Will Humble Uncategorized, Wills Blog

COVID-19 One Year On: A “Frank” Conversation with Valleywise Health’s Dr. Frank LoVecchio

As we mark the 1-Year Anniversary of COVID-19 as a global pandemic we invited Valleywise Health’s Dr. Frank LoVecchio to have a candid Zoom conversation with AzPHA members about the course of the pandemic from the perspective of an emergency department physician.

You can view his presentation about Dr. LoVecchio’s experiences over the past year as he reflects about clinical developments and muses about the policy choices made by our elected and appointed officials.

Dr. Frank LoVecchio is an emergency medicine physician with District Medical Group and Professor of Emergency Medicine at The University of Arizona and Creighton University School of Medicine. He has previously served as Vice Chair and Director of Research for the Valleywise Health Department of Emergency Medicine.

He is the Principal Investigator for the Infectious Disease Network (IDNet) studies, a group of Emergency Departments funded through Centers for Disease Control (CDC) to conduct Infectious Disease trials. Dr. LoVecchio is board-certified in Addiction Medicine, Medical Toxicology, Medical Forensics and Emergency Medicine.

Will Humble Uncategorized, Wills Blog

Interim Public Health Recommendations for Fully Vaccinated People

CDC released an initial set of recommendations for fully vaccinated individuals, defined as two weeks after the second dose of receiving the Pfizer or Moderna vaccine, or two weeks after the J&J/Janssen vaccine. These recommendations include specific situations in private or household settings where social distancing and masking are no longer needed, but also advise maintaining precautions in public and in settings where unvaccinated high-risk individuals may be present.

In public spaces, fully vaccinated people should continue to follow guidance to protect themselves and others, including wearing a well-fitted mask, physical distancing (at least 6 feet), avoiding crowds, avoiding poorly ventilated spaces, covering coughs and sneezes, washing hands often, and following any applicable workplace or school guidance.

Fully vaccinated people should still watch for symptoms of COVID-19, especially following an exposure to someone with suspected or confirmed COVID-19. If symptoms develop, all people – regardless of vaccination status – should isolate and be clinically evaluated for COVID-19, including SARS-CoV-2 testing, if indicated.

Interim Clinical Considerations for Use of COVID-19 Vaccines | CDC

The Advisory Committee on Immunization Practices (ACIP) has issued interim recommendations for the use of Pfizer-BioNTech, Moderna, and Janssen (Johnson & Johnson) COVID-19 vaccines for the prevention of coronavirus disease 2019 (COVID-19) in the United States. These clinical considerations provide additional information to healthcare providers and public health officials on use of COVID-19 vaccines.

The Ad Council Public Service Announcements

The Ad Council launched two PSAs, “It’s Up to You” and “COVID-19 Vaccine Facts”, featuring former Presidents Barack Obama, George W. Bush, Bill Clinton, Jimmy Carter, and former First Ladies Michelle Obama, Laura Bush, Hillary Clinton, and Rosalynn Carter. The videos encourage all Americans to get answers on top questions about the COVID-19 vaccines at GetVaccineAnswers.org and to get a vaccination when it’s available.

Will Humble Disease Control, Vaccination, Wills Blog

Upcoming Webinar Series: COVID-19 Vaccination and Reaching People with Disabilities

The Association of University Centers on Disabilities, Association of State and Territorial Health Officials and NACCHO are hosting a webinar series on strategies to prioritize people with disabilities in the COVID-19 vaccination effort. Each session is from 1-2 p.m. ET. (10am – 11am AZ time).

  • March 30: Navigation: Promising practices for scheduling and transporting persons with disabilities to COVID-19 vaccination appointments. Register here.

  • March 31: Consideration: Promising practices for vaccinating family members of persons with disabilities and those who are homebound. Register here.

  • April 7: Communication: Promising practices for reducing COVID-19 vaccine hesitancy and disseminating accessible messages. Register here.

