BA.5 shouldn't change how Americans think about living with Covid-19, or how officials give advice, a leading physician says

By Dr. Leana S. Wen, for The Washington Post

A new variant of the coronavirus, even more contagious than previous strains, is now dominant in the United States. But rising cases should not prompt calls for most Americans to hunker down or policymakers to reimpose restrictions. Instead, the rapid spread of the BA.5 omicron subvariant is a window into what the future with this coronavirus looks like.

Leana S. Wen, M.D. (Twitter photo)

We’ve seen this pattern before. The original omicron variant was more contagious than the delta variant before it and quickly became dominant last winter. There was a brief lull, after which that strain was replaced by a more contagious subvariant, BA.2. Infections caused by BA.2 have started decreasing, just in time for subvariants BA.4 and BA.5 to take over.

BA.5 now constitutes 65 percent of all infections in the United States. This should not be surprising. New variants are cropping up all the time, with more contagious strains displacing previous ones.

Lulls followed by surges are the new normal. Instead of reacting with alarm, health officials should set the expectation that as long as hospitals are not overwhelmed and vaccines still work to prevent severe illness, policies should focus on minimizing disruption to daily life.

Virologist and pediatrician Paul Offit agrees. Offit is the director of the Vaccine Education Center at Children’s Hospital of Philadelphia and a member of the Food and Drug Administration’s influential Advisory Committee on Vaccines. He told me in an interview that this coronavirus “will be here for my lifetime, my children’s lifetimes, and their children’s lifetimes.” He added, “We can’t keep forever masking and quarantining to prevent asymptomatic infection; we have to accept mild illness as a part of life with Covid-19.”

His goal, which I share, is to prevent people from becoming severely ill. For most people, vaccines are doing that well, including against BA.5. Hospitalizations are increasing, but they are about one-fifth of the peak of the first omicron wave. Since the true number of infections could be up to 10 times higher than the reported number, this means vaccines are doing their job and decoupling infection from severe illness.

It’s unreasonable to ask Americans to forgo traveling, going to restaurants or attending weddings to prevent what for most people will likely be mild illness. As I’ve argued before, government-imposed restrictions — including mask mandates — should be reserved for dire emergencies, which we are not in now. Instead, officials should scale up interventions that have broad support, such as testing, treatment and improved ventilation.

Resources should especially be directed to help those most vulnerable to severe outcomes from covid-19. Among those 65 and older who received the original two doses, about 30 percent have not yet had their first booster. And of those who did, only 34 percent received a second booster. We are also failing to use other tools to their fullest extent, such as the preventive antibody Evusheld and antiviral treatments including Paxlovid — all of which are effective against BA.5. This must change.

In the meantime, we need urgent investment in better vaccines, specifically a pan-coronavirus vaccine that will work across all strains, and nasal vaccines that reduce virus transmission. We need an “Operation Warp Speed Part 2” to expedite development of vaccines and additional therapeutics to treat Covid and long-haul symptoms.

This is not to say that those at low risk of severe disease should forgo precautions. Even if they are vaccinated and boosted or previously had Covid-19, there is a good chance they could contract BA.5. Without precautions, the incredible transmissibility of emerging variants means people might get Covid multiple times a year going forward.

Every time people are infected with the virus, they could end up with long Covid. Some will say this is precisely why they want to keep avoiding this coronavirus. They can continue strict precautions, including asking others to test before gathering and wearing a high-quality mask in indoor spaces. Others will say they are done; they don’t want to pay the increasingly high price to avoid Covid. Many will choose something in between; they won’t limit their activities, but they will keep up-to-date with boosters, mask in crowded places and test before visiting vulnerable relatives.

Offit explains that the definition of a pandemic includes changing the way we live, work and play. “We determine when the pandemic is over,” he said. “Based on people’s behavior, it seems like most of the country has decided that’s happened already.”

