Mosquito Hunters Set Traps Across Houston, Search For Signs Of Zika

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Mosquito control is serious business in Harris County, Texas.

The county, which includes Houston, stretches across 1,777 square miles and is the third most populous county in the U.S. The area’s warm, muggy climate and snaking system of bayous provide an ideal habitat for mosquitoes — and the diseases they carry.

The county began battling mosquitoes in earnest in 1965, after an outbreak of St. Louis encephalitis. Hundreds of people contracted the virus and 32 died.

These days, mosquito control efforts include chemical spraying: on foot, by truck and occasionally from airplanes. But spraying happens strategically, after careful research reveals the geographic distribution of infected mosquitoes, and sometimes birds, which carry West Nile.

To that end, the county employs 50 scientists and technicians year-round. In the summer, the county hires two dozen more workers. They set traps, sort mosquitoes by species and conduct lab tests for five viruses: St. Louis encephalitis, West Nile, dengue and chikungunya. This year, they’ve added Zika.

The county’s tab for mosquito control runs $4 million or more a year.

This story is part of a partnership that includes Houston Public Media, NPR and Kaiser Health News. It can be republished for free. (details)

The surveillance cycle begins outdoors. Technicians set and retrieve three kinds of traps every weekday, hiding them beneath manhole covers, in roadway medians and in yards (with homeowners’ permission, of course). The county is divided into 268 sectors and from May to October, researchers collect mosquitoes from each sector at least every other week.

Entomologist Christy Roberts makes her rounds in a white, county-issued pickup truck. At each stop she sets out orange traffic cones before retrieving traps that have typically been outside for about 12 hours.

One type, called a gravid trap, sits on top of a plastic tub of water. The stagnant, smelly water lures female mosquitoes. Alongside a house in one yard, Roberts pulls the tub out from underneath some bushes. She peers inside the trap’s cylindrical net, spotting individual insects in the blur of flickering wings.

“Lots of females, some of them are blood-fed, and we have males in there, too,” she said. “The female will fly over the water and then land on top of the water to lay their eggs,” Roberts explained. “And as they’re floating on top of the water, the fan will suck them up into the net.” The focus of surveillance is females: They need at least one blood meal in order to reproduce.

Roberts makes a circuit around southwest Harris County. The empty traps go in her truck bed, and she hangs the nets full of trapped mosquitoes inside from the roof of the cab. “We hang the nets so that the mosquitoes will be able to continue to fly,” she said. “And they won’t rub their scales off, which is what we need to identify them. And it also helps keep them alive until we can freeze them.”

At the lab, the mosquitoes are killed by flash freezing, which helps preserve any viruses they might harbor. A technician puts the cold mosquitoes in a box, labels them by location, then sorts them by sex and species.

Roberts sits down at a lab bench and uses green tweezers to pick through the fragile, feathery bodies. To the untrained eye, they just look grey. But Roberts is searching for banding, wing color, and variations in the shape and size of the insect’s proboscis and other organs.

“I am sorting for Culex quinquefasciatus, which is our primary vector for West Nile. And I’m just placing them directly in to the vial,” she said. (As the Latin name indicates, that mosquito has five bands across its abdomen.)

Christy Roberts, an entomologist in Harris County, Texas, sorts mosquitoes with tweezers.

Christy Roberts, an entomologist in Harris County, Texas, sorts mosquitoes with tweezers. (Carrie Feibel/Houston Public Media)

Vials then go to Harris County’s virology unit, where they are tested for West Nile, St. Louis encephalitis, dengue, and chikungunya viruses. For Zika testing, samples are currently sent to the University of Texas Medical Branch in Galveston. But soon, the lab will also be able to test for Zika on-site. The expansion will cost $300,000.

Harris County is home to 56 different species of mosquitoes, says Dr. Mustapha Debboun, director of mosquito control. But only three species are relevant, because they carry viruses harmful to humans.

“We have the Aedes aegypti, which is the yellow fever mosquito. And also the Aedes albopictus, also known as the Asian tiger mosquito, and the Culex mosquito,” Debboun explained. “These are the three that we are after. And thank God, we’re only dealing with three.”

Debbun says they mostly find West Nile — 1,286 cases in 2014, 406 in 2015, none so far this year. He says in the past five years, they’ve had four positive tests for St. Louis encephalitis (also carried by Culex), and none for dengue or chikungunya. Zika — as well as dengue and chikungunya — is transmitted by the Aedes mosquitoes and has not been found in Harris County mosquitoes.

In many municipalities, mosquito control simply means spraying chemicals, Debboun says. But in Harris County, spraying is done strategically. “We go hit the area where we know the mosquitoes have the disease in them,” Debboun explained. “We don’t just go randomly and just spray, and not only waste the pesticide, but also put a pesticide in the environment when you don’t need to.”

Selective spraying also keeps the insects from developing resistance, he says. Occasionally, the county will conduct aerial spraying, but that’s happened only twice recently — after Hurricane Ike in 2008 and during a West Nile outbreak in 2014.

Debboun says his team is prepared for Zika. In 2013, he diversified the traps, purchasing models that are especially attractive to Aedes species, so his employees have had a few years to learn to use those traps. He’s planning to ask the county commissioners for 74 more of the traps, at a cost of $300 each.

This story is part of a reporting partnership with NPR, Houston Public Media and Kaiser Health News.

