A tripledemic hurricane is making landfall. We need masks, not just tent hospitals

A viral hurricane is making landfall on health care systems battered by three pandemic years. With the official start of winter still weeks away, pediatric hospitals are facing crushing caseloads of children sick with RSV and other viral illnesses. Schools that promised a “return to normal” now report widespread absences and even closures from RSV and flu in many parts of the country, contributing to parents missing work in record numbers. With this year’s flu season beginning some six weeks early, the CDC has already declared a flu epidemic as hospitalizations for influenza soared to the highest point in more than a decade.

A storm of these proportions should demand not only crisis clinical measures, but also community prevention efforts. Yet instead of deploying public health strategies to weather the storm, the U.S. is abandoning them.

Even before the arrival of the so-called tripledemic, U.S. health systems were on the brink. But as the fall surge of illness threatens to capsize teetering hospitals, the will to deploy public health measures has also collapsed. Pediatricians are declaring “This is our March 2020” and issuing pleas for help while public health efforts to flatten the curve and reduce transmission rates of Covid-19 — or any infectious disease — have effectively evaporated. Unmanageable patient volumes are seen as inevitable, or billed as the predictable outcome of an “immunity debt,” despite considerable uncertainty surrounding the scientific underpinnings and practical utility of this concept.

The Covid-19 pandemic should have left us better prepared for this moment. It helped the public to understand that respiratory viruses primarily spread through shared indoor air. Public health practices to stop the spread of Covid-19 — such as masking, moving activities outdoors, and limiting large gatherings during surges — were incorporated into the daily routines of many Americans. RSV and flu are also much less transmissible than Covid-19, making them easier to control with common-sense public health practices.

Instead of dialing up those first-line practices as pediatric ICUs overflow and classrooms close, though, the U.S. is relying on its precious and fragile last lines of defense to combat the tripledemic: health care professionals and medical facilities.

Warnings and advisories recently issued by U.S. public health leadersclinical leaderspoliticians, and the media have consistently neglected to mention masking as a powerful short-term public health strategy that can blunt the surge of viral illness. Instead, recent guidance has exclusively promoted handwashing and cough etiquette. These recommendations run counter to recent calls to build on improved understanding of the transmission of respiratory viruses.

In the U.S.’s efforts to “move on” from thinking about Covid, it has created a “new normal” that is deeply abnormal — one in which we normalize resorting to crisis measures, such as treating patients in tents, instead of using common-sense public health strategies. Treating Covid like the flu — or the flu like Covid — has effectively meant that we treat neither illness as if it were a serious threat to health systems and to public health. Mobilizing Department of Defense troops and Federal Emergency Management Agency personnel to cover health system shortfalls is apparently more palatable than asking people to wear masks.

The tripledemic has already claimed its first child deaths in the U.S., adding to a large ongoing death toll from Covid. Allowing health systems to reach the brink of collapse will lead to many more preventable deaths among pediatric and other vulnerable patients who can’t access the care they need.

By any accounting, these losses are shocking and tragic. But they should strike us as particularly abhorrent and shameful because the tripledemic is a crisis that leaders, health agencies, and institutions have, in a sense, chosen. Over the past year, the Biden administration and its allies have repeatedly encouraged the public to stand down on public health measures, with the President even stating in September that “the pandemic is over.” By moving real risks out of view and failing to push for more robust measures to mitigate Covid, these messages have put the country on a path to its present circumstances, in which pediatric RSV patients are transferred to hospitals hundreds of miles away because there is no capacity to treat them in their own communities.

Living with viruses should mean embracing simple public health measures rather than learning to live with staggering levels of illness and death. Leaders in public health and medicine should issue timely and appropriate guidance that reflects the latest science instead of second-guessing the prevailing winds in public opinion. Instead of self-censoring their recommendations out of fear of political consequences, they should continue to promote the full range of public health strategies, including masking in crowded indoor public places during surges.

The tripledemic should bring renewed urgency to policies that will reduce the toll of seasonal illness on health, education, and the economy. Improvements in indoor air quality in public spaces, including schools, child care centers, and workplaces, can limit the spread of diseases and have many demonstrated health and economic benefits, yet the U.S. continues to lack standards to guide infrastructure or workplace safety standards. Paid leave enabling workers to stay home when they are ill can reduce the transmission of disease as well as loss of income, yet the U.S. is one of the only high-income countries without universal paid sick leave or family medical leave.

