Will Humble Community Health Workers, Early Childhood, Injury Prevention, Maternal Health, Public Health, Social Determinants

Arizona Research Finds that CHW’s Improve Birthweight in the Health Start Program

Through a comprehensive study of the last 10 years, researchers from NAU and UA found that pregnant women and mothers enrolled in Arizona’s Health Start Program (which employs community health workers to conduct home visits) have lower rates of low birthweight and preterm newborns than women who didn’t participate in Health Start.

BMJ recently published their results entitled, “ Addressing maternal and child health equity through a community health worker home visiting intervention to reduce low birth weight: retrospective quasi-experimental study of the Arizona Health Start Program.”

Most of the authors are AzPHA members: Samantha Sabo , Patrick Wightman, Kelly McCue , Matthew Butler, Vern Pilling , Dulce J Jimenez , Martín Celaya , Sara Rumann)

Abstract:

For more than 25 years, the Arizona Health Start Program has offered CHW led home visiting, education, and advocacy support to improve maternal and child health outcomes among medically and socially high risk, pregnant women and mothers with children under age 2.

The Arizona Health Start Program is a public health focused intervention program developed specifically to meet the unique needs of Arizona women, children and families that can improve birthweight and preterm outcomes among ethno-racially, socioeconomically, and geographically diverse mothers and infants of Arizona. Here’s the Abstract from the study:

Objective: To test if participation in the Health Start Program, an Arizona statewide Community Health Worker (CHW) maternal and child health home visiting program, reduced rates of low birth weight (LBW), very LBW (VLBW), extremely LBW and preterm birth.

Setting: Arizona is uniquely racially and ethnically diverse with comparatively higher proportions of Latino and American Indian residents and a smaller proportion of African Americans.

Participants: 7212 Health Start Program mothers matched to non-participants based on demographic, socioeconomic and geographic characteristics, health conditions and previous birth experiences.

Intervention: A statewide CHW MCH home visiting program.

Results: Using Health Start Program’s administrative data and birth certificate data from 2006 to 2016, we identified 7,212 Health Start Program participants and 53,948 matches. Program participation is associated with decreases in adverse birth outcomes for most subgroups.

Conclusion: This MCH home visiting intervention that employs CHWs as the primary interventionist may contribute to the reduction of LBW, VLBW, ELBW and PTB and could improve birth outcomes statewide, especially among women and children at increased risk for MCH inequity.

Will Humble Disease Control

Maricopa County Public Health Taking Orders from School Districts for BinaxNOW Rapid Tests

Maricopa County Department of Public Health has finalized their system to supply schools with BinaxNOW Self-Tests in K-12 students and staff.  These rapid tests augment already available school testing including pooled testing provided through ADHS, and community testing events and sites such as retail pharmacies.

Schools can order these test kits through the MCDPH resource Request Tool. They are asking public schools to coordinate the ordering and distribution of tests through their district office. Charter schools and private schools can order directly through the resource Request Tool.

Will Humble Disease Control, Early Childhood

School COVID Testing Is Free and Important: Get Your School On-Board!

Ideally we’d have a governor and health department director that support all evidence-based interventions to prevent COVID-19 infections in K-12 schools while maximizing the chance for in-person instruction by supporting CDC’s Guidance for COVID-19 Prevention in K-12 Schools.

Sadly, that’s not the deck that Arizona voters dealt us.  We’ve been dealt a hand that includes a governor who is actively hostile toward universal indoor K-12 masking, one of primary tools that helps prevent classroom infections.

But that doesn’t mean schools are helpless. Identifying COVID cases early and removing infected kids and their unvaccinated close contacts can prevent cascades of classroom cases and improve the chances for in-person school. A key to making that happen is school-based testing. Fortunately, classroom COVID testing will be much easier this fall because of the American Rescue Plan Act.  Arizona received $219M CDC to pay for voluntary COVID-19 testing in schools at no cost to schools.