I don’t think the pandemic is over. This coronavirus could have many more surprises in the years ahead. This fall, or the next, a new variant could emerge that’s much more lethal and that does not respond to existing vaccines and treatments. Health officials need to preserve their credibility to call for an emergency response when it’s truly needed. That time is not now with the BA.5 variant.

Leana Wen is a professor at George Washington University's Milken Institute School of Public Health, former Baltimore health commissioner, and author of Lifelines: A Doctor's Journey in the Fight for Public Health.

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Doctors worry about vagueness of Ky. abortion ban's exception for cases of risk to woman's life; federal officials try to clarify rules

Uterus diagrams via Medbullets, an educational site; click to enlarge

By Melissa Patrick

Kentucky Health News

Federal officials have issued guidance in an attempt to clarify when health-care providers can perform an abortion in states that ban the procedure. It says that a physician must stabilize a patient who seeks treatment in a hospital emergency department, according to the federal Emergency Medical Treatment and Labor Act, passed in 1986.

"A physician’s professional and legal duty to provide stabilizing medical treatment to a patient who presents under EMTALA to the emergency department and is found to have an emergency medical condition preempts any directly conflicting state law or mandate that might otherwise prohibit or prevent such treatment," says the Department of Health and Human Services document.

"If a physician believes that a pregnant patient presenting at an emergency department is experiencing an emergency medical condition as defined by EMTALA, and that abortion is the stabilizing treatment necessary to resolve that condition, the physician must provide that treatment. When a state law prohibits abortion and does not include an exception for the life of the pregnant person — or draws the exception more narrowly than EMTALA’s emergency-medical-condition definition — that state law is pre-empted." 

Kentucky's abortion ban, triggered by the U.S. Supreme Court's June 24 reversal of its Roe v. Wade decision, has an exception for a threat to the woman's life. It has been blocked, at least temporarily, by a lawsuit.

Several Kentucky health-care providers have voiced concern about how the law doesn't account for the complexities and complications that come with caring for women who need medical treatment for some miscarriages, Sarah Ladd reports for the The Courier Journal. 

Dr. Coy Flowers, vice chairman of Kentucky's chapter of the American College of Obstetricians and Gynecologists, described a number of scenarios to the Louisville newspaper in which the law poses a challenge, such as when a woman is hemorrhaging heavily despite a fetal heartbeat showing up on an ultrasound.

Flowers told Ladd that while the law allows abortion when there is no longer a fetal heartbeat, he said a patient may suffer from a condition or event that creates an "inevitable abortion" scenario. "That means there is still a heartbeat, but the pregnant person has a condition, such as cervical weakness, that complicates the future of the pregnancy and the health — and life — of the patient," Ladd explains. 

 

"There are definitely scenarios, particularly in the middle to late second trimester, before what we consider as viability for fetuses, where there's a lot of gray zone in our current trigger law that will put physicians at risk for liability, either monetarily or, particularly, a Class D felony," Flowers told Ladd.

Ladd reports that in a press call on the day Roe v. Wade was overturned, ACOG President Dr. Iffath Abbasi Hoskins discussed the challenges of caring for women who are in the middle of an "incomplete" abortion, "where there is still a heartbeat and the woman is cramping . . . or bleeding or both."

Now, when facing that situation, "Clinicians may be thinking that they have to wait," she said. "They may be needing to get additional opinions, whether it's a legal opinion, whether it's another medical opinion."

A Kentucky ACOG statement that day voiced concern about the phrasing of the state's trigger law, saying it places Kentucky physicians and patients in jeopardy. 

"The unclear language will, in all likelihood, force physicians to wait for a patient's condition to deteriorate so severely that significant bodily harm or even death could occur," the statement said. "Left to interpret ambiguous legal language in the middle of the night, Kentucky ACOG asserts that [the law] will deter physicians and hospital staff from providing life-saving interventions to patients whose health could worsen rapidly."

Flowers said there could be confusion when deciding whether the life of the patient or the fetus must take legal priority, so physicians may pause in the middle of treating complex cases. 