  • April 8: Prioritization: Promising practices for educating others about the importance of disability prioritizing in state vaccination plans. Register here.

Will Humble Immigration Policy, Prevention, Social Determinants, Wills Blog

DHS’ “Public Charge” Rule No Longer A Threat to the Social Determinants of Health

Back in 2019 the Trump Administration developed and briefly implemented a wide-ranging new rule for how the Department of Homeland Security (DHS) was supposed to make decisions about granting legal permanent resident applications. The rules (finalized back in 2019) was designed to block legal immigrants from extending their temporary visas or gaining permanent residency if DHS decides the applicant is “likely to rely on designated public benefits in the future”.

As you might expect, a lawsuit challenging the new law was filed immediately after the final rules were published. The case (called Department of Homeland Security v. New York, No. 20-449) had been winding its way through the federal courts, until last week when the case was (favorably) resolved at the request of both parties. Here’s some history:

Starting in February of 2020 DHS briefly began considering whether applicants for legal permanent status have received Medicaid (AHCCCS), the Supplemental Nutrition Assistance Program (food stamps), or Section 8 Housing assistance as they make decisions about extending visas or granting permanent residency.  The definition of a “public charge” in that Rule was:

“an individual who receives one or more designated public benefits for more than 12 months in the aggregate within any 36-month period”.  Medicaid limits eligibility (for immigrants) to qualified legal immigrants with refugee status, veterans, and people lawfully present in the US for 5 years or more. State Medicaid programs can elect to provide coverage to legally present immigrants before the 5-year waiting period ends (Arizona does not). 

Fortunately, the formerly final Rule did not consider whether benefits were used by an applicant’s kids. So, lawfully present kids that are receiving benefits (e.g. Medicaid) didn’t have that used against them if the child later applies for legal permanent residency (a “green card”).   The Trump administration’s public charge rule would have used a “totality of the circumstances” test for applicants, which means that DHS will use the statutory factors and now the new factors laid out in the final rule. Here’s my blog from about a year ago with more detail about that final rule.

However, DHS’ only implemented the new rules for a few days in early 2020 because US District Courts issued preliminary injunctions which stopped DHS from implementing their final rules. On December 2, 2020 the Ninth U.S. Circuit Court of Appeals upheld those preliminary injunctions.

The case then proceeded to the US Supreme Court.

A couple of weeks ago the US Supreme Court announced that it would hear the case (called Department of Homeland Security v. New York, No. 20-449) challenging DHS’ final public charge rules. 

At that point, the US Department of Homeland Security (now under new leadership) changed their position and decided to no longer challenge the decision by the 9th Circuit which upheld that District Court injunctions. The plaintiffs (the folks that filed the lawsuit in the first place – the New York Attorney General) also asked the US Supreme Court to dismiss the case, which they did.

OK…  so here’s where we stand.

The Northern District vacated the 2019  of Illinois’ judgement vacating the 2019 public charge rule is now in effect…. a convoluted way of saying that the Trump administration’s Public Charge Rule is no longer in effect.  According to DHS, they will continue to use the 1999 interim field guidance on the public charge inadmissibility provision (i.e., the policy that was in place before the 2019 public charge rule) is now in effect.”

So basically, DHS’ public charge rules still exist on paper but have no effect and DHS is using their old 1999 guidance to make decisions again.

Here is the Field Guidance on Deportability and Inadmissibility on Public Charge Grounds from 1999, if you are interested. DHS yesterday included this info on the 1999 Interim Field Guidance:

“Under the 1999 interim field guidance, DHS will not consider a person’s receipt of Medicaid (except for Medicaid for long-term institutionalization), public housing, or Supplemental Nutrition Assistance Program (SNAP) benefits as part of the public charge inadmissibility determination.  In addition, medical treatment or preventive services for COVID-19, including vaccines, will not be considered for public charge purposes.”