These federal funds allow schools to do both diagnostic testing of symptomatic kids and staff and surveillance screening testing to help schools identify infected individuals without symptoms so they can take action to prevent further transmission.

POOLED TESTING

Thanks to the Rescue Plan Act schools can implement routine ‘pooled testing’ of asymptomatic kids for free, including the administrative and technical support.

Here’s how it works. The free technical support team comes to the school and coordinates the sampling. Samples from multiple students in the same classroom are combined and taken to a Sonora Quest Lab’s main facility in Phoenix. The pooled specimen is analyzed the same day as collection (using PCR).  Results are available in less than 24 hours. If the test is negative, all students in the pool are presumed negative and no further action is necessary.

If the pooled test is positive, students in the positive pool are tested the next morning using the BinaxNOW 15-minute antigen test to determine which student is positive.

The biggest “game-changer” for schools that use pooled testing is that the program provides free technical and administrative on-site support to minimize the burden on staff. Healthcare providers manage all collection and logistical activities on all testing days taking the burden off school staff.

It’s all 100% federally funded making it reasonable for any district or school to implement. Of course, the program is voluntary both for schools and for parents and kids participate only if their parent provides consent.

Schools interested in exploring this opportunity can visit this K-12 COVID-19 Pooled Testing Website and can [email protected] to get started.

RAPID TESTING

Last semester, schools generally needed to partner with a community lab that is CLIA certified to do on-site rapid testing. The availability of the new Over-the-Counter BinaxNOW Rapid COVID-19 Test means that schools will no longer need to partner with a lab. On top of that, the Rescue Plan Act provides more than enough CDC money for the state and counties to buy the test kits and for schools to use them routinely for screening.

Arizona’s county health departments have been buying the BinaxNOW at-home testing kits and making them available to schools. Schools can ask their county health department for free test kits. Most counties (including Maricopa) have the BinaxNOW kits. In Maricopa County, schools can order these test kits through their School Resource Request Tool.

Schools can use the kits in ways they prefer. They could have tests available in the nurses or administrative offices and could do on-site testing (with parental consent of course). Alternatively, they can just send a kid home with the rapid test kit in their backpack and ask the parent to do the test at home. Results come in about 15 minutes.

Summary

Even though our governor is actively hostile toward universal indoor K-12 masking, schools still have tools to prevent classroom infections. Routine testing to identify COVID cases and removing infected kids and their unvaccinated close contacts can prevent cascades of classroom cases and improve the chances for in-person school.

Thanks to the Rescue Plan Act, schools can implement free routine testing in classrooms this fall.  They can use a pooled testing approach (which comes with free administrative and technical support) or use rapid tests.  Both approaches are free, and provide critical information that schools can use to keep kids safer this fall and minimize cascading cases that result in unnecessary distance learning.

Make sure to ask your school principal what their testing plan is. If they don’t have a testing plan, send them to this blog post to get them started!

Will Humble Disease Control, Public Health Law, Vaccination

School Mask Drama Coming To A Head

This article by Howie Fischer does a good job summarizing the legal issues and arguments surrounding the lawsuit filed against the Phoenix Union High School District for requiring that students and staff wear masks in classrooms. Last week the judge in the case declined to issue a temporary restraining order after an attorney for the district told him that there’s no law being violated — at least not yet, if ever.

The article goes into the fact that the law Ducey signed which will stop schools from requiring classroom masks probably doesn’t go into effect until September 29. There’s also a real constitutional question as to whether the ban is even constitutional because it violates the state constitution that all bills be of a “single subject”.

Here’s that article: New school mask mandates can remain in place pending hearing next week. You can also review last week’s blog post Expect Legal Action This Week.

As of this writing, there are 10 school districts that are putting in place policies that will require universal masking in indoor classrooms. Expect more to defy the governor over the coming week as governing boards meet with lawyers and as they hear from parents.

