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Mpox is almost gone in the US, leaving lessons and mysteries in its wake | CNN

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CNN
—

The US public health emergency declaration for mpox, formerly known as monkeypox, ends Tuesday.

The outbreak, which once seemed to be spiraling out of control, has quietly wound down. The virus isn’t completely gone, but for more than a month, the average number of daily new cases reported to the US Centers for Disease Control and Prevention has hovered in the single digits, plummeting from an August peak of about 450 cases a day.

Still, the US led the world in cases during the 2022-23 outbreak. More than 30,000 people in the US have been diagnosed with mpox, including 23 who died.

Cases are also down across Europe, the Western Pacific and Asia but still rising in some South American countries, according to the latest data from the World Health Organization.

It wasn’t always a given that we’d get here. When mpox went global in 2022, doctors had too few doses of a new and unproven vaccine, an untested treatment, a dearth of diagnostic testing and a difficult line to walk in their messaging, which needed to be geared to an at-risk population that has been stigmatized and ignored in public health crises before.

Experts say the outbreak has taught the world a lot about this infection, which had only occasionally been seen outside Africa.

But even with so much learned, there are lingering mysteries too – like where this virus comes from and why it suddenly began to spread from the Central and West African countries where it’s usually found to more than 100 other nations.

Before May 2022, when clusters of people with unusual rashes began appearing in clinics in the UK and Europe, the country reporting the most cases of mpox was the Democratic Republic of Congo, or DRC.

There, cases have been steadily building since the 1970s, according to a study in the CDC’s Morbidity and Mortality Weekly Report.

In the DRC, people in rural villages depend on wild animals for meat. Many mpox infections there are thought to be the result of contact with an animal to which the virus has adapted; this animal host is not known but is assumed to be a rodent.

For years, experts who studied African outbreaks observed a phenomenon known as stuttering chains of transmission: “infections that managed to transmit themselves or be transmitted from person to person to a limited degree, a certain number of links in that chain of transmission, and then suddenly just aren’t able to sustain themselves in humans,” said Stephen Morse, an epidemiologist at Columbia University’s Mailman School of Public Health.

Informally, scientists kept track, and Morse says that for years, the record for links in a mpox chain was about four.

“Traditionally, it always burned itself out,” he said.

Then the chains started getting longer.

In 2017, Nigeria – which hadn’t had a confirmed case of mpox in more than four decades – suddenly saw a resurgence of the virus, with more than 200 cases reported that year.

“People have speculated maybe it was a change in the virus that allowed it to be made better-adapted to humans,” Morse said.

From 2018 through 2021, eight cases of mpox were reported outside Africa. All were in men ages 30 to 50, and all had traveled from Nigeria. Three reported that the rashes had started in their groin area. One went on to infect a health care provider. Another infected two family members.

This Nigerian outbreak helped experts realize that mpox could efficiently spread between people.

It also hinted that the infection could be sexually transmitted, but investigators couldn’t confirm this route of spread, possibly because of the stigma involved in sharing information about sexual contact.

In early May 2022, health officials in the UK began reporting confirmed cases of mpox. One of the people had recently traveled to Nigeria, but others had not, indicating that it was spreading in the community.

Later, other countries would report cases that had started even earlier, in April.

Investigators concluded that mpox had been silently spreading before they caught up to it.

In early summer, as US case numbers began to grow, the public health response bore some uncomfortable similarities to the early days of Covid-19. People with suspicious rashes complained that it was too hard to get tested because a limited supply was being rationed. Because the virus had so rarely appeared outside certain countries in Africa, most doctors weren’t sure how to recognize mpox or how to test for it and didn’t understand all its routes of spread.

A new vaccine was available, and the government had placed orders for it, but most of those doses weren’t in the United States. Beyond that, its efficacy against mpox had been studied only in animals, so no one knew whether it would actually work in humans.

There was an experimental treatment, Tpoxx, but it too was unproven, and doctors could get it only after filling out reams of paperwork required by the government for compassionate use.

Some just gave up.

“Tpoxx was hard to get,” said Dr. Jeffrey Klausner, a clinical professor of public health at the University of Southern California’s Keck School of Medicine.

“I was scrambling to find places that could prescribe it because my own institution just became a bureaucratic nightmare. So I basically would be referring people for treatment outside my own institution to be able to get monkeypox treatment,” he said.

Finally, in August, the federal government declared a public health emergency. This allowed federal agencies to access pots of money set aside for emergencies. It also allows the government to shift funds from one purpose to another to help cover costs of the response – and it helped raise awareness among doctors that mpox was something to watch for.