Majority Of Texans And Floridians Want Medicaid Expansion, Survey Shows

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Americans who live in the two biggest states that haven’t expanded Medicaid have more complaints about health care costs and quality, according to a new survey released by the Texas Medical Center Health Policy Institute in Houston. They’d also like their states to expand Medicaid.

The survey, conducted by marketing research firm Nielsen, assessed attitudes about the health care system, and possible solutions, in five populous states: Texas, California, Florida, New York and Ohio.

The 5,000 respondents were also asked about their party affiliation and insurance status — and height and weight. Those measurements were used to estimate the rates of obesity, for questions about interventions.

The Affordable Care Act allowed states to expand Medicaid to cover more poor adults, but 19 states still have not done so.

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In California, New York and Ohio, politicians took advantage of federal funding in the law to expand Medicaid. The survey showed most residents in those three states approved of that decision.

The Republican leaders of Texas and Florida refused to expand Medicaid. However, the survey showed two-thirds of people in those two states wanted them to do it anyway.

“Both Texas and Florida, the residents there are hurting and are turning to the idea of Medicaid expansion,” said Dr. Tim Garson, the director of the Health Policy Institute.

Garson noted that more residents in Texas and Florida complained about the quality of health care and felt it was worse than two years ago. Texas was also the state with the most people — 65 percent — saying they were paying more out-of-pocket for health care than two years ago and were cutting down on other expenses to do so.

“This isn’t necessarily a political statement, this is simply, ‘What’s the data?’ And the data are Texas and Florida, the two without Medicaid expansion, are having perceived problems with cost and quality worse than the other three,” Garson said.

The survey did not ask Texans or Floridians if they thought those problems were because political leaders had not expanded Medicaid.

But 63 percent of Texans and 68 percent of Floridians did favor expansion.

Over all five states, the cost of health care was a common complaint, with 58 percent of respondents reporting that they paid more out-of-pocket for health care than they did two years ago.

“Clearly, we as a country, we as a state — couldn’t we find ways to decrease the overall cost of health care?” Garson asked.

The ACA has helped 20 million additional Americans get insurance, but Garson says the law didn’t do much to control the actual prices being charged in the health care industry. Consumers feel the financial pressure in their deductibles, copays and monthly premiums.

“Of the uninsured, 87 percent said when they went to the exchange they couldn’t afford it,” Garson said, referring to the online marketplaces where people can buy individual or family insurance plans if their employers don’t provide coverage.

The survey did not ask respondents if they liked the idea of a government-funded “single-payer” system. But many did say universal coverage was important.

“One of my biggest surprises is that 85 percent of everybody asked was looking for ‘coverage for all,’” Garson said. “They are worried about their sisters and brothers. And I think that, at some point, is going to show up in the voting rolls.”

But Ross Baker, a political scientist at Rutgers University in New Jersey, is skeptical about the power of health care as a campaign issue. Baker is not connected to the survey but examined it at the request of Houston Public Media.

Although candidates will talk about Obamacare and health costs, Baker is not convinced it’s the kind of pivotal issue that will motivate voters to choose one presidential candidate over another.

“Generally, people are mindful of the health care issues because they are very practical, day-to-day concerns, but whether or not they would get out of bed on Tuesday morning in November, and go to the polls based on their feelings about whether or not Medicaid should be expanded in their state is, I think, subject to challenge,” Ross said.

Rather, the expected contest between Clinton and Trump will probably be decided on their personality differences, Ross said.

The poll also asked about emergency room usage and interventions to combat obesity.

Forty-six percent of respondents admitted they had gone to an ER even when they knew it wasn’t an emergency. The primary reason they gave was the doctor’s office was closed, Garson said.

Respondents also answered questions about extra taxes on sugary drinks and fast food, with more than half of people in all five states saying they would favor such taxes. That held true even in the two more conservative states of Texas and Florida.

The majority of people picked a 25 percent tax as “reasonable,” while almost half (44 percent) said the tax could be as high as 50 percent on sugary drinks.

Politicians should take note that such taxes, often called “fat taxes,” might be acceptable to their constituents as an effective obesity intervention, Garson said.

It’s worked before, he noted: “When you go and look back and ask the World Health Organization about smoking, what was it that really led to the real decrease in smoking? It was the cigarette tax,” Garson said.

This story is part of a reporting partnership between Houston Public Media, NPR and Kaiser Health News.

For Substance Abusers, Recovery-Oriented Care May Show The Way To A Productive Life

WAYNESVILLE, N.C. — Every movement needs a champion, and in the largely rural counties of western North Carolina, Richie Tannerhill is a champion of the recovery-oriented care movement for people with mental health and substance abuse issues.

Recovery-oriented care is founded on the belief that people with behavioral health problems need guideposts to help them find their own routes back to a productive life — that medication compliance and symptom control aren’t ultimate treatment goals.

Advocates of this approach, which involves community-based supports to help people reintegrate into their communities, fear it could be undermined by the omnibus mental health bill sponsored in Congress by Rep. Tim Murphy, a Pennsylvania Republican and clinical child psychologist.

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The legislation is now pending in committee and critics say its focus on the needs of those with the most severe, persistent mental illnesses could shortchange many others with more common problems, such as substance abuse and depression, and limit funding for prevention.

Recovery advocates in North Carolina, where the recovery movement has been gaining momentum, believe such a federal refocus would be a big mistake.

