Teen Pregnancy Prevention Program Defunded in Baltimore…and Beyond

August 20, 2017 by

The teen pregnancy rate in Baltimore is 2-3 times the national average, with rates reaching upwards of 64 pregnant teens for every 1,000 female adolescents in 2009. According to the Center for Disease Control, teen pregnancy costs taxpayers $10 billion annually in health care and foster care costs. On the personal level, unplanned pregnancies significantly reduce life opportunities for teen moms, with the CDC finding that only 50% of teen moms graduating from high school by age 22. This lack of education causes a ripple effect, and teen moms have more chronic health problems and higher rates of incarceration.

Courtesy of the Baltimore Sun

Courtesy of Baltimore Sun

Teen pregnancy in Baltimore has seen a steady decline over the last decade, joining a national downward trend. This comes in no small part to programs such as the Health and Human Services’s Teen Pregnancy Prevention Program (TPPP). With funding from the TPPP, 80 city health departments have been empowered to create science-based prevention programs for teens to understand contraception and sexuality.

Unfortunately, the TPPP was abruptly defunded last week. The Trump administration offered little explanation, leaving pro-abstinence groups such as The Abstinence and Marriage Education Partnership to justify such cuts with claims that abstinence is correlated to lower rates of teen drug abuse.

Here in Maryland, the Baltimore City Health Department expressed frustration at losing $3.5 million out of the $214 milling being cut. Health Commissioner Leana Wen called the cuts “shocking.” The Health Department has joined the Big Cities Health Coalition, comprised of the 80 beneficiary cities of TPPP funds, in decrying the budget cuts. Even the American Academy of Pediatrics has joined the plea, adding a link to its website for pediatricians to contact their congressmen in protest.

There’s good news. The National Campaign to Prevent Teen and Unplanned Pregnancy found that 83% of adults support teen pregnancy prevention programs. Now is the time to tell Congress that the constituency wants the TPPP funded. Call your congressman today!

Shhh..not here, the kids are listening!

August 20, 2017 by

The largest democracy in the world is having problems, the most recurring is keeping half of its population safe. In the last few years India has been plagued with cases of gang rape, sexual assaults, molestation, child sexual abuse and other forms of sexual conflicts. While the cases are not first time occurrences, the exponential increase in these offenses is cause to worry. UNICEF reported that about 50% of the children have faced some form of sexual abuse. While this statistic is unsettling, the reality is most children and parents are in denial of the abuse and grow up accepting it as a way of life.

Experts say sex education and awareness is fundamental to battling this growing epidemic yet many government officials in India believe otherwise. Following the 2007 UNICEF study, the central government promoted a sex education program called the Adolescent Education Program, however this move was met by widespread opposition across the nation with 6 of the largest states ultimately banning sex education in their schools as it was against “ Indian Culture”. They propagated the ban claiming it would increase premarital sexual activity amongst youth and corrupt their values. This ban later spread to 12 states, nonetheless even the states where there is no ban, sex education is typically limited to elite private schools. In rural and lower income public schools where the need is greatest, education is is limited to descriptions of the human anatomy.

                                            ban_on_sex_education

Organizations such as the Family Planning Association of India have been leading efforts to overturn the ban but have only been instrumental in adding an addendum such as “Family Life Education” to some curriculums. To combat this issue effectively, to allow their women and children to be safe, the government of India needs a nationwide comprehensive sex education program for children and adolescents.

 

Improving Access to Buprenorphine: A Medication-Assisted Treatment to Address United States’ Opioid Epidemic

August 20, 2017 by

The United States recently declared the opioid epidemic as a national emergency. Buprenorphine is a prescribed partial agonist used in opioid medication-assisted treatments (MATs); it is particularly unique given that it can be administered in settings outside of opioid treatment programs like physician offices. Alarmingly, a recent study found that nearly 1 million people with opioid addictions in the U.S. could not access MATs due to prescribing capacity constraints, demonstrated in the figure below. Accordingly, it is critical that the U.S. focus on lifting the patient caps for prescribing buprenorphine.

