Journal Article of the Week: Child Firearm Deaths Overtake Deaths from Car Crashes in U.S.

Crossing Lines — A Change in the Leading Cause of Death among U.S. Children | NEJM

Injuries are the most common cause of death among children, adolescents, and young adults between 1 and 24 years of age in the United States; indeed, injuries are responsible for more deaths among children and adolescents than all other causes combined. For more than 60 years, motor vehicle crashes were the leading cause of injury-related death among young people. Beginning in 2017, however, firearm-related injuries took their place to become the most common cause of death from injury (see graph).

This change occurred because of both the rising number of firearm-related deaths in this age group and the nearly continuous reduction in deaths from motor vehicle crashes. The crossing of these trend lines demonstrates how a concerted approach to injury prevention can reduce injuries and deaths — and, conversely, how a public health problem can be exacerbated in the absence of such attention. 

Research has shown that most injuries can be prevented by means of the manufacture and appropriate use of safe products and the implementation of policies reducing product-related danger and the occurrence of hazardous situations — the principles of harm reduction.

Since the 1960s, continuous efforts have been directed toward preventing deaths from motor vehicle crashes. As a result, there has been a substantial reduction not just in fatality rates, but in rates of serious nonfatal injuries associated with motor vehicle crashes, among people of all ages.

 In 2000, motor vehicle–related injuries resulted in 13,049 deaths among young people (13.62 per 100,000 persons). Twenty years later, there has been a nearly 40% decrease, with 8234 motor vehicle traffic deaths (8.31 per 100,000 persons) recorded in 2020.

Slipshod Enforcement of Worker Safety Regulations Compels OSHA to Begin Revocation of AZ Industrial Commission Delegation Agreement

OSHA Set to Take Back Enforcement of Workplace Health and Safety Standards Due to Poor Performance by Governor Ducey’s Industrial Commission

Last week the Occupational and Safety & Health Administration started procedures to revoke their agreement with the state of Arizona to delegate OSHA’s workplace safety and health regulations to Arizona. In their announcement, OSHA cited a “decade-long pattern of failures” by the state.

OSHA cited long-standing poor performance by the Arizona Department of Occupational Safety and Health, which is overseen by Governor Ducey and part of the Arizona Industrial Commission.  The feds specifically cite lax penalties, standards, and follow-up. OSHA believes that Ducey’s ADOSH is “… either unable or unwilling to maintain its commitment to provide a program for worker safety and health protection.”

See: OSHA may strip Arizona of power to regulate workplace safety

Earlier this year, OSHA sent a sternly worded to Governor Ducey [see letter] admonishing the Governor for publicly stating that ADOSH was not going to enforce OSHA COVID-19 regulations. According to OSHA, Arizona was the ONLY state to make that brazenly irresponsible policy decision.

So far, the governor appears willing to cede ADOSH authority to OSHA given his only public statement on this matter is that this action is a “political stunt and power grab”. If he were really interested in keeping enforcement of workplace standards in house, you’d think he’d say “we’re looking into it and will make any necessary corrections. Stay tuned for more corrective action from ADOSH” or something like that.

Here is OSHA’s official notice of reconsideration/revocation and here’s the direct link to provide specific information to OSHA about ADOSH’s effectiveness at enforcing (or mostly not enforcing) workplace health & safety regulations in Arizona [Docket # OSHA-2021-0012]. We encourage Arizonans with specific information about ADOSH’s effectiveness at enforcing (or not enforcing) workplace health and safety standards to let OSHA know your thoughts on that link.

Summary: On June 20, 1985, the Federal Occupational Safety and Health Administration (OSHA) granted Arizona’s occupational safety and health plan (State Plan) final approval under Section 18(e) of the Occupational Safety and Health Act of 1970 (the OSH Act). In this notice, OSHA proposes to revoke its affirmative determination granting final approval to the State Plan. If revocation is determined to be appropriate, the Arizona State Plan will revert to initial approval and Federal authority for discretionary concurrent enforcement would resume, allowing Federal OSHA to ensure that private sector employees in Arizona are receiving protections that are at least as effective as those afforded to employees covered by Federal OSHA.