The government also set up a task force led by Robert Fenton, a logistics expert from the Federal Emergency Management Agency, and Dr. Demetre Daskalakis, director of the CDC’s Division of HIV and AIDS Research.

Daskalakis is openly gay and sex-positive, right down to his Instagram account, which mixes suit-and-tie shots from White House briefings with photos revealing his many tattoos.

“Dr. Daskalakis … really walks on water in most of the gay community, and then [Fenton is] a logistics expert, and I think that combination of leadership was the right answer,” Klausner said.

Early on, after the CDC identified men who have sex with men as being at highest risk of infection, officials warned of close physical contact, the kind that often happens with sexual activity. They also noted that people could be infected through contact with contaminated surfaces like sheets or towels.

But they stopped short of calling it a sexually transmitted infection, a move that some saw as calculated.

“In this outbreak, in this time and context to Europe, United States and Australia, was definitely sexually transmitted,” said Klausner, who points out that many men got rashes on their genitals and that infectious virus was cultured in semen.

Klausner believes vague descriptions about how the virus spread were intentional, in order to garner resources needed for the response.

“People felt that if they called it an STD from the get-go, it was going to create stigma, and because of the stigma of the type of sex that was occurring – oral sex, anal sex, anal sex between same-sex male partners – there may not have been the same kind of federal response,” Klausner said. “So it was actually a political calculation to garner the resources necessary to have a substantial response to be vague about how it spread.”

This ambiguity created room for misinformation and confusion, said Tony Hoang, executive director of Equality California, a nonprofit advocacy group for LGBTQ civil rights.

“I think there was a balancing dance of not wanting to create stigma, in terms of who is actually the highest rates of transmission without being forthright,” Hoang said.

Hoang’s group launched its own public information campaign, combining information from the CDC on HIV and mpox. The messaging stressed that sex was the risky behavior and made sure to explain that light brushes or touches weren’t likely to pass the infection, he said.

Klausner thinks the CDC could have done better on messaging.

“By giving vague, nonspecific information and making comments like ‘everyone’s potentially at risk’ or ‘there’s possible spread through sharing a bed, clothing or close dancing’ … that kind of dilutes the message, and people who engage in risk behavior that does put them at risk get confused, and they say ‘well, maybe this isn’t really a route of spread,’ ” he said.

In July and August, when the US was reporting hundreds of new mpox cases each day, health officials were worried that the virus might be here to stay.

“There were concerns that there would be ongoing transmission and that ongoing transmission would become endemic in the United States like other STIs: gonorrhea, chlamydia, syphilis. We have not seen that occur,” said Dr. Jonathan Mermin, director of the CDC’s National Center for HIV, Viral Hepatitis, STD, and TB Prevention.

“We are now seeing three to four cases a day in the United States, and it continues to decline. And we see the possibility of getting to zero as real,” he said.

At the peak of the outbreak, officials scrambled to vaccinate the population at highest risk – men who have sex with men – in the hopes of limiting both severity of infections and transmission. But no one was sure whether this strategy would work.

The Jynneos vaccine was approved by the US Food and Drug Administration in 2019 to prevent monkeypox and smallpox in people at high risk of those infections.

At that time, the plan was to bank it in the Strategic National Stockpile as a countermeasure in case smallpox was weaponized. The approval for mpox, a virus closely related to smallpox, was tacked on because the US had seen a limited outbreak of these infections in 2003, tied to the importation of exotic rodents as pets.

Jynneos had passed safety tests in humans. In lab studies, it protected primates and mice from mpox infections. But researchers only learn how effective vaccines are during infectious disease outbreaks, and Jynneos has never been put through its paces during an outbreak.

“We were left, when this started, with that great unknown: Does this vaccine work? And is it safe in large numbers?” Mermin said.

Beyond those uncertainties, there wasn’t enough to go around, and infectious disease experts feared that a shortage of the vaccine might thwart any effort to stop the outbreak.

So public health officials announced a change in strategy: Instead of injecting a full dose under the skin, or subcutaneously, they would inject just one-fifth of that dose between the skin’s upper layers, or intradermally.

An early study in the trials of the vaccine had suggested that intradermal dosing could be effective, but it was a risk. Again, no one was sure this dose-sparing strategy would work.

Ultimately, all of these gambles appear to have paid off.

Early studies of vaccine effectiveness show that the Jynneos vaccine protected men from mpox infections. According to CDC data, people who were unvaccinated were almost 10 times as likely to be diagnosed with the infection as those who got the recommended two doses.

Men who had two doses were about 69% less likely, and men with a single dose were about 37% less likely, to have an mpox infection that needed medical attention compared with those who were unvaccinated, according to the CDC.