AJPH Graph of Opioid Treatment Access Rates, July 2015

Source: American Journal of Public Health, July 2015

INCREMENTAL POLICY WINS

Per the Drug Addiction Treatment Act of 2000 (DATA), the number of patients that qualified physicians could treat with buprenorphine was capped at 30 patients at once, during the first year, expandable to 100 patients in the second year. The 2016 passage of the United States Code. Section 303(g)(2) of the Controlled Substances Act allows qualified physicians (who have treated 100 patients at once, for at least one year) the ability to apply for the treatment of 275 patients, at once. Key advocates who were successful in increasing the patient caps include the Substance Abuse and Mental Health Services Administration, American Medical Association, American Society of Addiction Medicine (ASAM), and the National Association of County and City Health Officials.

WHY STOP THERE?

A RAND study found that less than 10 percent of waived physicians treated more than 75 patients with buprenorphine, prior to the passage of the 2016 increase in patient caps. There are also great variations in the number of actively prescribing waived physicians in urban and rural communities. Lifting the patient caps for waived physicians is the most immediate and effective method of making buprenorphine available to a greater portion of the population, as it can be administered in any office-based setting; this policy change may also mitigate the “black market” for buprenorphine, which has been perpetuated by its limited access. An important component of the proposed change is that it will maintain the requirement for physician waivers. This will ensure that an appropriate standard of quality is met, and potentially limit the increases in the number of “pill mills” as compared to current trends, since those consumers may gain access to the full treatment through the proposed policy change.

Dr. Kelly Clark, president of ASAM, was succinct in her argument against patient caps: “This medication [buprenorphine] and this specialty of addiction medicine represent the only areas in medicine in which physicians are shackled and have a maximum number of patients that we can treat with an evidence-based medication…These limits are not evidence-based or clinically based.” It is critical that health care and public health professionals leverage their networks and join the fight to advocate for increased access to buprenorphine by lifting the patient caps for qualified physicians. The U.S. must take imminent action to provide an appropriate treatment response to the growing opioid epidemic.

Michigan Motorcycle Safety: The Need for a Universal Helmet Law

August 20, 2017 by

(Photo credits: Bridge Magazine, MLive.com)

In 2012, Michigan repealed a universal motorcycle helmet law that had been in place for 35 years, replacing it with a partial law. The American College of Surgeons (ACS) reports that unhelmeted motorcycle riders are significantly more likely to suffer fatal and non-fatal head injuries and that motorcycle riders hospitalized with brain injuries incur nearly double the costs as those without brain injuries, with the public incurring the majority of these costs. According to the ACS, helmets work, stating that “helmeted motorcycle riders have up to an 85 percent reduced incidence of serious, severe, and critical brain injuries compared with unhelmeted riders.”  These general observations have been borne out in Michigan since the repeal.

(Image credit: MLive.com)

Despite this, American Bikers Aiming Toward Education (ABATE) of Michigan continues to be very vocal in their opposition to universal helmet laws on behalf of motorcycle riders, justifying opposition to universal helmet laws by twisting the facts and providing red herring arguments.

In late 2016, Michigan Representative Peter Pettalia, who supported the repeal of the universal helmet law in 2012, died in a motorcycle accident. His death has reinvigorated the discussion of motorcycle safety laws, making now the time to act to make motorcycle riding safer. The American College of Surgeons reports that “when universal helmet laws are enacted, helmet use increases to nearly 100 percent, and fatalities and serious injuries decrease.” The Governors’ Highway Safety Association (GHSA) representing state and territorial highway safety offices and comprised of Governors’ representatives “urges all states to adopt a universal motorcycle helmet law and vigorously enforce existing laws.” I would urge Mike Prince, the Michigan representative to the GHSA, to act on behalf of the GHSA, the Michigan Office of Highway Safety Planning, and the people of Michigan by imploring Governor Rick Snyder to push a legislative agenda that includes a return to a universal motorcycle helmet law in Michigan.