Greater effort must also be made to increase vaccination coverage for flu and Covid and bring an RSV vaccine online as quickly as possible. Only about half of high-risk adults under 65 received a flu shot last year, a gap that can be closed with more energetic vaccination campaigns. Reducing annual flu deaths using a broader range of strategies enabled by the pandemic — rather than pegging Covid deaths to them — should be the goal.

Amid the many sobering stories of the tripledemic, there is some good news. As the experience of Covid-19 has shown, it is possible to limit the toll of respiratory viruses like flu and RSV. However, this work requires resources, appropriate policies, and political will. Americans don’t need to accept winter disease surges and overrun health systems as an inevitable new normal. Instead, the country should see the tripledemic as a call to reinvigorate public health strategies in response to these threats to the health of our communities.

COVID public health emergency (PHE) likely to extend past January

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The Department of Health and Human Services (HHS) appears set to extend the federal COVID PHE past its current expiration date of January 11, 2023, as HHS had promised to give stakeholders at least 60 days’ notice before ending it, and that deadline came and went on November 11th. Days later the Senate voted to end the PHE, a bill which Biden has promised to veto should it reach his desk. Measures set to expire with the PHE, or on a several month delay after it ends, include Medicare telehealth flexibilities, continuous enrollment guarantees in Medicaid, and boosted payments to hospitals treating COVID patients. 

The Gist: Despite growing calls to end the PHE declaration, and even as White House COVID coordinator Dr. Ashish Jha has said another severe COVID surge this winter is unlikely, the White House is likely trying to buy time to resolve the complicated issues tied to the PHE, some of which must be dealt with legislatively. 

And with a divided Congress ahead, it remains to be seen how these issues, especially Medicare telehealth flexibilities—a topic of bipartisan agreement—are sorted out. Meanwhile the continuation of the PHE prevents states from beginning Medicaid re-determinations, allowing millions of Americans to avoid being disenrolled.

New York declares polio a state emergency

New York Gov. Kathy Hochul on Sept. 9 declared a state of emergency amid evidence that polio is spreading in communities around the state. The move unlocks federal resources to help the state respond and boost vaccination rates. 

Under the declaration, pharmacists, emergency medical personnel and midwives can now administer polio vaccines. The executive order also requires providers to send polio vaccination data to the state’s health department. 

“On polio, we simply cannot roll the dice,” said Mary Bassett, MD, health commissioner at the state’s health department. “If you or your child are unvaccinated or not up to date with vaccinations, the risk of paralytic disease is real. I urge New Yorkers to not accept any risk at all.”

The declaration came the same day state health officials reported that the virus had been detected in wastewater samples from Nassau County. Officials have also found the virus in sewage samples from New York City, Orange County, Sullivan County and Rockland County, where the nation’s first polio case in nearly a decade was confirmed July 21 in an unvaccinated man. Health officials have suggested the Rockland County case may just be the “tip of the iceberg” with hundreds of other cases potentially going undetected in the state. 

The threat of polio’s resurgence is magnified by the many pockets of unvaccinated residents throughout the state. New York’s polio vaccination rate is 78.96 percent. That figure is lower in many of the counties where the virus has been detected in wastewater. In Rockland County, for example, the polio vaccination rate is 60.3 percent, state data shows. Nationwide, polio vaccination coverage sits at about 93 percent, according to the CDC.

Federal government adjusts monkeypox vaccine strategy

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This week, the Food and Drug Administration (FDA) announced a change intended to stretch out the limited supply of monkeypox vaccine doses, allowing the shots to reach five times the number of patients. Monkeypox, a disease in the smallpox family, is spread primarily through skin-to-skin contact, often causing patients to develop painful lesions.

Although most cases resolve within a few weeks, the rapid growth in cases, now more than 9K domestically and 30K globally, is still a cause for concern, leading federal officials to declare a public health emergency last week. The FDA is also recommending that providers administer the vaccine between layers of skin, rather than below the skin into fatty tissue. This dosing change will allow providers to extend the nearly half a million doses not yet sent to states, in order to reach the more than 1.6M Americans considered highest risk.