Well done, Governor Ducey. Well done indeed.

P.S. The Director of the Arizona Industrial Commission is James Ashley. His qualification to run the Commission? He was a republican political affairs consultant for 8 years and before that worked as a staffer to former Representatives Ben Quayle (2 years) and John Shadegg (8 years). No editorial comment needed.

Childhood Vaccination Rates Continue to Drop In the 2021-2022 School Year

Statewide Average Kindergarten MMR Vaccination Rate Now at 91%; Well Below the Community Immunity Threshold for Measles

State law requires the ADHS to collect data about the vaccination rates for Child Care/Preschool; Kindergarten; and 6th grade. Schools submit the data to the ADHS each fall (deadline is November 15) and in the spring ADHS is required to publish the data by school. Rather than showing the actual vaccination rates, the system records the percentage of exemptions (personal, medical and religious) as a proxy for vaccination rates.

ADHS posted the data this week (which ironically is National Infant Immunization Week). There are some aggregate tables but also a big giant spreadsheet with the vaccination rate by school. A clever parent that knows how to sort in Excel could quickly find the vaccination rate for their kid’s school. Here’s the big file with all the school data: Arizona Reporting Schools Coverage

There are also some summary tables with coverage levels for various vaccines by geographic region:

The news isn’t good. As has been the case throughout the Ducey Administration, childhood vaccination rates have continued their insidious decline, with the statewide immunization rate for Kindergarteners now at 91%, well below the community immunity threshold for measles of 95%.

Vaccination rates aren’t uniform across the state. Yuma and Santa Cruz counties continue to enjoy the highest vaccination rates (above 95% for MMR among Kindergarteners). Also as usual… Yavapai had the lowest vaccination rates with MMR coverage at only 74% and nearly 10% of students totally unvaccinated among Kindergarteners.

Another continuing trend… students enrolled in charter schools have vaccination rates much lower than students in district public schools. Also, higher income districts tend to have lower vaccination rates.

There are several evidence-based strategies that can be implemented at a statewide level, but such initiatives require leadership by a state health department and governor…  something that’s in short supply in Arizona these days.

Interventions to increase pediatric vaccine uptake: An overview of recent findings

For information on school immunization requirements, review the Guides to Arizona Immunization Requirements for Child Care/Preschool and Grades K-12.

Perhaps childhood vaccination will again become a priority when we get a new governor & state health director in 250 days.

CMS Finalizes Medicare Coverage Policy for Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease

CMS Finalizes Medicare Coverage Policy for Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease

Medicare will cover monoclonal antibodies that target amyloid (or plaque) for the treatment of Alzheimer’s disease CMS, as a part of this decision, will provide enhanced access and coverage for people with Medicare participating in CMS-approved studies, such as a data collection through routine clinical practice or registries.

This decision is specific to individuals who have a clinical diagnosis of mild cognitive impairment due to Alzheimer’s Disease or mild dementia with a confirmed presence of plaque on the brain.

Editorial Note: I think this is a good decision. FDA’S advisory committee urged former FDA Commissioner Woodcock not to approve Aduhelm because the data were unclear whether the drug is effective. This approach will allow for data collection to determine whether it actually works. It will also cut down on the enormous drain that would have occurred to the Medicare Trust Fund that would have occurred given that the drug costs a whopping $56,000 per year per patient.

April 25, 2022 Legislative Roundup

Budget Drama

The highlight last week at the state legislature was an attempt to get the budget negotiations started by trying to pass a ‘skinny budget’ – which is basically a carbon copy of last year’s budget with some tweaks for enrollment in state programs and population growth.

A series of about a dozen ‘skinny’ budget bills were brought up for votes in the House Appropriations Committee by Chair Regina Cobb. The pitch made by the chair to the committee was that the skinny budget would pass and then members, including Democrats, could propose floor amendments.

The drama wasn’t very long-lasting because the first bill failed 7-6 with Rep. Udall and Hoffman voting no with all the Democrats (for different reasons). The drama left the room as bill after bill met the same fate- losing 7-6. If there are other strategies for the upcoming week- I don’t know what they are.