"I've been in a situation where a woman is wheeled in from the ER," he told Ladd. "She's been brought in in an ambulance. They rush her down to labor and delivery and you stand her up from the wheelchair to get into the bed. And you literally can hear … blood hitting the floor, bleeding that intensely. What if that happened? You stick an ultrasound on, and there's a heartbeat. What do you do in that instance?"

At the 2022 Association of Health Care Journalists conference, Dr. Lisa Harris, an obstetrician-gynecologist at the University of Michigan, also talked about the vagueness of abortion bans that make exceptions if the mother's life is at risk, asking the question, "How much risk does someone need to take on to have an abortion count as life-saving?" 

Harris continued: "For example, there are patients with cardiac disease who we will quote a 25 to 30 percent chance of dying if they continue the pregnancy and give birth. Is that enough of a risk of dying to have qualified, I guess, to use that word, to qualify for an abortion? Or does it need to be 50 percent or 100 percent? How are we to know this?"

In a June 24 statement, Kentucky Attorney General Daniel Cameron said the state's trigger law "has no application when a pregnant mother suffers a miscarriage. Nor does it prohibit medical treatment to help a mother in this circumstance."

The HHS guidance addresses these issues and says that under EMTALA, physicians will be protected.

In a letter to all health-care providers, HHS Secretary Xavier Becerra wrote, "The federal EMTALA statute protects your clinical judgment and the action that you take to provide stabilizing medical treatment to your pregnant patients, regardless of the restrictions in the state where you practice." 

Rachel Roubein reports for The Washington Post, "Doctors don’t need to wait for a condition to worsen or for the patient to be close to death before intervening, senior HHS officials told reporters yesterday. EMTALA also permits a provider to terminate a pregnancy when an emergency condition could seriously impair the patient’s health."  

HHS tried to make clear that it wasn't writing new rules, saying near the top of the document: “This memorandum is being issued to remind hospitals of their existing obligation to comply with EMTALA and does not contain new policy." 

EMTALA requires that anyone who seeks care in an emergency department be stabilized, treated or transferred, regardless of their ability to pay. Violation could lead to the hospital being fined or losing its ability to get Medicare reimbursements for care, the guidance notes.

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Doctor shares how to support your child in a Covid-19 vaccination

Photo illustration from Sussex Travel Clinic

By Dr. Lindsay Ragsdale
University of Kentucky

If you have with children under the age of 5, you may be now looking to bring your child to a vaccination clinic to receive the Covid-19 vaccine following the recent emergency-use authorization from the Food and Drug Administration and the recommendation from the Centers for Disease and Control Prevention Advisory Committee on Immunization Practices.

The Pfizer and Moderna vaccines are the two vaccines authorized for children ages 6 months to 5 years old. The Moderna vaccine is a two-dose series separated by 28 days and the Pfizer vaccine is a three-dose series separated by 21 days and 60 days, respectively. At many clinics, parents will be offered the choice of either Moderna or Pfizer for their child.

Here are some helpful tips to support your child before and during COVID-19 vaccination:

• Be honest and calm. Talk to your child in simple terms before vaccination about where the shot will go, and what they can expect to feel when receiving a shot.
• Role-play before the appointment. Planning and practicing what exactly will happen can help reduce fear in children who may be afraid of needles.
• Bring items that comfort your child, such as a favorite blanket, toy or book.
• Distract your child. Bringing your child’s attention away from the professional administering the shot can help relieve stress and lessen fear.
• Ask your doctor for a numbing cream or spray.
• Ask your child to sit or lay down during vaccination to prevent fainting. Younger children can also be held in recommended ways that gives comfort and support.

After your child receives the Covid-19 vaccine, it is important to stay for 15 to 30 minutes so your child can be observed in case they have a severe allergic reaction. You can ask your child’s health care provider for steps you can take at home to relieve pain and comfort your child after vaccination. Also, make sure that your child receives their Covid-19 Vaccination Record card before leaving the clinic.

Mild reactions, such as some pain and swelling where the shot was administered, or a fever are common symptoms. If any occurring symptom after the vaccination concerns you, contact your child’s doctor.