The Gist: The country is now dealing with two public health emergencies from highly contagious diseases simultaneously. While monkeypox isn’t nearly as transmissible, deadly, or overwhelming to the healthcare system as COVID, the public health response has nonetheless been lackluster (and this week’s new COVID guidance suggests that the CDC has largely given up on managing the response, devolving responsibility to individuals in nearly all settings). 

For those hoping that the COVID experience would spark faster action by our public health system, the federal response to monkeypox shows we haven’t applied the lessons learned. Public health authorities aren’t conducting rigorous disease surveillance, testing and treatments remain hard to get, and Congress isn’t dedicating funds for the response. The lack of proactive leadership is likely to result in healthcare providers again bearing the brunt of efforts to manage another unsuppressed viral outbreak. 

U.S. declares public health emergency over monkeypox

The Biden administration has declared the monkeypox outbreak a public health emergency — a move that gives officials more flexibility to tackle the virus’ spread.

Why it matters: New YorkCalifornia and Illinois all declared public health emergencies related to monkeypox in the last two weeks. The World Health Organization has already declared monkeypox a global emergency.

Details: Department of Health and Human Services secretary Xavier Becerra made the announcement Thursday in a briefing on monkeypox.

  • Federal health officials can now expedite preventative measures to treat monkeypox without going through a full federal review, the Washington Post reports.

What they’re saying: “We’re prepared to take our response to the next level in addressing this virus,” Becerra said Thursday. “We urge every American to take monkeypox seriously and to take responsibility to help us tackle this virus.”

  • Dr. Rochelle Walensky, the director of the Centers for Disease Control and Prevention, said the declaration will help “exploit the outbreak” and potentially increase access to care for those at risk.
  • Dr. Demetre Daskalakis, the White House national monkeypox response deputy coordinator, said “today’s actions will allow us to meet the needs of communities impacted by the virus … and aggressively work to stop this outbreak.”

State of play: Dr. Robert Califf, the commissioner of the Food and Drug Administration, said the U.S. is “at a critical inflection point” in the monkeypox outbreak, requiring “additional solutions to address the rise in infection rates.”

  • There are 6,600 cases of monkeypox in the U.S. as of Thursday, Becerra said.
  • There were less than 5,000 cases of monkeypox last week, he added.

The big picture: Biden’s decision to declare monkeypox a public emergency allows him to raise awareness of the virus and unlock more flexibility for spending on ways to treat and tackle the virus.

  • About 20% of Americans are worried they’ll contract monkeypox, Axios previously reported. But there are still some gaps in Americans’ knowledge of the virus and how it impacts our population.

What’s next: U.S. health officials said that 800,000 monkeypox vaccine doses will be made available for distribution. But in hotspot states for the monkeypox outbreak, there’s a drastic disconnect between the number of doses that local health officials say they need versus what they have been allotted.

  • The U.S. will receive another 150,000 monkeypox vaccine doses in the strategic national stockpile in September, Dawn O’Connell, administrator at HHS’ Administration for Strategic Preparedness & Response, told reporters Thursday. These were previously scheduled to arrive in October.

San Francisco, New York state call monkeypox an emergency: 5 updates

New York state declared an imminent threat and San Francisco issued a state of emergency over monkeypox July 28 as the virus continues to spread in the U.S., NBC News reported. 

The news comes after the World Health Organization declared monkeypox a global emergency July 23 and as the CDC reported 4,907 confirmed cases nationwide as of July 28. California and New York account for more than 40 percent of the reported cases in the U.S., according to The Washington Post.

In a statement, New York State Commissioner of Health Mary Bassett, MD, said the declaration allows local health departments “to access additional state reimbursement, after other federal and state funding sources are maximized, to protect all New Yorkers and ultimately limit the spread of monkeypox in our communities.” It covers monkeypox prevention response and activities from June 1 through the end of the year. 

In San Francisco, the monkeypox public health emergency takes effect Aug. 1, city officials said in a news release. The release, from Mayor London Breed and the San Francisco Department of Public Health, said the declaration “will mobilize city resources, accelerate emergency planning, streamline staffing, coordinate agencies across the city, allow for future reimbursement by the state and federal governments and raise awareness throughout San Francisco about [monkeypox].”