Next, I expect the Department of Homeland Security to open a new Rulemaking to develop what they see as more appropriate rules governing DHS’ decision-making around applications for visa extension and permanent residency… but that’s just a guess.

Elections matter.

Will Humble Disease Control, Vaccination, Wills Blog

State Government Still Denying Persons with Intellectual Disabilities Under 55 Vaccine Access

Pima County Health Department Pushes Back & Prioritizes this Important Population

We were hopeful (but not optimistic) that ADHS Director Christ would recognize that her decision to go to a strictly age-based approach to prioritize COVID vaccine left persons with intellectual and developmental disabilities out in the cold. Sadly, our advocacy and the advocacy of so many others failed, and it is now clear that she is unwilling to consider adding members AHCCCS’ ALTCS or Arizona Long Term Care System to the list of prioritized persons. 

ALTCS members are folks that have a disability (often an intellectual or developmental disability like Down’s Syndrome). Some ALTCS members live in a congregate setting but most receive support services in a home or community-based setting.

For example, many ALTCS members are persons with Down Syndrome. After adjusting for age and sex, ethnicity, BMI, care home residency, and congenital heart disease, research shows that folks with Down’s Syndrome have a 10 times higher risk of death if diagnosed with COVID-19.

There are about about 20,000 ALTCS members between 18 and 54 years old. About 4,000 of them live in group homes (and have had an opportunity to get vaccinated), which means we’re talking about 16,000 vulnerable adults enrolled in ALTCS and living in the community who will now need to wait even longer for an opportunity to get vaccinated.

NEW: VIEW THIS EPISODE OF SUNDAY SQUARE OFF FOR A CONCISE SUMMARY OF THIS INJUSTICE

Even this compelling letter from Representative Cook and many other legislators and this letter from the ADES’ Developmental Disabilities Advisory Council failed to convince Director Christ to help out persons with intellectual and developmental disabilities. It would have been simple for Director Christ to make this sympathetic gesture. Sadly, she was unwilling to do so and high risk persons with intellectual and developmental disabilities will now need to wait until their age is called to get vaccinated- despite their much higher risks.

UPDATE: The Pima County Health Department Ethics Committee reviewed the current guidance under the Tentative Vaccination Guidance for priority group 1A.3 and advised the Director (Pima County Health Director Dr. Theresa Cullen) to include those receiving long-term care services at home. This was subsequently approved. The revised 1A.3 guidance now includes:

Adults 18 years and over, living with disabilities (physical, intellectual/developmental, mental health and /or sensory) and/or high risk medical conditions who are receiving long term care service at home will now be eligible for vaccination.

Will Humble Federal Budget, Maternal Health, Medicaid, Opioids, Prevention, Public Health, Social Determinants, Wills Blog

“American Rescue Plan Act” to Provide Tons of Resources to Address Health Disparities & Boost the Public Health Workforce

The American Rescue Plan Act is landmark legislation that will provide significant resources with which to address the social determinants of health and to reinforce the public health workforce.

Of course, the mere fact that there are additional resources being provided doesn’t mean that we will see improvements in the field. That will only happen if our elected and appointed officials that will control these funds use them in evidence-based ways that have a high return on investment. Whether that will happen in Arizona remains to be seen.

There still aren’t clear dollar figures for Arizona, but the Joint Legislative Budget Committee made some estimates this week based on the finding formula. They estimate that state government will receive about $12B (more than the entire state general fund for a single year), with an additional $2.6B to local governments, and $1.2B in business aid. $8.5B of the $12B consists of the stimulus payments some people will be getting.

State Government:

State government will receive $4.8B between now and December 31, 2024, so much of the funding will be available to the next governor (the Ducey Administration will be gone in January 2023). The $4.8B (spread out over 4 years) can be used “… to respond to COVID-19 or its negative economic impacts, premium pay to essential workers (up to a maximum of $25,000 per worker), lost revenues, and broadband infrastructure.” That sounds pretty open-ended and it will be very important for stakeholders from all sectors to keep a close eye on how the Governor and his agency heads use these funds.