“This movement will be set back decades if the Murphy bill passes,” said Sharon Young, cofounder of Full Circle Counseling and Wellness in Hendersonville and a recovery-movement supporter.

Broughton Hospital, a state-run psychiatric facility, shifted to a recovery-oriented approach to care in 2013, and there’s been a strong push of late to open peer-run respite centers throughout the state. In addition, the seventh annual One Community in Recovery Conference was held near Winston-Salem in November, drawing recovery-movement advocates from around the country.

Those skeptical of recovery-oriented care argue that its results aren’t quantifiable. But Tannerhill and other advocates stress that it’s usually part of a broader strategy that includes evidence-based clinical treatment and support services, as recommended by the federal Substance Abuse and Mental Health Services Administration (SAMHSA).

Data collected by the North Carolina Department of Health and Human Services in July 2015 offers evidence that the combination is beginning to show results at Broughton. In the two years after the recovery initiative was launched, the hospital experienced a 16 percent reduction in the use of all types of restrictive interventions.

Peer support is a central element of Broughton’s recovery approach and of recovery-oriented care in general. And it’s Tannerhill’s strength.

He’s a trainer of certified peer support specialists for Smoky Mountain, the managed care organization responsible for public funding for mental health, substance abuse and intellectual and developmental disability services for most of mountainous western North Carolina.

Peer-support specialists are counselors who, like Tannerhill, can relate to a person in crisis because they’ve been down that road. They provide moral support and practical assistance, helping clients find affordable housing, fill out job applications or get to a doctor’s appointment.

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Read more about Richie Tannerhill’s journey here.

Tannerhill says he was first arrested in third grade and was regularly using and dealing drugs by age 12. Much of the first three decades of his life was spent in one form of lockup or another. At 31, he was an alcoholic and facing an extended future in the criminal justice system.

But while in prison, he entered a long-term treatment program. That’s when he began to embrace the tenants of recovery, and it’s the message he now strives to communicate to others.

“You have to do the work,” Tannerhill said. “And that work that I do is called recovery.”

SAMHSA defines recovery as a “process of change through which individuals improve their health and wellness, live self-directed lives and strive to reach their full potential.”

Counselors and peer supporters help a client determine what they want their lives to look like, said Cherene Allen-Caraco, CEO of the Charlotte-based Promise Resource Network, which provides information, training and support to the recovery community.

Tannerhill acknowledges there are many pathways to the threshold of recovery. People may well begin to heal in treatment programs and therapy sessions.

But, he said, “People recover in their communities.” He argues they do so more effectively when those communities offer support.

He points to housing as perhaps the most critical need for those in crisis or who are reintegrating into their communities after a stay in an institution. And he is working with advocates from other states with more-established recovery-oriented initiatives in hopes of learning from their experiences.

One such example: Projects to Empower and Organize the Psychiatrically Labeled Inc., or PEOPLe, a not-for-profit peer-run advocacy and crisis-diversion services organization based in Poughkeepsie, New York, provides temporary housing for those in need.

CEO Steve Miccio pointed out the program has also reduced hospital recidivism and spending. A stay at one of PEOPLe’s homes costs $193 a night; a psychiatric inpatient bed generally runs up to, and sometimes beyond, $1,000 a night.

Last spring, Tannerhill met Phil Valentine, executive director of the Connecticut Community for Addiction Recovery, a former addict and a pioneer in the recovery-oriented care movement.

Valentine, who was hiking the Appalachian Trail to raise awareness of recovery, speaks of overcoming shame, an essential element of recovery.

“Treatment is the initiation of recovery,” Valentine explained. “That’s when you get that respite to say, ‘OK, I’ve initiated my recovery, I’ve got that stuff out of my system, the fog is starting to lift … I’m starting to see that there’s hope that I can build a life.’”

Connecticut’s recovery-oriented care movement has been going strong for about 15 years, Valentine said. His organization has a staff of 16 and some 400 volunteers. Many of them publicly share their stories of recovery.

Recovery advocates, he said, are acknowledged in Connecticut’s health care discussions, including in the state legislature, as voices that “need to be heard.”

The voices of recovery, Tannerhill agrees, must be heard in the debate on Capitol Hill concerning mental health and substance abuse issues, and in communities.

“People get well and say, ‘I’m done. I don’t want to be associated with that anymore.’ So we don’t get to hear those stories,” he said. These are stories that, he believes, are woven into the histories of most every family, stories of navigating home to “normalcy.”

A Rocky Road To Recovery

Both of Richie Tannerhill’s parents had mental health and substance abuse disorders. His dad was sentenced to an extended prison term, and Tannerhill said he was “passed around from friend to friend, family member to family member.”

By the age of 4, he’d lived in five states.

His first arrest came when he was in third grade and got caught breaking into a school. He was dealing drugs at 12, and by 14 had sampled pills, mushrooms, cocaine and LSD. At 15, he landed in the behavioral health unit of a hospital in Kailua, Hawaii, and a year later, a Nebraska prison, charged with breaking into two restaurants.

He entered adulthood needing a drink each morning just to ease the shakes.

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At 31, he was back in jail, facing a 15-year stretch for a string of felony charges ranging from assault with a deadly weapon with intent to kill (subsequently dismissed as self-defense) to possession of precursor chemicals with the intent to manufacture and distribute.