Yellow fever vaccine shortage: Time for policy on vaccine back up plans?

August 20, 2017 by

yf500,000 doses are distributed annuallySanofi Pasteur is the sole manufacturer of the only FDA approved yellow fever vaccine YF-VAX in the US.  500,000 doses are distributed annually, one third to the US military are two thirds to the civilian clinics. In November, 2015 the vaccine supply was impacted when Sanofi Pasteur began the process of moving manufacturing of the vaccine to a new facility.  A large number of vaccines were lost in a production problem therefore diminishing the supply.  Although efforts were made by Sanofi Pasteur to extend the supply by rationing the doses left, the CDC was not notified of the issue and imminent depletion of supplies until spring of 2016

Sanofi Pasteur does manufacture another yellow fever vaccine that is used widely around the world, Stamaril.  Special approval as an investigational new drug (IND) was obtained from the FDA to be allow supply and administration of Stamaril in the US.  Stamaril and the YF-VAX are stamarilcomparable in efficacy and risk of side effects therefore seen as interchangeable.  Usually, roughly 4,000 sites in the US administer YF-VAX, while only 250 have been chosen to be allowed to supply Stamaril.

Currently there is no policy in place to address vaccine production in a vaccine shortage situation, and this must be addressed in further regulation and policy.

This vaccine shortage is not the first nor unfortunately the last that will take place.  With this in mind, a policy addressing vaccine production issues has to be put forth. This should include a notification process allowing enough time for enacting a contingency plan to boost supply through alternate production and possible rationing.  A national policy that outlines the procedure of notifying the CDC of possible shortages along with penalties to the company if not followed is imperative to lessen the impact of a shortage or to prevent it altogether.  A new component of the FDA vaccine approval process and annual inspection should be added as well requiring an action plan to produce vaccines in case of a failure of supply or of production transfer in cases of withdrawal of the company from the market. It is unacceptable that one manufacturer’s difficulty, mistake, or withdrawal from the market impacts the health of the entire nation when this could be prevented with planning and coordination. 

We’re Doing it Wrong: Chronic Care in America

August 20, 2017 by

Graph - Chronic Conditions

Americans are chronically ill.  The prevalence of chronic conditions in America is trending to be 1 in every 2 persons by 2030. We all know people with chronic conditions and it is safe to say that they suffer from worse quality of life. Unfortunately, our healthcare system is ill-equipped to meet the needs of those with chronic diseases. But there are ways to change that.

The majority of Americans on Medicare are chronically ill and they have to pay a co-pay every time they interact with their physician. Every. Single. Time. It’s annoying enough to pay for that yearly physical (which we should all do and by the way; Medicare pays for it). How about paying every month for hypertension management? Or being required to schedule a timely face-to-face visit with your provider to discuss the blood pressures you’ve been checking yourself? Still have to pay. And the reality is many of us can’t.

Is it all down to the greedy physicians? Unfortunately, it’s not that simple. Providing care to medically complex, chronically ill adults is burdensome and time-consuming. Primary care providers are already under-compensated for the work they do – and the lack of incentive for a team based approach is causing physician burn-out.

So what’s the solution? One might be to invest in Comprehensive Primary Care programs that promote chronic care management. These programs can provide special services to patients that give them more access to their provider’s health team. By eliminating patient co-pays, CPC programs actually improve patient satisfaction and lower the cost of healthcare.

For providers, funding for these programs allows for investment in the infrastructure needed to provide a team based approach to chronic care. Oh yeah – and the fee schedule adjustments allow them to be fairly compensated for all their labors.

Here’s the kicker – the CPC models actually costs Medicare less than traditional fee-for-service models. So you know the drill – call your congressperson and tell him/her that you support funding for Comprehensive Primary Care programs.