Mermin says studies have since showed that the vaccine worked well no matter if was given into the skin or under the skin – another win.

Still, the vaccine is almost certainly not the entire reason cases have plunged, simply because not enough people have gotten it. The CDC estimates that 2 million people in the United States are eligible for mpox vaccination. Mermin says that about 700,000 have had a first dose – about 36% of the eligible population.

So it’s unlikely that vaccination was the only reason for the steep decline in cases. CDC modeling suggests that behavior change may have played a substantial role, too.

In an online survey of men who have sex with men conducted in August, half of participants indicated that they had reduced their number of partners and one-time sexual encounters, behaviors that could cut the growth of new infections by 20% to 30%.

If that’s the case, some experts worry that the US could see monkeypox flare up again as the weather warms.

“The party season was during the summer, during the height of the outbreak, and we’re in the dead of winter. So there’s a possibility that behavior change may not able to be sustained,” said Gregg Gonsalves, an epidemiologist at the Yale School of Public Health.

Although we’re clearly in a much better position than we were last summer, he says, public health officials shouldn’t make this a “mission accomplished” moment.

“Now, put your foot on the accelerator. Let’s get the rest of these cases,” Gonsalves said.

Mermin says that’s exactly what the CDC intends to do. It isn’t finished with the response but intends to switch to “a ground game.”

“So much of our work in the next few months will be setting up structures so that getting vaccinated is easy,” he said.

Nearly 40% of mpox cases in the United States were diagnosed in people who also had HIV, Mermin said. So the CDC is going to make sure Jynneos vaccines are available as a routine part of care at HIV clinics and STI clinics that offer pre-exposure prophylaxis, or PrEP, for HIV.

Mermin said officials are also going to continue to go to LGBTQ festivals and events to offer on-site vaccinations.

Additionally, they’re going to study people who’ve been vaccinated and infected to see whether they remain immune – something else that’s still a big unknown.

Experts say that’s just one of many questions that need a closer look. Another is just how long the virus had been spreading outside Africa before the world noticed.

“We’re starting to see some data that suggests that asymptomatic infection and transmission is possible, and that certainly will change how we how we think about this virus and and risk,” said Anne Rimoin, an epidemiologist at the Fielding School of Public Health at UCLA.

When researchers at a sexual health clinic in Belgium rescreened more than 200 nasal and oral swabs they had taken in May 2022 to test for the STIs chlamydia and gonorrhea, they found positive mpox cases that had gone undiagnosed. Three of the people reported no symptoms, while another reported a painful rash, which was misdiagnosed as herpes. Their study was published in the journal Nature Medicine.

“Mild and asymptomatic infections may have indeed delayed the detection of the outbreak,” study author Christophe Van Dijck of the Laboratory of Medical Microbiology at the University of Antwerp in Belgium said in an email to CNN.

While researchers tackle those pursuits, advocacy groups say they aren’t ready to relax.

Hoang says Equality California is pushing the CDC to address continuing racial disparities in mpox vaccination and treatment, particularly in rural areas.

He’s not worried that gay men will drop their guard now that the emergency has expired..

“We’ve learned that we have to take health into our own hands, and I do think that we will remain vigilant as a community for this outbreak and future outbreaks,” Hoang said.

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FDA vaccine advisers vote to harmonize Covid-19 vaccines in the United States | CNN

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CNN
—

A panel of independent experts that advises the US Food and Drug Administration on its vaccine decisions voted unanimously Thursday to update all Covid-19 vaccines so they contain the same ingredients as the two-strain shots that are now used as booster doses.

The vote means young children and others who haven’t been vaccinated may soon be eligible to receive two-strain vaccines that more closely match the circulating viruses as their primary series.

The FDA must sign off on the committee’s recommendation, which it is likely to do, before it goes into effect.

Currently, the US offers two types of Covid-19 vaccines. The first shots people get – also called the primary series – contain a single set of instructions that teach the immune system to fight off the original version of the virus, which emerged in 2019.

This index strain is no longer circulating. It was overrun months ago by an ever-evolving parade of new variants.

Last year, in consultation with its advisers, the FDA decided that it was time to update the vaccines. These two-strain, or bivalent, shots contain two sets of instructions; one set reminds the immune system about the original version of the coronavirus, and the second set teaches the immune system to recognize and fight off Omicron’s BA.4 and BA.5 subvariants, which emerged in the US last year.

People who have had their primary series – nearly 70% of all Americans – were advised to get the new two-strain booster late last year in an effort to upgrade their protection against the latest variants.

The advisory committee heard testimony and data suggesting that the complexity of having two types of Covid-19 vaccines and schedules for different age groups may be one of the reasons for low vaccine uptake in the US.