He had a 4-year-old and an infant at home and two more kids he wasn’t allowed to visit. He was, he said, “everything I didn’t want to be.”

“I was physically, mentally, spiritually, financially — I was broken, man.” And ready to reassemble. Solitary confinement had sobered him up, and he was convinced he was ready to stay clean.

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For Substance Abusers, Recovery-Oriented Care May Show The Way To A Productive Life

He entered a courtroom and said, “‘Judge, I’ve had a spiritual awakening. I’m good.’” The judge said, “‘Richie, I’m glad to hear that. Two more years.’”

He went back to prison.

“And guess what? It turned out to be exactly what I needed,” Tannerhill said. He spent that first year in a long-term treatment program, “clean time,” where he was introduced to the tenets of recovery.

In November 2007, he re-entered the world, homeless and lacking a driver’s license. But nurturing that spark of hope.

A Doctor Yearns For A Return To The Time When Physicians Were ‘Artisans’

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In his recent book, “The Finest Traditions of My Calling,” Dr. Abraham Nussbaum, 41, makes the case that doctors and patients alike are being shortchanged by current medical practices that emphasize population-based standards of care rather than individual patient needs and experiences.

Nussbaum, a psychiatrist, is the chief education officer at Denver Health Medical Center and practices on the adult inpatient psychiatric unit there. I recently spoke with him and this is an edited transcript of our conversation.

Q. Your book is in some ways a lament for times gone by, when physicians were “artisans” who had more time for their patients and professional independence. But you’re a young doctor and you must have known at the outset that wasn’t the way medicine worked anymore. Why do you stick with it?

A. The first thing I’d say was that I didn’t know right away that medicine is no longer universally understood as a calling instead of a job. We are describing health as if it is just another consumer good, and physicians and other health practitioners as the providers of those goods. That is the language of a job. When you remember that being with the ill is a calling, then you remember that it is a tremendous privilege to be a physician. People trust you with their secrets, their fears and their hopes. They allow you to ask about their lives and to assess their bodies. So my lament is not for the loss of physician privilege — goodbye to that — but to the understanding of medicine as a calling.

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Q. You don’t like checklists and quality improvement measures that dictate how physicians care for patients because you say it turns doctors into technicians and is an obstacle to “moral reasoning.” But those tools, which generally take a systems approach to providing care and rely on evidence-based guidelines, aren’t going away anytime soon. How do you do the kind of doctoring you want to do in this environment?

A. Quality improvement seems to be here to stay. Regulators at all levels require it. But I believe that evidence of its success is not as clear as they suggest. Just last week, the British Medical Journal published a study that found no evidence that introducing quality metrics has resulted in a significant reduction in patient mortality. The leaders of the quality movement’s version of quality improvement developed out of industrial engineering, so they are always comparing the care of patients to things like the production of cars or the flying of airplanes. People are far more varied than cars on assembly line or planes on the runway. So quality metrics always feel forced to me, especially for the more interactive medical encounters.

Dr Nussbaum

Dr. Abraham Nussbaum (Courtesy of Paul D. Weinrauch)

In my own specialty, the current quality metrics all encourage me to perform standardized screens on patients or to document carefully. None of them require me to develop a relationship with a patient so that I can, say, foster hope after a suicide attempt, or knit a psychotic person back into the life of their family. Yet that it was my patients want, those human relationships. It is also what physicians want, and the most recent studies suggest that most physicians are dispirited by quality metrics.

Q. But not all physicians are equally skilled or conscientious. As a patient, I feel more comfortable knowing there are rules and standards that doctors have to meet.

A. I don’t think physicians should be free to do whatever they want. Their thinking and decision-making should be held up to scrutiny. A physician’s standard of quality should be evidence-based, but even more, it should be patient-centered. The standard should be what the patient defines as what matters. So if you are suffering chronic pain, it is not just a reduction of your score on a standardized pain scale, but your ability to resume the activities you identify as constitutive of your life.

Q. You talk about wanting to be able to sit with patients and talk with them, to really “see” them. All that takes time that physicians don’t generally have. I understand your book isn’t a how-to manual. But, really, how can physicians do this, even if they want to?

A. It’s a real challenge. It’s important to use the time you have in service of the patient’s needs. I don’t review records while I’m in the room with a patient. I try to make every question be about the patient. I have to ask standard questions, but I try to do that as way to get to know the patient. For example, if I have to ask questions about what they can remember, I’d ask about a book they have with them. Part of my concern about checklists is that they train you to follow a script instead of following your patients.

Q. Only 55 percent of psychiatrists take insurance compared with nearly 90 percent of physicians in other specialties. That puts their services out of financial reach for many people who could use their help. How does that square with your vision of doctors as healers and teachers?

A. It’s deeply concerning to me. I’ve made a conscious choice to work at a safety net hospital, so I can see people regardless of their ability to pay. I hope that through things like the Medicaid expansion and mental health parity, more psychiatrists will work with people who have mental illness.

Q. You talk about the virtues of “slow” medicine, similar to the slow food movement, where physicians reject providing care in a standardized, mass-produced fashion. One path that some physicians have chosen is to establish boutique practices that accept a limited number of patients who pay extra fees for more personal attention and better access. What’s your perspective on that?