Optimal Infant & Young Child Feeding (IYCF) In Nigeria: Starting out right

August 20, 2017 by

Optimal nutrition in the early years is an essential ingredient for children to attain their full potential physically and intellectually. Hence, the WHO/UNICEF developed the Global Strategy for IYCF aimed at reawakening the attention to benefits of optimal childhood nutrition.

In August 2011, the Nigerian Federal Ministry of Health (FMOH) adopted this strategy as a National Policy for IYCF. It actively encourages Exclusive Breastfeeding (EBF) for the first six months of life and thereafter, introduction of safe and age-appropriate complementary foods based on locally available food materials; and continued breastfeeding for two years or more.

Even with the implementation of IYCF, malnutrition continues to be a concern. Stunting declined by only 4%, while the rates of wasting and underweight increased to 18% and 29%. These rates are indicative of nutritional deficiency due to suboptimal feeding practices. The causes of malnutrition in the first 2 years of life include inappropriate breastfeeding and complementary feeding as well as high rates of infections. Only 17% of children are exclusively breastfed at six months with median duration of EBF being 0.5 months in Nigeria.

In addition, infants are introduced to complementary food too early/late and only about 10% of children aged 6-23 months meet the recommendations of the IYCF practices. These feeds are often inadequate in energy, protein, vitamins/minerals such as iron, vitamin A, iodine and zinc.

Intervention

While treatment of malnutrition remains important, Federal and state governments through the ministries of health must pay attention to the important aspect of promotive and preventive health for effectiveness and sustainability. Healthcare professionals must educate pregnant women during ante/postnatal classes on the importance of EBF and implications of starting complementary feeding too early/late. Community health workers should be trained to go into the community to encourage mothers, their spouses and other family/social support groups on EBF, continued breastfeeding and age-appropriate complementary feeding based on locally available food materials.

Also, the FMOH should adopt policies to increase maternity leave to a minimum of 6 months, and mandating employers to provide baby-friendly environment to encourage EBF.

All levels of government need to collaborate to provide leadership, coordination and funding by involving the ministries of education, agriculture, social development, women affairs and information. Resources must be allocated and all strategies must be adequately implemented to support and enhance the capacity to address infant and young child feeding practices in different situations and circumstances.

(by @seunowoniyi and @okowamildred)

Regulation by Florida of Cancer Treatment Costs for Medicare Beneficiaries

August 20, 2017 by

Cancer comes with one of the costliest medical expenses. Doctors often diagnose individuals 65+ years old with new cancers, so Medicare and its beneficiaries must pay for the high treatment costs. Medicare requires high-cost sharing among its beneficiaries, which leads to financial distress for example bankruptcy. Florida has one of the largest populations of senior citizens (19.9%), two million of which are Medicare beneficiaries. The high out-of-pocket burden from cancer treatment costs leads Medicare beneficiaries towards decreased medication adherence or medical care postponement. Overall, beneficiaries have poorer cancer treatment outcomes compared to privately insured individuals.

nci-vol-8498-72

Photo from: NCI Visuals Online

The Florida Department of Health, along with Gov. Rick Scott, should negotiate cancer treatment costs at quality cancer centers in Florida, such as Moffitt Cancer Center, and with pharmaceutical companies like Bristol-Myers Squibb to reduce out-of-pocket expenses for Medicare beneficiaries. The Florida Department of Health should place caps on cancer treatment costs to maintain them at reasonable prices. This political action would test whether cancer treatment cost negotiations at the state level are more effective than federal level negotiations. Biomedical companies can flexibly negotiate cancer treatment prices based on prevalences and morbidities in distinct states.

Florida’s House will not expand Medicaid health insurance coverage, and pharmaceutical companies refuse to negotiate drug prices for Medicare beneficiaries. Placing treatment cost negotiations and caps in the state’s health department’s hands may reduce Medicare beneficiaries’ substantial out-of-pocket cancer treatment expenses. Cancer incidence and morbidity has declined. However, cancer treatment costs and Medicare spending have only risen and are expected to continue growing.