For families who are undecided about the Covid-19 vaccination for younger children, we encourage open conversations with their pediatrician or primary care provider. More information can be found at the CDC website and American Academy of Pediatrics website.

Lindsay Ragsdale, M.D., is chief medical officer for Kentucky Children's Hospital.

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Behavioral health hotline for suicide prevention, mental health and substance use crisis will go live on Saturday, July 16; call 988

By Melissa Patrick
Kentucky Health News

Starting Saturday, July 16, the new behavioral-health crisis hotline number will be 988, much like 911 for medical crises and other emergencies.

"It's substance use, mental health, and suicide -- so all of the continuum of care,"  Beck Whipple, suicide-prevention coordinator for the state Department of Behavioral Health, Developmental and Intellectual Disabilities, said in a webinar about the 988 rollout. 

Callers currently reach the National Suicide Prevention Lifeline by calling a 10-digit number: 1-800-273-8255 (TALK). This number will remain operational during the 988 transition and after it is completed, according to the Federal Communications Commission. 

The 988 system does not use geo-location yet, so Kentuckians who call 988 will be routed to the closest regional call center according to their area code and the phone exchange, said Whipple. If that regional call center is unable to take the call, the call will be redirected to a back-up call center, he said. 

Kentucky's 13 call centers operate through the state's community mental-health centers, which are able to de-escalate a crisis, make a referral for mental health services, connect the caller with a mobile crisis team, or send emergency medical services.  

"About 80 to 85 percent of the calls that come into 988 are de-escalated verbally," Whipple said. 

He said Kentucky's lifeline call centers have seen an increase in callers since the pandemic, as well as  longer calls with more acute problems, and more first-time callers. 

He added that they expect to see even more with the roll-out of 988. At this time, he said Kentucky averages about 20,000 calls a year and that is projected to "grow exponentially." A slide from the presentation said they expect about 42,600 calls in the next year. 

"We're still very much dealing with the psychological, mental-health impacts of the pandemic and its devastating effects," Whipple said.

The new call line is not only for people in crisis, it is also for those trying to support people in crisis.

"988 is definitely for that support person, that friend who doesn't know how to respond to somebody who just unloaded on you? Right? Like, what are the options in your area? 988 can connect you to those options in your area," Marcie Timmerman, executive director for Mental Health America of Kentucky, said on the webinar.

Funding for the new number comes from several sources. Congress appropriated funds to create it in 2020, the U.S. Substance Abuse and Mental Health Services Administration awarded Kentucky $9.5 million in grants, and the state legislature allocated $2.8 million more for its implementation, Linda Blackford reports for the Lexington Herald-Leader. 

Timmerman said there are plans to re-introduce legislation in the next General Assembly for a 70-cent mobile phone fee to create a sustainable funding stream for the service, similar to what is taken out for 911 services. This year's version of that bill, House Bill 373, got one of the six required reading, but was not heard in its assigned committee. 

Kentucky plans to do a large scale roll-out of the 988 number in 2023.

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UK College of Nursing runs a clinic in the small town of Wilmore, with care for mental health, LGBTQIA+ individuals and more

The staff of the Phyllis D. Corbitt Community Health Center in Wilmore, left to right: Anthony Carney, Amy DelRe, Sharon Lock and Lori Fugate. (University of Kentucky photo)

By Parry Barrows
University of Kentucky

It’s a small-town clinic with just a few rooms, named for a physician from an era when house calls were common. What you’ll find inside, though, is remarkably progressive.

The Phyllis D. Corbitt Community Health Center in Wilmore, population 6,400, completely staffed by faculty of the University of Kentucky College of Nursing, is a lifeline for those struggling with depression or anxiety, and where LGBTQIA+ patients can find specialized care and an understanding ear.

The primary care center has come a long way from its opening in 2015.