A. It sounds appealing to me. In most descriptions of boutique medicine, they talk about it like a lovely restaurant, one that I couldn’t afford to go to every night. I think it’s an interesting model but not a solution to the large problems facing medicine, in particular the ability to provide care to the most needy among us and the indigent.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Doctors’ House Calls Saving Money For Medicare

Looking for ways to save money and improve care, Medicare officials are returning to an old-fashioned idea: house calls.

But the experiment, called Independence at Home, is more than a nostalgic throwback to the way medicine was practiced decades ago when the doctor arrived at the patient’s door carrying a big black bag. Done right and paid right, house calls could prove to be a better way of treating very sick, elderly patients while they can still live at home.

“House calls go back to the origins of medicine, but in many ways I think this is the next generation,” said Dr. Patrick Conway, who heads the Center for Medicare and Medicaid Innovation, which oversees Independence at Home.

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In the first year of the experiment, Housecall Providers of Portland, Oregon, which had been operating at a loss, saved Medicare an average of almost $13,600 for each patient in the pilot project. Its share of the savings was $1.2 million. The house calls practice at MedStar Washington Hospital in Washington, D.C., cut the cost of care an average of $12,000 per patient.

Medicare reported overall savings of $25 million in the pilot’s first year, officials reported last June. From that money, nine practices earned bonuses totaling nearly $12 million, including a $2.9 million payment to a practice in Flint, Michigan.

After three practices dropped out, there are now 14 around the country participating in the project — including five sites run by the Visiting Physicians Association.

Medicare officials are expected to announce the second round of payments next month.

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By all accounts, saving any money on these patients is a surprise. Independence at Home targets patients with complicated chronic health problems and disabilities who are among the most expensive Medicare beneficiaries. But a key study, published in 2014 in the Journal of the American Geriatrics Society, found that primary care delivered at home to Medicare patients saved 17 percent in health spending by reducing their need to go to the hospital or nursing home.

In addition to Medicare’s usual house calls payment, doctors in the Independence at Home project get a bonus if patients have at least 5 percent lower total Medicare costs than what is expected for a similar group of beneficiaries. Medicare keeps the first 5 percent of the savings and the house call providers can receive the rest. The doctors must meet at least three of the six performance goals — such as reducing emergency room visits and hospital readmissions, and monitoring patients’ medications for chronic conditions such as diabetes, asthma and high blood pressure.

Under the law creating the program, practices could join only if they make house calls to at least 200 patients with traditional Medicare who have been hospitalized and received rehab or other home health care within the past year. These patients also must have trouble with at least two activities of daily living, such as dressing or eating. The health care providers must be available 24 hours a day, seven days a week. They make visits at least once a month to catch any new problems early, and more often if patients are sick or there’s an emergency.

“You never know what you’re walking into,” said Terri Hobbs, Housecall Providers’ executive director. “This is a very sick group of people, with multiple chronic conditions, taking multiple medications and [they] have a very long problem list.” About half the Portland patients have some degree of dementia.

Yet the Medicare reimbursement for house calls is about the same as an office visit and doesn’t cover travel time or the extra time needed to take care of complex patients. It’s not enough to convince most doctors “to leave the relatively comfortable controlled environment of an office or hospital to do this sort of work,” said Dr. William Zafirau, medical director for Cleveland Clinic’s house calls program in Ohio, which has 200 patients in the Medicare pilot and plans to add 150 more.

A house calls doctor can see only five to seven patients a day. One reason is that a house call visit can take longer than an office visit, even after taking travel time into account. After Zafirau examines his patients, he also takes a look around the home. He may open their refrigerators to make sure they have enough food or see if medicine bottles are running low. He may arrange home-delivered meals or other social services.

“How people are functioning is often the best indicator of their overall health,” he said.

The care can also extend to other professional services. Portland’s Housecalls Providers hired a nurse and a social worker to serve as an advocate for patients who enter the hospital. When the patient returns home, they visit. “They make sure if patients are supposed to get an antibiotic, a hospital bed or oxygen, that they get them,” said Hobbs.

Hospital admissions dropped so significantly that Hobbs expanded the transition team to serve house calls patients who were not part of the pilot program when they were hospitalized.

A similar team serves MedStar Washington Hospital Center’s house calls patients, said Dr. Eric De Jonge, director of geriatrics at the hospital and president-elect of the American Academy of Home Care Medicine. “When patients go to the hospital, there is very little contact from the primary care doctor with the hospital care,” he said. Independence at Home “is actually pushing back to reverse that trend.”

Ironically, Medicare doesn’t pay for the transition team even though Hobbs said it saves Medicare “a tremendous amount of money.”

KHN’s coverage of aging and long term care issues is supported in part by a grant from The SCAN Foundation.

A Tender Steak Could Be A Little Dangerous

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A new label on some of the steaks in your grocery store highlights a production process you may have never heard of: mechanical tenderizing.

This means the beef has been punctured with blades or needles to break down the muscle fibers and make it easier to chew. But it also means the meat has a greater chance of being contaminated and making you sick.

The labels are a requirement from the U.S. Department of Agriculture that went into effect this week.

“Blade tenderized,” that label might read, followed by safe cooking instructions: “Cook until steak reaches an internal temperature of 145°F as measured by a food thermometer and allow to rest for 3 minutes.”

Here’s how it can make you sick: If pathogens like E. coli or salmonella happen to be on the surface of the steak, tenderizing transfers those bacteria from the surface to the inside. Since the inside takes longer to cook and is more likely to be undercooked, bacteria have a higher chance for survival there.