At some point in August, the courts will end up answering the legal questions brought up in this blog post Ducey’s Ban on School Mask Requirements is Unconstitutional and in this analysis by the Network for Public Health Law.

If Ducey loses in court, it could have a cascade effect and call into question the constitutionality of all the Budget Reconciliation Bills, which were loaded down like a Christmas tree- in clear violation of the constitution’s single subject requirement.

Will Humble Disease Control, Vaccination

Why Haven’t the Pfizer and Moderna Vaccines Been Approved Yet?

Many Americans say they’re waiting until a vaccine is approved (not just emergency authorized) to get vaccinated. With so many still unvaccinated and Delta sparking exponential growth and increases in hospitalizations and deaths (see Dr. Gerald’s Sobering Epidemiology & Hospital Capacity Update), there’s growing pressure for the FDA to approve one or more of the authorized vaccines.  In addition to getting hesitant folks off the fence, approval would make universities, governments and employers feel more comfortable implementing vaccine requirements.

It has been disappointing to see the FDA be so opaque about where the vaccines are in the approval pipeline and what still remains to be completed before they will entertain approval. After all, the highly effective mRNA vaccines by Pfizer-BioNTech and Moderna have been administered to tens of millions of people in the United States and worldwide without significant problems.

Pfizer and BioNTech submitted their request for full approval way back on May 7, and Moderna began a rolling submission in June. The emergency use authorization for Pfizer was based on clinical trial data of 21,700 people with a 2 month follow-up (and an equal number of placebo folks).  Many placebo people have since received the vaccine, and the follow-up for everyone is at least six months, which is now complete.

We finally got a little info from FDA last week when they said that one of the hold-ups has been the manufacturing approval process which is much more detailed than it is for EUA. They also need to do additional inspections of facilities, and with lots of facilities involved in different countries, that entails a lot of travel and legwork.

The FDA still hasn’t given an estimated date for approval of either Pfizer or Moderna. .

On the vaccine front for younger kids… Pfizer says they expect to ask the FDA for emergency use authorization for kids 5-11 years old in September or October and for the 6 month to 4 year old group the month after that.

Those clinical trials are using lower doses, with 5-11 year-olds getting a 10 microgram dose and kids under 5 getting 3 micrograms. Those trials started back in March. The FDA is asking for 6 months of follow up for these pediatric trials both because of the lower doses and to make sure they have a clear picture of the rare myocarditis events. That extra follow-up time is partly why authorization in the younger kid group is taking longer.

It would be nice if the FDA would be more transparent about where they are in the process and were to communicate that clearly. Good communication can provide confidence in the process and the vaccines. By being so opaque, they have really been missing opportunities to build more public confidence.

Honestly, I think it’s time for HHS Secretary Becerra to nominate a new permanent FDA Commissioner – and preferably one that’s good at communication.

Will Humble Disease Control

Sobering Epidemiology & Hospital Capacity Update from Dr. Gerald

VIEW THIS WEEK’S FULL REPORT

Summary from Dr. Gerald’s Report: This past week saw another marked increase in viral transmission. Arizona is now experiencing high levels of transmission that will be sustained for weeks to come. This outbreak will almost certainly be as big as the one experienced in summer of 2020. While I am optimistic it will not reach the levels seen in the winter of 2021, the experience of other similar states (e.g., Louisiana, Florida, and Texas) suggests this could be wishful thinking.

As of August 1st, new cases were being diagnosed at a rate of 195 cases per 100,000 residents per week. The rate is increasing at 51 cases per 100,000 residents per week. Another wave of cases and hospitalizations, caused by the increasing prevalence of the Delta variant is now certain. The Delta variant now accounts for >75% of all cases.

Resumption of in-person instruction in K – 12 schools and universities in August will lead to frequent school-associated outbreaks and will undoubtedly increase community transmission without vaccine or mask mandates, weekly surveillance testing, and adequate ventilation. The transmissibility of the Delta variant combined with high levels of transmission among adults will essentially force transmission among children.