Four other updates: 

1. HHS announced July 28 that nearly 800,000 additional monkeypox vaccine doses will be available for distribution to states and jurisdictions. The 786,000 additional doses are on top of the more than 300,000 doses already distributed. This means the U.S. has secured a total of about 1.1 million doses “that will be in the hands of those who need them in the next several weeks,” HHS Secretary Xavier Becerra said during a July 28 news conference. The additional doses will be allocated based on the total population of at-risk people and the number of new cases in each jurisdiction. “This strategy ensures that jurisdictions have the doses needed to complete the second dose of this two-dose vaccine regimen for those who have been vaccinated over the past month,” HHS said in a news release. 

2. As of the morning of July 29, the U.S. has held off on declaring a national monkeypox emergency. Mr. Becerra said July 28 that HHS “continue[s] to monitor the response throughout the country on monkeypox” and will weigh any decision regarding a public health emergency declaration based on the response.

3. The monkeypox response is straining public health workers. Health experts are concerned over how the monkeypox response will further deplete the nation’s public health workforce, still strained and burnt out from the ongoing COVID-19 pandemic. Barriers to testing, treatment and vaccine access largely mirror the missteps in the early coronavirus response, Megan Ranney, MD, emergency physician and academic dean of  Brown University School of Public Health in Providence, R.I, told The Washington Post. “I can’t help but wonder if part of the delay is that our public health workforce is so burned out,” she said. “Everyone who’s available to work on epidemiology or contract tracing is already doing it for COVID-19.” 

4. Monkeypox testing demand is low, commercial laboratories told CNN. In recent weeks, five major commercial laboratories have begun monkeypox testing, giving the nation capacity to conduct 80,000 tests per week. While Mayo Clinic Laboratories can process 1,000 samples a week, it’s received just 45 specimens from physicians since it began monkeypox testing July 11, according to the July 28 CNN report. “Without testing, you’re flying blind,” William Morice, MD, PhD, president of Mayo’s lab and chair of the board of directors at the American Clinical Laboratory Association, told the news outlet. “The biggest concern is that you’re not going to identify cases and [monkeypox] could become an endemic illness in this country. That’s something we really have to worry about.”

WHO declares monkeypox a global health emergency

The World Health Organization (WHO) has declared the monkeypox outbreak a global health emergency after the virus reached more than 70 countries around the world. 

WHO Director General Tedros Adhanom Ghebreyesus said at a press conference on Saturday that he decided the outbreak represents a “public health emergency of international concern.”

WHO’s assessment is that the risk of monkeypox is moderate globally and in all regions, except in the European region where we assess the risk as high,” he said.

Tedros said the WHO’s International Health Regulations Emergency Committee came to a consensus at a meeting a month ago that monkeypox did not represent an international public health emergency, but the situation has changed.

He said the WHO had received reports of just more than 3,000 cases from 47 countries at the time, but more than 16,000 cases have now been reported from 75 countries and territories. He said there have been five deaths.

Tedros said the committee was unable to reach a consensus on whether the outbreak should be considered a public health emergency of international concern, but he considered five factors in declaring it an emergency.

He said the first factor is information countries have shared with the WHO, and that data from countries around the world shows that the virus has spread rapidly to many countries that have not seen it before.

He added that the second factor is the definition of a public health emergency and that the three criteria for declaring such an emergency have been met.

A public health emergency of international concern is considered a situation that is serious, sudden, unusual or unexpected, carries implications for public health beyond a country’s borders and may require immediate international action, according to the WHO.

Tedros said the third factor is the advice of the committee, which was divided, and the fourth factor is scientific principles and evidence, which is currently “insufficient” and leaves “many unknowns.”

He said the fifth factor is the risk to human health, international spread and the potential for interfering with international traffic.

He said there is a “clear risk” for international spread, but the risk of interfering with international traffic is currently low.

“So in short, we have an outbreak that has spread around the world rapidly, through new modes of transmission, about which we understand too little and which meets the criteria in the International Health Regulations,” Tedros said.