And without a label, you can’t tell if you need to be especially careful your steak.

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“It doesn’t look any different,” said a spokesperson for USDA’s Food Safety and Inspection Service. “It’s not filled with holes from the needle piercings.”

Mechanical tenderizing is not an unusual occurrence. FSIS estimates that 2.7 billion pounds or about 11 percent of the beef labeled for sale has been mechanically tenderized. The new labels will affect an estimated 6.2 billion servings of steaks and roasts every year, according to FSIS.

The U.S. Centers for Disease Control and Prevention has tracked six outbreaks of foodborne illness since 2000 that were attributable to mechanically tenderized beef products prepared in restaurants and consumers’ homes.

In 2009, 21 people in 16 states were infected with the most common strain of dangerous E. coli called O157. Nine had to be hospitalized, and one victim developed hemolytic uremic syndrome, a potentially fatal kidney disease. USDA food safety officials connected the illnesses to blade-tenderized steaks from National Steak and Poultry, and the company recalled 248,000 pounds of beef products.

“We need to improve how we tell consumers and the food service workers about the particular risks that would be involved in cooking it so that they can reduce the risk of illness,” said Patricia Buck, co-founder and executive director of the Center for Foodborne Illness Research & Prevention, a nonprofit advocacy group.

Buck, who has been pushing for the labeling rule since 2009 said she’s “very excited” to see it happening. “I think it’s an important step in the direction we need to go.”

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The label on blade tenderized beef sold at Costco recommends 160 degrees as the minimum internal temperature, which doesn’t require a 3-minute rest time. (Lydia Zuraw/KHN)

The National Cattlemen’s Beef Association “worked closely” with USDA on the label, said spokesman Chase Adams. “We will continue to work with them to provide helpful guidance for our members.”

Before the label became a requirement, Costco had been voluntarily labeling its meat. According to Consumer Reports, the grocery giant began labeling its mechanically tenderized beef in 2012 after an E. coli outbreak in Canada was linked to their blade-tenderized steaks.

Consumer advocate Buck lost her toddler grandson to an E. coli O157 infection in 2001. “I don’t like scaring people,” she said, “but on the other hand, people don’t really know that these can be really deadly pathogens.”

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

People With HIV Are Less Likely To Get Cancer Treatment

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We’ve made great progress treating people who are infected with HIV, but if they get cancer they’re less likely to get the care they need, a recent study found.

Researchers examined treatment for a variety of cancers, including upper gastrointestinal tract, colorectal, prostate, lung, head and neck, cervix, breast, anal and two blood cancers. With the exception of anal cancer, treatment rates differed significantly between HIV-infected people and those who weren’t infected, according to the study.

For example, 33 percent of patients with HIV and lung cancer failed to receive any treatment for the cancer compared with 14 percent of those who weren’t infected. Similarly, 44 percent of people who were HIV positive didn’t receive treatment for upper GI cancer versus 18 percent of those where weren’t infected with HIV. Twenty-four percent of men with prostate cancer who were HIV positive didn’t get treatment compared with 7 percent of non-HIV infected men.

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Cancer treatment was defined as radiation, chemotherapy and/or surgery.

“To have made such great strides with treating HIV only to have them succumb to cancer is devastating,” said Dr. Gita Suneja, a radiation oncologist at the University of Utah’s Huntsman Cancer Institute in Salt Lake City and the lead author of the study. It was published online this month in the journal Cancer.

The study used the National Cancer Data Base to analyze treatment for adults younger than 65 who were diagnosed with any of the 10 most common cancers to affect HIV patients between 2003 and 2011. The study included 10,265 HIV-infected adults and 2.2 million without HIV.

The data base, which is sponsored by the American Cancer Society and the American College of Surgeons, captures roughly 70 percent of newly diagnosed cancer cases in the United States.

woman patient in hospital with saline intravenous (iv)The study noted that more than a third of the patients with HIV had stage 4 cancer — cancer that has metastasized — when they were diagnosed, while only 19 percent of those without HIV did.

Improvements in antiretroviral therapy to treat HIV have helped reduce the incidence of cancers such as Kaposi sarcoma that are closely linked to AIDS, but rates for other cancers often associated with normal aging have increased among HIV patients. In addition, people with HIV have a higher incidence of some lifestyle-related cancers, such as lung cancer, which could be linked to higher rates of smoking. Cancer is now the second most common cause of death among HIV-infected people, behind AIDS-related causes.

HIV patients are more likely to be uninsured or underinsured, and lack of coverage can affect access to cancer care. But having insurance didn’t eliminate the problem: privately insured people with HIV were significantly more likely to be untreated for many cancers than were privately insured people without HIV, the study found.

“We know that people with Medicaid or who are uninsured receive subpar cancer treatment, and that’s a big public health issue,” said Suneja. “But even factoring that in, HIV-infected people are still less likely to receive cancer treatment. That means there are other drivers that we couldn’t measure in the study.”

Disparities in cancer treatment could exist for several reasons. For one thing, for most cancers there are no national treatment guidelines for HIV-infected patients, Suneja said. One of the few exceptions is anal cancer, the only cancer for which the study found little discrepancy in treatment among HIV-infected and non-infected patients. According to the research, the difference among those not receiving treatment was 4.8 percent for HIV patients versus 3.1 percent for others.