Hospital COVID-19 occupancy is increasing and is likely to exceed 15% of all beds in the general ward and 20% of beds in the ICU for many weeks. Access to care remains somewhat restricted as occupancy remains unseasonably high. Once again, elective procedures are likely to be postponed. Hospitals should (and likely are) preparing for another meaningful surge that will strain staffing in critical care areas.

Current levels of hospital and ICU occupancy are similar to or slightly ahead of those of the winter 2021 outbreak. Current community transmission is impacting hospitals similarly to how it did this past winter despite a high degree of vaccine update among those >65 years. We should not hold a false sense of security that this outbreak will necessarily have less impact on our already overburdened hospital system.

Arizona is now experiencing 50 deaths per week. This amount will increase in the coming weeks and will almost certainly exceed 100 per week by the end of August.

VIEW THIS WEEK’S FULL REPORT

Will Humble Disease Control

When All Is Said & Done, Mix & Match Vaccines May Provide the Best Protection

NATURE: IMMUNOGENICITY AND REACTOGENICITY OF HETEROLOGOUS CHADOX1 NCOV-19/MRNA VACCINATION

Abstract: In this observational study we show that, in healthy adult individuals, the heterologous vaccine regimen induced spike-specific IgG, neutralizing antibodies and spike-specific CD4 T cells, the levels of which which were significantly higher than after homologous vector vaccine boost and higher or comparable in magnitude to homologous mRNA vaccine regimens.

Moreover, spike-specific CD8 T cell levels after heterologous vaccination were significantly higher than after both homologous regimens. Spike-specific T cells were predominantly polyfunctional with largely overlapping cytokine-producing phenotypes in all three regimens.

Translation: This journal article has super-interesting results, suggesting that combining a regimen of mRNA and non-mRNA vaccines may induce the best and longest-lasting protection against COVID-19. They found that “mix and match” vaccination with AstraZeneca and mRNA vaccines induces terrific immunity- both in antibody titer and T Cells.

That mix and match produced basically the same antibody response as 2 mRNA vaccines, and better than 2 AstraZeneca shots. Interestingly, T-cell immunity was significantly higher among mix and match participants- higher than in the group that got 2 mRNA vaccines.

Note: This is a small sample size and should not be used to make policy decisions, but it does provide interesting results!

Will Humble Disease Control

Pima County Health Department Issues Standing Order for COVID Cases in Schools

DIRECTIVE DEFIES MS. HARRIER’S SILLY LETTER ‘PROHIBITING’ QUARANTINE

The Pima County Health Department issued a standing order last week specifying the requirements that schools and students must must follow when there are COVID-19 cases in schools.

The order also outlines the necessary isolation timelines for vaccinated and unvaccinated students and aims aims to eliminate confusion among schools in Pima County’s jurisdiction and to slow the spread of COVID-19.

NEW MARICOPA COUNTY DEPARTMENT OF PUBLIC HEALTH EDUCATION CAMPAIGN

Maricopa County recently launched a COVID-19 Vaccine Campaign Campaign. The campaign (supported through federal funds) includes television and radio ads, billboards, and social media promotions in English and Spanish.

Every person featured is a real Maricopa County resident who got vaccinated against COVID-19. Many of the photos are from actual vaccine events organized by Maricopa County (these are not simply ads featuring a political appointee in a parking lot reading a script).

You can read kore Maricopa.gov/COVID19Vaccine for English and maricopa.gov/vacunacovid19 for Spanish. You can Download shareable campaign assets here.

Will Humble Disease Control

CDC Recommends Vaccinated People Wear Masks in Public in Areas of High Transmission

IMPLEMENTING COVID-19 PREVENTION STRATEGIES IN THE CONTEXT OF VARYING COMMUNITY TRANSMISSION LEVELS & VACCINATION COVERAGE

Last week CDC changed their guidance for people living in areas of high transmission (like Arizona) urging everyone to wear a mask whether or not they’re vaccinated. There was a lot more to the guidance – but that was the top line change.

