo/Federica Narancio)

In most states, the new budget year begins July 1, and furloughs, layoffs and pay freezes have already begun in some places. Tax revenues evaporated during lockdowns, all but ensuring there will be more. At least 14 states have already cut health department budgets or positions or were actively considering such cuts in June, according to a KHN-AP review.

Since the pandemic began, Michigan temporarily cut most of its state health workers’ hours by one-fifth. Pennsylvania required more than 65 of its 1,200 public health workers to go on temporary leave, and others lost their jobs. Knox County, Tennessee, furloughed 26 out of 260 workers for eight weeks.

Frieden, formerly of the CDC, said it’s “stunning” that the U.S. is furloughing public health workers amid a pandemic. The country should demand the resources for public health, he said, just the way it does for the military.

“This is about protecting Americans,” Frieden said.

Cincinnati temporarily furloughed approximately 170 health department employees.

Robert Brown, chair of Cincinnati’s Primary Care Board, questions why police officers and firefighters didn’t face similar furloughs at the time or why residents were willing to pay hundreds of millions in taxes over decades for the Bengals’ football stadium.

“How about investing in something that’s going to save some lives?” he asked.

In 2018, Boston spent five times as much on its police department as its public health department. The city recently pledged to transfer $3 million from its approximately $60 million police overtime budget to its public health commission.

Looking ahead, more cuts are coming. Possible budget shortfalls in Brazos County, Texas, may force the health department to limit its mosquito-surveillance program and eliminate up to one-fifth of its staff and one-quarter of immunization clinics.

Months into the pandemic response, health departments are still trying to ramp up to fight COVID-19. Cases are surging in states including Texas, Arizona and Florida.

Meanwhile, childhood vaccinations began plunging in the second half of March, according to a CDC study analyzing supply orders. Officials worry whether they will be able to get kids back up to date in the coming months. In Detroit, the childhood vaccination rate dipped below 40%, as clinics shuttered and people stayed home, creating the potential for a different outbreak.

Cutting or eliminating non-COVID activities is dangerous, said E. Oscar Alleyne, chief of programs and services at the National Association of County and City Health Officials. Cuts to programs such as diabetes control and senior nutrition make already vulnerable communities even more vulnerable, which makes them more likely to suffer serious complications from COVID. Everything is connected, he said.

It could be a year before there’s a widely available vaccine. Meanwhile, other illnesses, including mental health problems, are smoldering.

The people who spend their lives working in public health say the temporary coronavirus funds won’t fix the eroded foundation entrusted with protecting the nation’s health as thousands continue to die.

Contributing to this report were: Associated Press writers Mike Stobbe in New York; Mike Householder in Toledo, Ohio; Lindsay Whitehurst in Salt Lake City, Utah; Brian Witte in Annapolis, Maryland; Jim Anderson in Denver; Sam Metz in Carson City, Nevada; Summer Ballentine in Jefferson City, Missouri; Alan Suderman in Richmond, Virginia; Sean Murphy in Oklahoma City, Oklahoma; Mike Catalini in Trenton, New Jersey; David Eggert in Lansing, Michigan; Andrew DeMillo in Little Rock, Arkansas; Jeff Amy in Atlanta; Melinda Deslatte in Baton Rouge, Louisiana; Morgan Lee in Santa Fe, New Mexico; Mark Scolforo in Harrisburg, Pennsylvania; and AP economics writer Christopher Rugaber, in Washington, D.C.

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