For other cancers, “the oncologist may pause and ask, ‘Does the HIV infection mean they shouldn’t get standard cancer treatment?’” Suneja added.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Study Of Birth Defects, Folic Acid In Foods Finds More Questions Than Answers

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Adding folic acid to foods like cereal and bread — long considered one of the most successful public health interventions to prevent birth defects — may be a less effective strategy than once thought, according to a provocative new study from Stanford University.

In 1998, the U.S. Food and Drug Administration required folic acid, a B-vitamin, to be added to cereal grain products to prevent neural tube defects, which can cause spina bifida, anencephaly, cleft palate and other devastating congenital abnormalities. Major food manufacturers were already adding the vitamin supplement to foods voluntarily two years earlier.

The Stanford researchers examined 1.3 million births and pregnancies over two decades in eight central California counties, and they were surprised by what they found. They knew that neural tube defects had been declining in California even before folic acid fortification of food became widespread, though the reasons are unclear.

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The researchers anticipated the defects would drop even more sharply after the FDA mandate. That didn’t happen: the neural tube defects did decline after 1998, but far less sharply than before the fortification started.

“It wasn’t what we expected,” said Stanford pediatrics professor Gary Shaw, the study’s senior author. “What we may be seeing, at least in California in this time period, is that the fortification of foods under the current program has reached its limit in preventing neural tube defects. We don’t know why. We’re in a quandary at this point.”

Shaw hopes researchers in other regions will examine local birth data for similar patterns.

The Stanford study isn’t the first to provide a more nuanced view of the impact of folic acid fortification on reducing birth defects. A 2009 study concluded that folic acid supplements taken by pregnant women weren’t enough to prevent some neural tube defects. Public health experts have debated whether to increase the current required level of folic acid supplementation in food, without reaching a consensus.

The U.S. Centers for Disease Control, which sponsored the study, declined to make an expert available for an interview but provided this statement: “Unfortunately, even with folic acid fortification, not all women of reproductive age are getting the recommended amount of folic acid, which is 400 micrograms daily. A recent CDC study showed that nearly a quarter of U.S. women of reproductive age (22.8%) did not have enough folate in the blood to prevent neural tube defects. Additional public health interventions targeting these women could help further reduce the number of neural tube defects that occur each year.”

The study, published today in the journal Birth Defects Research Part A, comes on the heels of the FDA’s decision last month to allow voluntary folic acid fortification of corn masa flour used in tortillas, a move Latino health advocates have long sought.

The children of Latinas are at higher risk of neural tube defects, perhaps because the mother’s diets contain less folic acid, studies have shown. The Central California counties studied by the Stanford researchers have large Hispanic populations, but the researchers did not find significant differences in birth defects between Hispanics and non-Hispanics, Shaw said. He acknowledged, however, that the actual numbers of neural tube defects covered by the study were small. Larger population studies might yield different results.

Neural tube defects, which affect a baby’s brain or spinal cord, can be devastating and often fatal. They occur in about 3,000 U.S. pregnancies every year.

The defects are caused by the failure of the fetus’ neural tube — which typically develops into a brain and spinal cord — to close completely before the end of the first month of pregnancy. That can result in spina bifida, which can leave children paralyzed for life, and anencephaly, in which the brain does not completely develop, usually resulting in death shortly after birth. Researchers still know little about what causes neural tube defects or exactly how folic acid works to prevent them.

Shaw says emphatically that the study’s results do not suggest folic acid is ineffective. Nationwide, neural tube defects have dropped by about 35 percent since folic acid fortification started, according to the CDC. The public health intervention has prevented an estimated 1,300 neural tube defects each year, the CDC has reported.

Women of childbearing age should continue to follow federal public health recommendations to consume 0.4 mg (400 micrograms) of folic acid daily, in addition to a nutritious diet, Shaw emphasized. Women shouldn’t wait until they know they are pregnant, because neural tube defects occur within the first month of pregnancy.

Other environmental and cultural factors may be complicating the effects of folic acid fortification in preventing neural tube defects. For example, folic acid fortification starting in the late 1990s coincided with a shift to lower-carbohydrate diets that eschewed the very cereals and bread being fortified.

Obesity among pregnant women also has risen, and the extra weight has been linked to a higher risk of neural tube defects. And neural tube defects may be dropping in part because they can be detected through prenatal screening, causing some pregnancies to be terminated.

The Stanford study did examine birth defects that weren’t originally targeted in the folic acid fortification program but are believed to be affected by it, including cleft lip, cleft palate and gastroschisis — an increasingly prevalent birth defect in which a baby is born with some of its intestines outside the body. The folic acid intervention seemed to help reduce the proliferation of those defects, Shaw said.

Finally, it’s possible that some women may not benefit as much as others from folic acid because of their genetic makeup, Shaw noted.

Some experts have questioned whether the required levels of folic acid added to food are adequate, but the FDA isn’t likely to revisit the issue anytime soon, said Lynn Bailey, a well-known folate researcher at the University of Georgia who was not involved with the Stanford study.

Raising levels much higher could cause unintended health effects. Rather, Bailey suggested, public health experts need to target specific populations, such as Hispanic women, who remain at higher risk for neural tube defects.