Besides other factors that affect cancer treatment like transportation costs, psychosocial stressors, and reduced quality of life, add stress to a patient’s cancer care experience despite the financial resources provided by organizations like the American Cancer Society.

Expanding Medicare’s Immunosuppressive Drug Coverage to All Kidney Transplant Recipients

August 20, 2017 by
The high cost of necessary transplant medicines can lead to some kidney transplant recipients losing their new kidneys.

The high cost of necessary transplant medicines can lead to some kidney transplant recipients losing their new kidneys.

As of January 2016, about 660,000 individuals in the United States are being treated for kidney failure. While dialysis can be an effective solution for some individuals, the current best care for renal failure is a kidney transplant, which offers better health outcomes and is less expensive long term than dialysis. While the initial transplant costs about $90,000 and required post-transplant medicines cost $16,000 per year, dialysis costs about $44,000 per year; most transplants pay for themselves and become cheaper than dialysis after 2 to 3 years. Kidney transplant recipients must take expensive immunosuppressive medications to keep their transplants healthy and working. Medicare currently pays for dialysis and kidney transplants as needed for everyone in the United States. However, while Medicare will cover the cost of transplant medications indefinitely for those 65 and older or disabled, Medicare will only cover transplant medications for 36 months for those under 65. After 36 months, many transplant recipients are not able to afford their medication and stop taking it; many then lose their transplant and have to go back on dialysis.

A doctor preparing a donated kidney for transport.

A doctor preparing a donated kidney for transport.

Multiple professional, patient-centered, and nonprofit groups support changing the law to expand Medicare’s indefinite immunosuppressive drug coverage to anyone in the United States with a kidney transplant. While bills have been introduced multiple times in Congress to address this issue, none have yet passed. A proposal put forward in 2009 was blocked by a major industry coalition who opposed plans to generate cost-savings from dialysis care to pay for the new coverage.  Subsequent proposals have failed to make it to a vote, due both to a Congress unwilling to address more health legislation in the wake of the Affordable Care Act and to real concerns about continued funding for Medicare. While the long term savings will be high, initial funding for such a measure may be difficult to find. Nevertheless, expanding post-transplant drug coverage in this way has substantial advantages both in increased quality of life for patients and in long-term savings for Medicare. Patients, health care professionals, and kidney-focused nonprofit groups should continue to contact their legislators through both private communication and public statements to urge them to expand transplant drug coverage.

 

Policy Proposal: Performing Mental Health Screenings for Deaf College Students on College Campuses in the DMV (District of Columbia, Maryland & Virginia) – A Surveillance Tool

August 20, 2017 by

Mental health effects one in four college students but there is no statistical data about how many Deaf college students face mental health issues because it is often coupled with other forms of disability. Lack of effective communication, competent mental health providers/counselors who are either Deaf or knowledgeable about the Deaf and Hard-of-Hearing (DHOH) community is scarce, and not enough qualified mental health interpreters are available for the Deaf client seeking mental health services.

College is a crucial time in a young adult’s life and 73% of mental health episodes occur on college campuses and the Deaf are likely to suffer more from mental health episodes. Mandatory screening efforts needs to be established for all incoming Deaf college students. Currently there is no such health policy that exists. This is a proposal to require incoming Deaf college students on various college campuses in the District of Columbia, Maryland, and Virginia (DMV), to undergo a mental health screening with their primary healthcare provider or with their respective college counseling center before enrolling (they can accept/deny services but must be presented with the opportunity for data collection purposes; the information will be disseminated to the state’s respective public health office for analysis and interpretation). Efforts will effectively obtain a more accurate account of what mental health disorders Deaf college students face and how to provide semantically/linguistically equivalent services.

Source: YouTube – Gallaudet Counseling and Psychological Services

As an advocate for the DHOH community, I am for this position on the issue. This effort would increase mental health awareness among the DHOH community, increase access to services, and identify their unique needs while making the evidence/data more widely available. Other stakeholders such as the NAD, NCMHDI, and RID are organizations that strongly believe in revamped policy development for DHOH people in public mental health.