Currently, only about two-thirds of Americans have had the full primary series of shots. Only 15% of the population has gotten an updated bivalent booster.

Data presented to the committee shows that Covid-19 hospitalizations have been rising for children under the age of 2 over the past year, as Omicron and its many subvariants have circulated. Only 5% of this age group, which is eligible for Covid-19 vaccination at 6 months of age, has been fully vaccinated. Ninety percent of children under the age of 4 are still unvaccinated.

“The most concerning data point that I saw this whole day was that extremely low vaccination coverage in 6 months to 2 years of age and also 2 years to 4 years of age,” said Dr. Amanda Cohn, director of the US Centers for Disease Control and Prevention’s Division of Birth Defects and Infant Disorders. “We have to do much, much better.”

Cohn says that having a single vaccine against Covid-19 in the US for both primary and booster doses would go a long way toward making the process less complicated and would help get more children vaccinated.

Others feel that convenience is important but also stressed that data supported the switch.

“This isn’t only a convenience thing, to increase the number of people who are vaccinated, which I agree with my colleagues is extremely important for all the evidence that was related, but I also think moving towards the strains that are circulating is very important, so I would also say the science supports this move,” said Dr. Hayley Gans, a pediatric infectious disease specialist at Stanford University.

Many others on the committee were similarly satisfied after seeing new data on the vaccine effectiveness of the bivalent boosters, which are cutting the risk of getting sick, being hospitalized or dying from a Covid-19 infection.

“I’m totally convinced that the bivalent vaccine is beneficial as a primary series and as a booster series. Furthermore, the updated vaccine safety data are really encouraging so far,” said Dr. David Kim, director of the the US Department of Health and Human Services’ National Vaccine Program, in public discussion after the vote.

Thursday’s vote is part of a larger plan by the FDA to simplify and improve the way Covid-19 vaccines are given in the US.

The agency has proposed a plan to convene its vaccine advisers – called the Vaccines and Related Biological Products Advisory Committee, or VRBPAC – each year in May or June to assess whether the instructions in the Covid-19 vaccines should be changed to more closely match circulating strains of the virus.

The time frame was chosen to give manufacturers about three months to redesign their shots and get new doses to pharmacies in time for fall.

“The object, of course – before anyone says anything – is not to chase variants. None of us think that’s realistic,” said Jerry Weir, director of the Division of Viral Products in the FDA’s Office of Vaccines Research and Review.

“But I think our experience so far, with the bivalent vaccines that we have, does indicate that we can continue to make improvements to the vaccine, and that would be the goal of these meetings,” Weir said.

In discussions after the vote, committee members were supportive of this plan but pointed out many of the things we still don’t understand about Covid-19 and vaccination that are likely to complicate the task of updating the vaccines.

For example, we now seem to have Covid-19 surges in the summer as well as the winter, noted Dr. Michael Nelson, an allergist and immunologist at the University of Virginia. Are the surges related? And if so, is fall the best time to being a vaccination campaign?

The CDC’s Dr. Jefferson Jones said that with only three years of experience with the virus, it’s really too early to understand its seasonality.

Other important questions related to the durability of the mRNA vaccines and whether other platforms might offer longer protection.

“We can’t keep doing what we’re doing,” said Dr. Bruce Gellin, chief of global public health strategy at the Rockefeller Foundation. “It’s been articulated in every one of these meetings despite how good these vaccines are. We need better vaccines.”

The committee also encouraged both government and industry scientists to provide a fuller picture of how vaccination and infection affect immunity.

One of the main ways researchers measure the effectiveness of the vaccines is by looking at how much they increase front-line defenders called neutralizing antibodies.

Neutralizing antibodies are like firefighters that rush to the scene of an infection to contain it and put it out. They’re great in a crisis, but they tend to diminish in numbers over time if they’re not needed. Other components of the immune system like B-cells and T-cells hang on to the memory of a virus and stand ready to respond if the body encounters it again.

Scientists don’t understand much about how well Covid-19 vaccination boosts these responses and how long that protection lasts.

Another puzzle will be how to pick the strains that are in the vaccines.

The process of selecting strains for influenza vaccines is a global effort that relies on surveillance data from other countries. This works because influenza strains tend to become dominant and sweep around the world. But Covid-19 strains haven’t worked in quite the same way. Some that have driven large waves in other countries have barely made it into the US variant mix.

“Going forward, it is still challenging. Variants don’t sweep across the world quite as uniform, like they seem to with influenza,” the FDA’s Weir said. “But our primary responsibility is what’s best for the US market, and that’s where our focus will be.”