Importantly, the funds can’t be used to directly or indirectly cut taxes.

Local Government:

Local governments will get about $2.6B over the 4-year period. I can’t find much on what that can be used for. Local government in AZ also qualifies for an additional $187M for capital projects to carry out “…critical capital projects directly enabling work, education and health monitoring, including remote options, in response to the public health emergency.”  

There’s also $40M “Tribal Consistency Fund” available to AZ tribes (until September 30, 2023)

Public Health & Healthcare:

There are a ton of additional resources that will be coming to public health and healthcare in addition to the state and local fund distributions.

ADHS

The ADHS will be getting about $1.7B (which is several times higher than their annual state budget). Most of that must go toward COVID-19 testing, contact tracing, and mitigation ($960M) and buying vaccine including administration fees ($150M).  

However, a very sizeable chunk of money ($153M) will be for “…  state/local public health departments for recruiting, hiring, and training of public health workers”.  Thankfully, those funds never expire which means that they could be spread out over a several year period (for example over a 10-year period) which could really help our long-term public health workforce infrastructure.

Because it will be spread out over many years, not all the decisions will be made by the Ducey Administration, and we will also have an opportunity to influence a future administration on evidence-based uses for these funds (the Ducey Administration will be leaving in 21 months – January 2023).

For example, we could modify the state loan repayment program to include public health professions including community health workers and significantly boost overall funding to that program. There are many other opportunities for using these funds that we will be exploring at our August 26 Conference.

AHCCCS

There are significant investments that will help AHCCCS to provide additional evidence-based services as well. Here are some of those line items:

  • Grants for Teaching Health Centers that operate Graduate Medical Education: $7M (thru 9/2023)

  • Community Mental Health Services Block Grant: ($30M) (thru 9/2325).

  • Substance Abuse Prevention Treatment Block Grant: ($30M).

AHCCCS will also be able to extend eligibility to women for 12 months postpartum for the next 5 years, will have enhanced federal match at 85% for mobile crisis intervention services; and will have no cap placed on drug rebates.

Coronavirus Capital Projects Fund:

Arizona will get $187M for capital projects to carry out “critical capital projects directly enabling work, education and health monitoring, including remote options, in response to the public health emergency.” States need to apply to the US Department of Treasury to use these earmarked funds.

Education ($3.2B) – ADE; ADES; Universities, Community Colleges, & the Arizona Commerce Authority. Details here

Other safety net resources that will come through the Act over the next few years include:

  • Federal Pandemic Unemployment Compensation (additional $300/week): 100% federal funding through September 6, 2021.

  • Many tax provisions designed to assist working low-income persons.

  • Human Services ($979M) – for ADES, ADE, Department of Child Safety, Department of Veterans’ Services programs.

  • Arizona Department of Housing ($787M) for various programs

Editorial Note: There will be more information coming out in the coming months about how these resources may be lawfully used. It’s our job as the independent voice for public health (along with many other nonprofit organizations in Arizona in the health and human services sector) to influence how these funds are used and to ensure that the decisions that the Ducey administration makes are evidence-based and fair.

Will Humble Disease Control, Wills Blog

Dr. Gerald’s Weekly Epidemiologic Update

Below is a summary discussion of Dr. Gerald’s weekly update. As always, I encourage you to view the full report for much more interesting detail.

  • This week saw an eighth straight week of meaningful declines in Covid-19 cases and hospital occupancy. In all but Coconino County, absolute levels of SARS-CoV-2 viral transmission have fallen below the 100 new cases per 100,000 residents per week threshold.

  • As of March 7th, new cases were being diagnosed at a rate of 79 cases per 100,000 residents per week (Figure 10 below). This rate is declining by 16 cases per 100,000 residents per week.