Bad Bills Pass

Last Monday, the Senate have final approval to two bad bills that have been sent to the goveronr for his rubber stamp. The most harmful is HB2616 which permanently takes universal masking away as a public health intervention in classrooms.

It’s roundabout way says schools can’t require kids to wear masks ‘without the express consent of the parent‘, nullifying the intervention because classroom masking only works when it’s universal (basic masks are good at stopping particles from leaving mouths and noses but they’re poor filters except for N95’s and equivalent).

HB2498 stops cities/counties from ever requiring a COVID vaccine for staff. This one is less harmful than HB2616 in that it’s limited in scope and only applies to the COVID-19 vaccines.

TAPI has a campaign and send Dr. England’s letter to both Governor Ducey and Dr. Carmona at AZDHS urging a veto:

I expect the governor to enthusiastically sign both this upcoming week.

Several other bad bills are poised for floor votes this upcoming week. No agendas have been posted yet- so I’ll spare you any details right now- but stay tuned to my blog and Policy Committee action alerts as things can happen.

Among the bills I expect to see action are SB 1009, which greatly restricts the public health emergency authority that future governors have. While our current governor under-used and at times mis-used that authority to harm the COVID response, I’m hopeful that we will never again have a governor that will as brazenly misuse emergency authority the way this one has- and so it would be nice to keep the authority in tact.

 See our April 18, 2022 Legislative Roundup for the list of bills we’re following. Here is this week’s Spreadsheet Tracker

AZ Supreme Court Legislates from the Bench: Decrees A Top State Individual Income Tax Rate of Only 2.5%

Decree Will Make It Much Harder to Address Pressing Public & Social Determinants of Health Issues

Last week the Arizona Supreme Court set a new individual state income tax rate of 2.5% decreasing revenue to the state by more than $1B annually, perhaps more. Here’s what went down:

Voters approved Proposition 208 in 2020, which imposed a surcharge of 3.5% on incomes above $250,000 for single filers ($500K for joint filers) with the proceeds earmarked for K-12 education. The state’s maximum marginal individual income tax rate was 4.5%, so after Prop 208 the top rate should have been 8%.

The majority in the legislature didn’t like what the voters had approved, so they passed a law that did an end-around the surcharge last year. They set a flat tax of 2.5% for those not subject to the Proposition 208 surcharge. The tax rate for those subject to the surcharge was capped at 4.5%. People subject to the surcharge would pay the 3.5% into the Proposition 208 fund and another 1% into the state’s general fund.

People that didn’t like Prop 208 sued and that case worked its way through the courts. Last week the AZ Supreme Court ruled that the proceeds from Prop 208 were subject to a spending cap that had been approved by voters decades ago. 

But, instead of finding that the Prop 208 money was subject to the spending limit and allowing it to be collected but not spent unless the legislature approved annual increases in the limit (which they can do under the decades old initiative), the Court nullified the surcharge, setting the income tax limit at 2.5% instead of the pervious 4.5%.

In summary, Arizona had a top individual income tax rate of 4.5%. Voters increased it to 8% with Prop 208. The Legislature returned it to 4.5%… but last week the Arizona Supreme Court dismissed that cap and set the top individual state income tax rate at only 2.5%.

Editorial note: This action from the state supreme court is flat-out legislating from the bench, the very thing that Governor Ducey and many ‘conservatives’ rail about. But when legislating from the bench helps himself and his wealthy pals, it’s hunky dory.

If you recall, the Governor expanded the Court by 2 seats even though the court said they didn’t need more justices. By packing the court, he has achieved a key objective: drastically lowering taxes on the wealthy through the bench.

AZ Hospital Compare

Let’s face it.  When it comes to being in control as a consumer- information is power.  And being in control of your own health and health care is probably one of the most important things you can do as you go through life.  Up until the last couple of years, the healthcare world has been opaque when it comes to getting the information that you need to make good decisions- whether it’s quality indicators or costs.  But that’s changing rapidly- especially in Arizona.