I initially had a beef with the CDC on that change because they relied on unpublished data to make the policy change:  “… based on emerging evidence suggests that fully vaccinated persons who do become infected with the Delta variant are at risk for transmitting it to others”  (CDC COVID-19 Response Team, unpublished data).

I have a problem with agencies making policy changes without disclosing the data sources that they’re using. In this case, CDC made a major policy change that impacts the behavior of hundreds of millions of people based on data that was unpublished.

Decision-making like that makes it very difficult for public health people in the field to defend the new policy. The agency is essentially saying ‘trust us, we’re right but we won’t tell you what the data is that drove the decision‘. Furthermore, it impairs adherence to the new policy because it’s not backed up by reviewable data.

Later in the week, CDC finally published the data that they used to develop the policy change earlier in the week.

Some of those data were published Friday in CDC’s Morbidity and Mortality Weekly Report.  It presented data suggesting that Delta infection results in similarly high SARS-CoV-2 viral loads in vaccinated and unvaccinated people… suggesting an increased risk of transmission in vaccinated persons with breakthrough infections (this has not been known to be the case in previous strains).

I’m OK with the guidance now, but I sure wish they had published their sources before making the policy change.

Remember, that the vast majority of persons infected with the virus at any given time are unvaccinated, so I’d still characterize the CDC’s decision to recommend public masking of vaccinated persons something that is being done ‘out of an abundance of caution’.

Will Humble Disease Control, Public Health Law

Expect Legal Action This Week

There’ll no doubt be some legal action this week challenging the laws the governor signed that micromanage COVID mitigation by schools, counties and cities. There are several court challenges that could happen. Here are a few examples:

K-12 Schools

The state legislature prohibited school districts from requiring students to wear masks inside classrooms in the K-12 budget bill. Governor Ducey enthusiastically signed the bill preventing districts from requiring masks (despite CDC guidance, American Academy of Pediatrics recommendations and tons of evidence for this important protective measure).

I expect one or more school districts to file an action in Superior Court challenging the K-12 Budget Reconciliation Bill because it violates the State Constitution’s requirement that all bills have a single subject (see this blog post and this report from the Network for Public Health Law).

Another argument may include the fact that Ducey’s restriction makes it impossible for schools to have fidelity to in loco parentis (“in the place of a parent”) which refers to the legal responsibility of schools to take on some of the functions and responsibilities of a parent on campus.

The Phoenix Union High School District is already ignoring the governor, announcing in their letter to parents entitled: PXU Announces Mask Requirement and the Safe Return to In-Person Learning that they’ll be requiring universal masking of all staff students and visitors regardless of vaccination status.

Expect more districts to defy the directive and require masks in classrooms despite ARS 15-342.05. This will probably trigger an action by A.G. Brnovich and/or Ducey to try to compel the district to stand down, sending the case to Superior Court- but this time with the school district as the defendant rather than the plaintiff.

Note: ARS 15-342.05 doesn’t take effect until September 29 (90 days after the end of the legislative session), however bill included a retroactivity clause back to June 30, 2021. A legal question is whether the restriction on districts takes effect on September 29 or whether it is already in effect because of retroactivity.

Cities & Counties

In light of the new guidance from the CDC regarding mask wearing in areas of high transmission (see next piece) we could see cities and/or counties to require visitors to city and county buildings to wear masks regardless of their vaccination status. Such a policy would be in violation of SB 1819 which prohibits:

“… a county, city or town from making or issuing any order, rule, ordinance or regulation… including an order, rule, ordinance or regulation that mandates the use of face coverings…”.

For example, cities could require city library visitors to wear masks regardless of vaccination status. Such a policy would likely trigger an action by Brnovich or Ducey to try to compel the city to comply with the new law- sending the case to court. Cities/counties could then make an argument that SB 1819 also violates the single subject requirement in the state constitution.

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