  • In some communities, absolute levels of transmission and test positivity have reached levels that warrant a return to in-person instruction using a hybrid mode or reduced attendance (see CDC Recommended Mitigation Strategies for K – 12 Learning Modes). Full in-person instruction is not recommended by the CDC until transmission falls below 50 cases per 100K residents per week.

  • Hospital Covid-19 occupancy continues to decline in the ward and ICU. Access to care however, remains somewhat restricted as the backlog of medically necessary non-Covid procedures is addressed.

  • Arizona is still reporting a large number of weekly deaths and this count may underestimate true fatalities. The week ending January 17th will be Arizona’s deadliest with >1000 deaths. Arizona’s weekly tally of deaths ranks it 9th in the nation while its overall rank remains 6th since the outbreak began.

  • According to the CDC, 14.6% of Arizona adults have received at least 2-doses of vaccine while another 13.4% have received 1-dose. The ADHS Dashboard is reporting slightly higher levels.

Will Humble Uncategorized, Wills Blog

When Is Assisted Living the Right Option for Your Loved One?

  • Guest Blog by AzPHA Member Lydia Chan

 It’s perfectly normal for seniors to want to stay in their own homes, and being a caregiver can help your loved one do that for a while. But there is only so much you can do, and the time may come when staying at home is no longer best. Even if you aren’t sure when exactly the right time will be, you can open the conversation and work towards guiding your loved one through these decisions with these tips from the Arizona Public Health Association.

Starting the Conversation

For many families, starting this conversation is the hardest part. Ideally, this should be an ongoing conversation, but it helps to bring it up in relation to something they’re going through that’s worrisome to you. Let them know why you’re concerned, but be prepared to listen to how they feel, too.

It also helps to start doing some research so you can show your loved one some options. This doesn’t mean you’re deciding for them. In fact, Reader’s Digest explains the importance of your loved one being involved in making a decision for themselves.

For example, during the conversation, you and your loved one may decide that staying at home is the best option. This can be due to a number of factors, including the current condition of your loved one’s health, how much you can afford to spend on care, and the decision to stay close to your loved one. When it comes to in-home care, keep in mind that not all in-home caregivers are licensed or certified, so be sure to research services that hire these professionals. You’ll also need to research whether your loved one is qualified for Medicare coverage for in-home care. If they don’t meet the qualifications, you’ll have to find other means of paying for their care. Some long-term care (LTC) insurance policies will cover in-home care. But LTC insurance can be costly, depending on the age of the insured when the policy was purchased.

If both you and your loved one decide to look into assisted living, you can use an online search tool to find out what’s available where you live. You can even tailor your search by filtering for things like the type of room they offer, amenities, and other features. Of course, cost is a major factor in ultimately making a decision, too. To pay for assisted living, you may need to dig into your loved one’s savings or even sell their home (research Phoenix home prices to get a better idea of the value of their home). With cost and other features in mind, you and your loved one can then pick a few places to visit and ask the staff questions to get a feel for which one may be the best fit.

Knowing When the Time is Right

There may not be an answer that’s crystal clear, but when you start to notice concerning actions, health problems, or signs around your loved one’s home, this combination of factors may mean the time is right.

Mental Health and Memory

●     Do you see indications that your loved one is struggling with poor mental health? Many of the symptoms of depression, such as fatigue and loss of interest in life, are somewhat common with aging. However, this doesn’t mean that depression is normal, and having the resources of an assisted living community often helps seniors find a new purpose in life.

●     Do they have a hard time or not want to get out of the house anymore? Senior isolation is a major risk factor for depression, and it can have serious negative health effects.

●     Do you have concerns about your loved one’s memory? A decline in memory is normal for seniors, but when someone starts to show signs of dementia or Alzheimer’s, there may be a bigger issue at hand.

Health and Well-being

●     Have you noticed a decline in hygiene or appearance that may indicate they aren’t caring for themselves as well as they should? Some seniors have a difficult time preparing meals and will end up losing weight and potentially even becoming malnourished. Aside from weight loss, signs of malnutrition may include muscles becoming flaccid and a yellowing of the skin.