“We started out as a limited-services clinic treating colds and sprains because at the time it was the quickest way we could get up and running,” said Sharon Lock, the center’s director and the nursing college's assistant dean of faculty practice. “We had a lot of help from people at UK HealthCare to figure out how to make that all happen. After about two years, it became clear, though, that if we were going to make it, we needed to offer primary care services, as well.”

Today, five faculty members, who are also advanced practice registered nurses (APRNs), work in the clinic at least one day a week, and each is typically matched with a nursing student.

Serving both a community and UK

The center first opened to provide an opportunity for faculty at the College of Nursing to practice, Lock says.

“At the time, I was the coordinator of the family and nurse practitioner track for UK, and it was extremely difficult to do clinical placements because you’d think you had a student placed and then something changed,” Lock says. “We wanted a facility where we knew we would have a place for students while also serving the community.”

“The opportunity just sort of fell into our laps,” said Practice Manager Amy DelRe, who has worked for the College of Nursing since 2005. “Dr. Lock had wanted this for years, and one day we got a call from the owner of a building in Wilmore, who saw my name and phone number on the university’s website.”

The building needed extensive renovations, and it took two years of planning from the time they first saw it until they were able to open the clinic. But the rent was reasonable, there was a pharmacy next door, and the residents of Wilmore had been missing a convenient place to find care since Corbitt retired.

Several visits to the UK surplus warehouse later, the facility was ready to open in the summer of 2015, albeit on a shoestring budget. In 2018, the center began offering comprehensive health care for people of all ages, or “those taking their first breath until their last breath,” as DelRe says.

Seeing mental-health needs everywhere

As the center expanded the type of care it provided, the need for practitioners grew. In 2018, the staff expanded with the addition of Lori Fugate, D.N.P., an assistant professor at the College of Nursing.

Fugate has worked as a family and women’s health nurse practitioner for 15 years. While providing primary care services in Wilmore, she and Lock soon realized many patients needed a different type of care than she could provide.

“I returned as a student to the College of Nursing to earn my post-graduate psychiatric mental health nurse practitioner certificate program of study when I realized there was such a great need for behavioral health services — here, anywhere — and in a town this small, they would have a long wait to see a behavioral health specialist,” said Fugate.

While Fugate completed the 18-month program of study, Lock and DelRe negotiated to lease an apartment upstairs from the clinic for additional office space. On a typical Wednesday, Fugate now sees between eight and 10 behavioral health patients in the upstairs office, an atmosphere that is more casual and less clinical.

“With the right medication and the right dose, you can see improvement in six to eight weeks. It’s amazing to see. Now when I see the patient back and they’re doing better — oh, my gosh, I get goosebumps!” said Fugate.

Fugate says as the clinic continues to grow, she hopes it will eventually provide care for substance abuse.

An ally to a diverse community

The next step forward for the center came in 2020, with the arrival of Anthony Carney, D.N.P., an assistant professor and two-time graduate (bachelor's of nursing degree and doctorate of nursing practice) of the College of Nursing.

Carney says the clinic has allowed him to treat a group historically underserved by the medical community: LGBTQIA+, or lesbian, gay, bisexual, transgender, queer and asexual. The plus sign "represents members of the community who identify with a sexual orientation or gender identity that isn’t included within the LGBTQIA acronym," GoodRx explains. "It’s an inclusive way of representing gender and sexual identities that letters and words cannot yet fully describe."

Carney said, “There have been numerous health disparities with the LGBTQIA+ community in terms of mind, body and spirit. Screenings are delayed, usually because of fear or distrust, and there are increased rates of depression, anxiety and substance-use disorders.”

Carney has been focused on caring for a diverse population since college, when he was mentored by Dr. Keisa Fallin-Bennett, director of UK HealthCare’s Transform Health Services, a resource that meets the unique health needs of LGBTQIA+ individuals.

“Patients who come to me for Transform Health needs are incredibly excited to have health care that’s sensitive to their needs, especially patients who are there for gender care," says Carney. "It’s a big life decision to come out to your provider, to say you have issues with gender dysphoria or with your sexual orientation.”

Carney says he sees about one patient a week in the LGBTQIA+ population.