That’s why, back in 2013 our team developed Arizona Hospital Compare which provides Arizona consumers with data on quality, care, costs, and charges at Arizona hospitals.  The info on Arizona Hospital Compare can help you make better decisions when choosing a hospital for childbirth or an elective procedure.  It can also help you negotiate price if you’re paying cash.  Hospital administrators can use the data to make sure they’re on track for their own goals and compare themselves to the competition.

For example, if you need an operation, you may want to look at how safe hospitals are for patients needing surgery.  You also might want to look at some of the quality data that comes from patients themselves.  If you’re planning to have a baby, you can look up the percentage of births by hospital that end up in C sections (there’s a wide range).

The costs and charges sections give the most recent data available for how much hospitals are charging on average and how much those services cost the hospital to provide. 

Like I said- information is power when it comes to making smart decisions as a consumer- and our new AZ Hospital Compare site provides you with more information to put you in the driver seat.

AzPHA thanks ADHS for keeping Az Hospital Compare going (albeit they have only loaded data through 2019).  

Journal Article of the Week: Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020–21

Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020–21

The global all-age rate of excess mortality due to the COVID-19 pandemic was 120·3 deaths per 100000 of the population, and excess mortality rate exceeded 300 deaths per 100 000 of the population in 21 countries.

The number of excess deaths due to COVID-19 was largest in the regions of south Asia, north Africa and the Middle East, and eastern Europe.

At the country level, the highest numbers of cumulative excess deaths due to COVID-19 were estimated in India, the USA, Russia, Mexico, Brazil, Indonesia, and Pakistan. Among these countries, the excess mortality rate was highest in Russia (374 deaths per 100, 000) and Mexico (325 per 100,000), and was similar in Brazil (186 per 100,000).

Note: Arizona’s per capita COVID death rate is 415 per 100,000, making Arizona the worst in the entire globe in this study if we were a country, thanks mostly to the decisions made by Governor Ducey and former ADHS Director Christ.

Interpretation: The full impact of the pandemic has been much greater than what is indicated by reported deaths due to COVID-19 alone. Strengthening death registration systems around the world, long understood to be crucial to global public health strategy, is necessary for improved monitoring of this pandemic and future pandemics.

In addition, further research is warranted to help distinguish the proportion of excess mortality that was directly caused by SARS-CoV-2 infection and the changes in causes of death as an indirect consequence of the pandemic.

A Final Report Card on the States’ Response to COVID-19

The 50 states and their governors and legislators made many of their own pandemic policy choices to mitigate the damage from the virus.

This study is a report card of how pandemic health, economy, and policy varied across the 50 states. It examines three variables: health outcomes, economic performance throughout the pandemic, and impact on education. 

The authors rank Arizona 37th overall (considering all 3 factors), giving Arizona a grade of D. Not surprisingly, Arizona was the absolute worst in the country in the health component (51st) because, according to their metric, Arizona has had the highest per-capita COVID death rate in the country.

A Final Report Card on the States’ Response to COVID-19

AzPHA Looking for Intern to Examine Firearm Epidemiology in Arizona

For decades, injuries have been the leading cause of death among kids in the U.S. In fact, injuries are responsible for more deaths among children and adolescents than all other causes combined.

For more than 60 years, car crashes were the leading cause of injury-related death among kids. Beginning in 2017, firearm-related injuries took their place to become the most common cause of death from injury. Crossing Lines — A Change in the Leading Cause of Death among U.S. Children | NEJM

Are you a public health student looking for experience by examining firearm epidemiology in Arizona? AzPHA has an internship/research opportunity regarding firearm safety in Arizona. Gather and review data, speak with stakeholders, write a white paper, influence policy in Arizona. We need you! 

Wanted: Researcher interested in firearm safety to author a white paper for AzPHA. Funding and internship available. 

Turn your public health internship into change for Arizonans! AzPHA seeks a white paper on firearm safety. The right candidate will have an interest in data, epidemiology, and public health policy. Funding available. 

Contact Kelli Donley Williams for more

Note: It’s the job Arizona Department of Health Services’ job to do this kind of epidemiological work. Sadly, because governor Ducey and current ADHS top leadership are so pro firearm, current ADHS leadership is unwilling to do this type of analysis. We’ll do it for them just like we’ve done throughout the COVID-19 pandemic.