“Neural tube defects continue to occur even among those taking vitamin supplements,” Shaw said. “We want to identify clues to try to help us understand better ways or additional ways to prevent these birth defects. Have we done everything that we could to prevent neural tube defects? Right now, I’d say there’s more to do.”

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

Georgia Women Weigh Zika Risks As Mosquito Season Arrives

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Earlier this year, Katy Mallory’s husband, Dan, traveled to Mexico for business. That itself is not typically a big deal, but Katy is pregnant with twin girls, and Mexico is among the countries where the Centers for Disease Control and Prevention say mosquitoes are actively spreading Zika, a virus that’s been linked to severe birth defects.

Dan Mallory says in the middle of his trip, news hit that the Zika wasn’t only transmitted by mosquitoes, but could also be sexually transmitted. So when he returned, the Decatur couple decided to follow the CDC’s recommendation: use condoms during sex.

“It was a little bit weird to think about needing to use protection having been together for 10 years and not having had that conversation in a really, really, really long time,” Katy Mallory said.

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While the couple knew the risk of Dan having Zika and transmitting it to his wife were small, “Fear of the unknown was enough to cause pause and be pretty careful,” he said.

Weighing The Risks

“Careful” describes the approach many women in the South say they’re taking as mosquito season starts up in the region.

The CDC has linked Zika to microcephaly, a birth defect where babies are born with smaller heads and smaller brains that don’t develop properly. The World Health Organization says as of the middle of May 2016, more than 1,300 cases of microcephaly and other neurological disorders believed to be Zika-related had been reported from nine countries, including the U.S.

Georgia has seen 13 Zika cases so far, all of them in people who have traveled to one of the 55 countries where the WHO says Zika is active. None of the cases were in pregnant women.

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This image made available by the Centers for Disease Control and Prevention in March shows a map of the United States with an estimated range of the Aedes aegypti mosquito for 2016 indicated in blue. (Centers for Disease Control and Prevention)

While the virus hasn’t been seen in mosquitoes in Georgia yet, the potential for transmission, while small, exists.

The disease is spread primarily through one species of mosquito, the Aedes aegypti, though experts say the tiger mosquito could also carry it. Both species of mosquito are found in Georgia and about 30 other U.S. states. Health officials say their presence means the U.S. could eventually see small, local clusters of the Zika virus.

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The CDC says in addition to Aedes aegypti, the tiger mosquito, or Aedes albopictus, could also carry the Zika virus. The tiger mosquito can be found in more states throughout the U.S. than the Aedes aegypti. (Centers for Disease Control and Prevention)

“One bite can do it,” said Sarah Grzywacz, an Atlanta resident who canceled a trip to Mexico after consulting with her doctor. “One bite and you can be infected, and this child we so deeply planned for and deeply wanted could be forever changed and forever injured by our desire to have a vacation.”

Grzywacz, who’s seven months pregnant, says because the mosquitoes that carry Zika are also in Georgia, she tries to stay inside as much as possible and wears pants and long-sleeved shirts when she goes outside. She knows the risk of getting Zika is very, very small, but she wants to be cautious.

“We feel mostly powerless to control what happens because it’s mosquito bites,” Grzywacz said. “How can you go outside in the summer and not get bitten by a mosquito?”

Family Planning

Some Georgia women told WABE they’re holding off on planning a pregnancy this year altogether because of Zika.

“This summer, do I need a full-body net? That is everyone’s question,” said Emory Healthcare gynecologist Dr. John Horton.

Of course there’s no need for body nets, Horton says, but he understands why women are so worried.

His office hands out a Zika form that asks patients about recent travel and any symptoms they may have. At this point, however, Horton would not recommend women delay pregnancy because of Zika.

“I recognize it’s on our Caribbean door, but we haven’t seen it yet, and it may not come,” Horton said.

Horton points out the mosquitoes that carry Zika also carry viruses like dengue, yellow fever and chikungunya. Those haven’t been widely spread in the U.S., in part because people here are better shielded from mosquitoes by screens and air conditioning.

“If it gets here, we will figure this out,” Horton says.

Georgia Department of Public Health Commissioner Brenda Fitzgerald says at this point travel poses the biggest Zika threat to pregnant woman. (Michell Eloy/WABE)

Georgia Department of Public Health Commissioner Brenda Fitzgerald says travel poses the biggest Zika threat to pregnant woman right now. (Michell Eloy/WABE)

Stopping Zika’s Spread

That “if,” though, has state health officials on alert.

“It’s very important that people are very aware of cleaning up around their house,” said Georgia Department of Public Health Commissioner Brenda Fitzgerald.

The DPH commissioner says the state is taking the risk of Zika seriously. She says the department has set up mosquito traps to figure out where Zika risks might exist. There’s also a public service campaign underway to educate residents on preventing mosquito breeding grounds.

“Toss any container around your home that you’re not using,” Fitzgerald said. “Make sure you empty your gutters. Make sure you get rid of any standing water.”

Fitzgerald says right now the biggest risk to pregnant women is travel-related, but it’s not a minimal one, given that Atlanta’s Hartsfield-Jackson airport hit a record 100 million passengers last year.

The CDC recommends women wait eight weeks after traveling to a Zika-infected country to conceive. If a women’s male partner shows symptoms of Zika, which include rash, joint pain and eye inflammation, the couple should wait six months because the virus can linger in semen.

This story is part of a partnership that includes WABE, NPR and Kaiser Health News.