The Hill has reached out to the WHO for comment.

Monkeypox has spread quickly in the United States since cases were first detected in the country in May. The virus appears to be spreading primarily among men who have sex with men and spreads through extended physical contact.

The virus can cause symptoms like lesions, a rash and swelling of lymph nodes.

Ghebreyesus said he is making recommendations for four categories of countries in managing monkeypox.

For countries that have not seen any cases or not reported a case in 21 days, they should take measures like activating health mechanisms to prepare to respond to monkeypox and raise awareness about transmission, according to a WHO statement.

Countries with recently imported cases of monkeypox and that are experiencing human-to-human transmission — which includes the United States — should implement a coordinated response, work to engage and protect their communities and implement public health measures like isolating cases and using vaccines.

The Biden administration announced earlier this month that it would distribute an additional 144,000 doses of the Jynneos vaccine to address monkeypox after having distributed about 40,000 doses previously.

The third group of countries are those with the “known or suspected” transmission of the virus from animals to humans. They should establish or activate mechanisms for understanding and monitoring the animal-to-human and human-to-animal transmission risk and study transmission patterns.

The fourth group are countries with the manufacturing capacity to create vaccines and other medical countermeasures. The WHO statement calls on these countries to increase production and availability of these measures and work with WHO to ensure necessary supplies are made available based on public health needs at “reasonable cost” to countries that need support the most.

Ghebreyesus said the outbreak is concentrated among men who have sex with men and especially those with multiple sexual partners.

“That means that this is an outbreak that can be stopped with the right strategies in the right groups,” he said.

He added that countries should work with communities of men with male sexual partners to inform them and offer support and to adopt measures that protect the “health, human rights and dignity of affected communities.”

Ghebreyesus said civil society organizations, especially those with experience working with people who are HIV-positive, should work with WHO to fight stigma and discrimination.

The spread of HIV and AIDS in the 1980s led to increased stigma for those who identify as gay as the virus was initially reported to be spreading among gay men.

BA.5 spurs new calls to fund next-generation COVID-19 vaccines

The rise of the BA.5 variant is spurring new calls for funding for an Operation Warp Speed 2.0 to accelerate development of next-generation COVID-19 vaccines that can better target new variants. 

The BA.5 subvariant of omicron that now makes up the majority of U.S. COVID-19 cases is sparking concern because it has a greater ability to evade the protection of current vaccines than past strains of the virus did.

Pfizer and Moderna are working on updated vaccines that target BA.5 that could be ready this fall, but experts say that by the time they are ready, a new variant very well could have taken hold.  

As alternatives to vaccine makers chasing each variant, experts point to research on “pan-coronavirus” vaccines that are “variant-proof,” targeting multiple variants, as well as nasal vaccines that could drastically cut down on transmission of the virus.

There is ongoing research on these next-generation vaccines, but unlike in 2020, when the federal government’s Operation Warp Speed helped speed the development of the original vaccine, there is less funding and assistance this time around.  

COVID-19 funding that could help develop and manufacture new vaccines more quickly has been stalled in Congress for months.

“There’s no Operation Warp Speed,” said Eric Topol, professor of molecular medicine at Scripps Research. “So it’s moving very slowly. But at least it’s moving.” 

Leana Wen, a public health professor at George Washington University, wrote in a Washington Post op-ed this week that the U.S. needs “urgent investment” in next-generation vaccines and “we need an ‘Operation Warp Speed Part 2.’” 

Pfizer and Moderna are working on updated vaccines that target BA.5 that could be ready this fall, but experts say that by the time they are ready, a new variant very well could have taken hold.  

As alternatives to vaccine makers chasing each variant, experts point to research on “pan-coronavirus” vaccines that are “variant-proof,” targeting multiple variants, as well as nasal vaccines that could drastically cut down on transmission of the virus.

There is ongoing research on these next-generation vaccines, but unlike in 2020, when the federal government’s Operation Warp Speed helped speed the development of the original vaccine, there is less funding and assistance this time around.  

COVID-19 funding that could help develop and manufacture new vaccines more quickly has been stalled in Congress for months.

“There’s no Operation Warp Speed,” said Eric Topol, professor of molecular medicine at Scripps Research. “So it’s moving very slowly. But at least it’s moving.” 