●     Has your loved one fallen? Psychology Today explains why falling is a serious concern for senior citizens that can have major consequences.

●     Does your loved one have worsening health conditions or a hard time managing their medications?

Around the Home

●     Does your loved one seem to be ignoring general housekeeping? If their home is no longer as clean or orderly as before, this may be a sign of mental decline or a physical struggle with maintaining a home.

●     Does your loved one forget regular responsibilities, like opening mail and paying bills?

The reality is that just one of these concerns probably isn’t enough to mean the time is right. In most cases, it’s a combination of factors, which start to add up over time. What matters most is that your loved one is safe, healthy, and happy. When the time comes, the right assisted living center can be the solution that provides for these essential needs.

The Arizona Public Health Association is dedicated to protecting and improving the health of Arizona’s citizens. Become a member today!

Will Humble Disease Control, State Legislature, Wills Blog

Podcast Makes the Arizona Legislative Process Understandable

Health Policy & Advocacy is Focus of New Podcast Hosted by UA Alumna | Mel and Enid Zuckerman College of Public Health

Policy is one of the most powerful tools public health professionals have to effect positive health changes at a community level.

Krista R. Cardenas, MPH, a senior instructional specialist for the Western Region Public Health Training Center at the University of Arizona Mel and Enid Zuckerman College of Public Health and alumna, is the creator and host of the new podcast Arizona Common Ground (AZCG), an eight episode educational podcast series that will take listeners through the legislative process of how a bill is passed in Arizona. 

Listen to the Arizona Common Ground Podcast.

Journal Article of the Week

Association of State-Issued Mask Mandates and Allowing On-Premises Restaurant Dining with County-Level COVID-19 Case and Death Growth Rates

Universal masking and avoiding nonessential indoor spaces are recommended to mitigate the spread of COVID-19.

Mandating masks was associated with a decrease in daily COVID-19 case and death growth rates within 20 days of implementation. Allowing on-premises restaurant dining was associated with an increase in daily COVID-19 case growth rates 41–100 days after implementation and an increase in daily death growth rates 61–100 days after implementation.

Mask mandates and restricting any on-premises dining at restaurants can help limit community transmission of COVID-19 and reduce case and death growth rates. These findings can inform public policies to reduce community spread of COVID-19.

Will Humble Disease Control, Vaccination, Wills Blog

Gila County Public Health Goes Rouge & Gets Good Results

The New Your Times had a terrific piece this week highlighting the innovative work that Gila County Public Health has been doing to get their communities vaccinated.

Short take is that they went rogue and avoided falling into the trap of adopting ADHS directives. By and large- they have opened up vaccinations without requiring an up-front appointment which allows residents to bypass the buggy ADHS appointment system. Here are some excerpts from the piece in the NY Times entitled: Can’t Get a Covid Vaccine? In This County, Everybody is Eligible 

Health officials say they also adopted a more imaginative approach to vaccinations, especially after Gila County moved past the phases for vaccinating teachers, child care workers and people 65 and older.

Gila County started off with a set of qualifying standards as well. But it has been so successful at vaccinating its residents that it is now one of the first places in the United States to open eligibility to the general population, offering a glimpse of what vaccination could start to look like in the rest of the country weeks or months from now.

Doctors and nurses on the front lines in Gila County said they were able to open up vaccinations for all adult residents only after meeting targets for vaccinating high-risk groups like seniors and essential workers. Because they did so well, Arizona state officials allotted the county a larger number of doses, enabling it to become one of the few places in the country that could offer the vaccine to whole adult population.

I don’t live in Gila County- but from the sounds of this article local control and local decisions seem to be satisfying the residents of Gila County. That doesn’t mean that their approach would be appropriate or accepted everywhere- but at least for that part of the state folks seem to be OK with it.

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