“This particular type of care is not that common outside of major metropolitan areas, so it’s very exciting to offer it in Wilmore," Carney said. "The entire staff is on board, which I love, and it’s been an overwhelmingly positive experience for everyone so far.”

Carney has helped work with undergraduate nursing students on special considerations for the LGBTQIA+ population, such as pronoun usage and screenings. He eventually would like to start training other providers across the state to offer inclusive care that is sensitive and comprehensive. “Right now,” he said, “I just look forward to coming into the clinic every Wednesday.”

What's next in Wilmore

The center has continued to adapt to community needs. At the start of the Covid-19 pandemic, the clinic began offering telehealth visits for the first time.

“When COVID came, we were just hitting our stride. Now, though, we are back to pre-Covid levels of visits,” Lock said. "More than 1,600 visits were billed in 2020. The staff also now includes a registered nurse to assist with patients."

In 2021, the clinic made a significant investment in connecting to the same system for electronic health records used by UK HealthCare. For patients, it will mean access to information and a portal that’s easier to use.

Like Lock and the rest of the staff, Fugate says the clinic has been good for Wilmore and rewarding for everyone working at the clinic.

“Here in Jessamine County, we don’t have the public transportation you’d find elsewhere, so many of our patients actually walk here from their homes,” Fugate said. “They’re very thankful we’re here.”

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Judge gives sides in abortion lawsuit until July 18 to file pleadings; until then, at least, legal abortion can continue in Kentucky

Abortion can legally continue in Kentucky until at least July 18, the deadline a Louisville judge set to file briefs in a lawsuit seeking to create a right to abortion under the Kentucky Constitution.

Jefferson Circuit Judge Mitch Perry is considering whether to issue an injunction that would maintain the status quo until he tries the lawsuit filed by the state's two abortion clinics. His June 30 restraining order allowed abortions to resume in Kentucky after the U.S. Supreme Court’s overturning of its 1973 Roe v. Wade decision.

A Kentucky law, triggered by the decision, bans abortion except when the woman's life is threatened. Perry's order blocked the law temporarily.

Perry "said he was undecided" about issuing a more lasting injunction, reports Mark Maynard of Kentucky Today. Attorney General Daniel Cameron, who tried to get appellate courts to reinstate the trigger law, "does not understand why Kentucky’s new abortion laws are being delayed."

A lawyer for the abortion clinics argued that women would be “forced to remain pregnant against their will,” in violation of the first two sections of the state constitution. Those sections say Kentuckians have “the right of seeking and pursuing their safety and happiness” and “Absolute and arbitrary power over the lives, liberty and property of freemen exists nowhere in a republic, not even in the largest majority.”

Kentucky courts have found in those sections a limited right to privacy. The state Supreme Court cited the sections and cases in 1992 when it struck down a law banning sexual activity between people of the same sex.

The state legislature, perhaps anticipating a similar decision regarding abortion, put on the Nov. 8 ballot a constitutional amendment saying that the constitution, written in 1891, does not create a right to abortion or government funding of it.

Gov. Andy Beshear said Thursday that he would vote against the amendment because it has no exceptions for rape and incest. Beshear said he "generally" supports Roe v. Wade but opposes late-term abortion.

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Commission that will allocate money from state's settlement with opioid companies will hold its first meeting Tuesday

The first meeting of the commission that will allocate half the money from the state's settlement with opioid companies will be held at 1 p.m. ET Tuesday in Frankfort.
    
The 11-member Kentucky Opioid Abatement Advisory Commission will meet in the attorney general's offices at 1024 Capital Center Dr., Suite 200. The meeting is open to the public, and will be livestreamed here.

Katie Marks, Ph.D.

The meeting agenda is available here. It includes a presentation from commission member Van Ingram, director of the state Office of Drug Control Policy, and Katie Marks of the University of Kentucky, project director of the Kentucky Opioid Response Effort, which oversees federal grants.

The state will get $483 million from the settlement. State government will get half and local governments will get the other half.

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