Leana Wen, a public health professor at George Washington University, wrote in a Washington Post op-ed this week that the U.S. needs “urgent investment” in next-generation vaccines and “we need an ‘Operation Warp Speed Part 2.’” 

Administration health officials pointed to funding when asked about next-generation vaccines at a press briefing on Tuesday.

“We need resources to continue that effort and to accelerate that effort,” said Anthony Fauci, the government’s top infectious disease expert. “So although we’re doing a lot and the field looks promising, in order to continue it, we really do need to have a continual flow of resources to do that.” 

But COVID-19 funding has been stuck in Congress for months. Republicans have long said they do not see any urgency in approving the money. Democrats, while generally calling for the funding, have been caught up in their own internal divisions, like when a group of House Democrats objected to a way to pay for the new funding in March.

“Of course more funding would accelerate some parts of the development,” Karin Bok, acting deputy director of the National Institutes of Health’s (NIH) Vaccine Research Center, said in an interview.  

She also cautioned that development of next-generation vaccines like nasal vaccines would take longer than the original vaccines, because less groundwork has been laid over the preceding years.  

Experts stress that even for BA.5, the current vaccines still provide important protection against severe disease and hospitalization, and are urging people to get their booster shots now. But there is potential for further improvement in the vaccines as well.

Aside from funding, another obstacle is obtaining copies of the existing COVID-19 vaccines for use in research, said Pamela Bjorkman, a California Institute of Technology professor working on a next-generation vaccine. 

“I would say we’ve wasted at least six months,” with various procedural hurdles on that front, she said. “It’s just ridiculous.” 

For example, she said at one point when her team was able to get access to the AstraZeneca COVID-19 vaccine, it then took two or three months to get an import permit to send it from the United Kingdom.

“This is a hot topic,” Bok, of the NIH, said of access to existing vaccine doses for researchers. “The government is working very hard on an agreement with the companies to provide it to us and to all the investigators…that are funded by NIH.” 

Asked about providing vaccine doses for researchers and any talks with the administration on that front, a Moderna spokesperson said: “We do provide vaccine in certain investigator-initiated studies where physicians and scientists propose research they have designed and want to conduct with our support,” pointing to a South African study as an example.  

More broadly, the White House says it is working on accelerating next-generation vaccine research and will have more announcements soon.  

“Let me be very clear: We clearly need a true next-generation vaccine,” White House COVID-19 response coordinator Ashish Jha told reporters on Tuesday. 

“You’ll hear more from us in the days and weeks ahead,” he added. “This is something that we have been working quite assiduously on.” 

COVID is not done with us, part six (…seven? eight?)

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The rise of ubiquitous self-testing and the paucity of accurate, timely data from the CDC on COVID numbers has left us feeling our way in the dark in terms of the current state of the pandemic. Clearly there’s a new surge underway, driven by the BA.5 variant. What we can report from our experiences on the road over the past few weeks is that the wave is significant. 

We’re hearing from our health system members that inpatient COVID volumes and COVID-related ED visits are significantly up again—often double or more what they were just two months agoalthough still well below levels of past surges. Length of stay for COVID inpatients is shorter, with fewer ICU visits than during the Delta surge—about the same intensity, proportionally, as during Omicron.

But COVID-related staffing shortages are once again having a real impact on hospitals’ ability to deliver care—clinical and non-clinical staff callouts are at high levels again, as during Omicron.

One piece of good news: masking is back in vogue among many health system executive teams, likely in response to a number of “superspreader” events: gatherings of hospital staff over the past few weeks that resulted in clusters of cases. One system described an all-hands session for anesthesiologists that resulted in more than a dozen cases across the next week—forcing the hospital to cancel procedures. 

We’re worried that this BA.5 surge is just getting started, and with booster uptake stagnating and masking all but nonexistent in the general population, the late summer and early autumn situation could be significantly worse.

Be careful out there.

Gun Violence as a Public Health Issue

Gun violence is a public health problem, but we don’t approach it like one. The debate often gets framed as “guns or no guns” when it isn’t that black and white. In this episode we break down how and why to approach gun violence as a public health problem, what the current research has to say, and what we need to move forward.