Eventually, the FDA hopes that Americans would be able to get an updated Covid-19 shot once a year, the same way they do for the flu. People who are unlikely to have an adequate response to a single dose of the vaccine – such as the elderly or those with a weakened immune system – may need more doses, as would people who are getting Covid-19 vaccines for the first time.

At Thursday’s meeting, the advisory committee also heard more about a safety signal flagged by a government surveillance system called the Vaccine Safety Datalink.

The CDC and the FDA reported January 13 that this system, which relies on health records from a network of large hospital systems in the US, had detected a potential safety issue with Pfizer’s bivalent boosters.

In this database, people 65 and older who got a Pfizer bivalent booster were slightly more likely to have a stroke caused by a blood clot within three weeks of their vaccination than people who had gotten a bivalent booster but were 22 to 42 days after their shot.

After a thorough review of other vaccine safety data in the US and in other countries that use Pfizer bivalent boosters, the agencies concluded that the stroke risk was probably a statistical fluke and said no changes to vaccination schedules were recommended.

At Thursday’s meeting, Dr. Nicola Klein, a senior research scientist with Kaiser Permanente of Northern California, explained how they found the signal.

The researchers compared people who’d gotten a vaccine within the past three weeks against people who were 22 to 42 days away from their shots because this helps eliminate bias in the data.

When they looked to see how many people had strokes around the time of their vaccination, they found an imbalance in the data.

Of 550,000 people over 65 who’d received a Pfizer bivalent booster, 130 had a stroke caused by a blood clot within three weeks of vaccination, compared with 92 people in the group farther out from their shots.

The researchers spotted the signal the week of November 27, and it continued for about seven weeks. The signal has diminished over time, falling from an almost two-fold risk in November to a 47% risk in early January, Klein said. In the past few days, it hasn’t been showing up at all.

Klein said they didn’t see the signal in any of the other age groups or with the group that got Moderna boosters. They also didn’t see a difference when they compared Pfizer-boosted seniors with those who were eligible for a bivalent booster but hadn’t gotten one.

Further analyses have suggested that the signal might be happening not because people who are within three weeks of a Pfizer booster are having more strokes, but because people who are within 22 to 42 days of their Pfizer boosters are actually having fewer strokes.

Overall, Klein said, they were seeing fewer strokes than expected in this population over that period of time, suggesting a statistical fluke.

Another interesting thing that popped out of this data, however, was a possible association between strokes and high-dose flu vaccination. Seniors who got both shots on the same day and were within three weeks of those shots had twice the rate of stroke compared with those who were 22 to 42 days away from their shots.

What’s more, Klein said, the researchers didn’t see the same association between stroke and time since vaccination in people who didn’t get their flu vaccine on the same day.

The total number of strokes in the population of people who got flu shots and Covid-19 boosters on the same day is small, however, which makes the association a shaky one.

“I don’t think that the evidence are sufficient to conclude that there’s an association there,” said Dr. Tom Shimabukuro, director of the CDC’s Immunization Safety Office.

Nonetheless, Richard Forshee, deputy director of the FDA’s Office of Biostatistics and Pharmacovigilance, said the FDA is planning to look at these safety questions further using data collected by Medicare.

The FDA confirmed that the agency is taking a closer look.

“The purpose of the study is 1) to evaluate the preliminary ischemic stroke signal reported by CDC using an independent data set and more robust epidemiological methods; and 2) to evaluate whether there is an elevated risk of ischemic stroke with the COVID-19 bivalent vaccine if it is given on the same day as a high-dose or adjuvanted seasonal influenza vaccine,” a spokesperson said in a statement.

The FDA did not give a time frame for when these studies might have results.

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It’s been three years since the first Covid-19 case in the United States. What have we learned and what more do we need to understand? | CNN

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CNN
—

It’s been three years since the first Covid-19 case was diagnosed in the United States, on January 20, 2020. In the time since, nearly 1.1 million Americans have died from the coronavirus; the US has reported 102 million Covid cases, more than any other country, according to Johns Hopkins University. Both figures, many health officials believe, are likely to have been undercounted.

There have also been remarkable scientific achievements in our response to the pandemic, not least of which is the development of Covid-19 vaccines. But there are still many unanswered questions. To help with reflections on what we’ve learned and what more we need to understand, I spoke with CNN Medical Analyst Dr. Leana Wen, an emergency physician, public health expert and professor of health policy and management at the George Washington University Milken Institute School of Public Health. She is also author of “Lifelines: A Doctor’s Journey in the Fight for Public Health.”

CNN: You’re a physician caring for patients, a public health researcher and professor. What are the key lessons you’ve learned from the last three years of Covid-19?

Dr. Leana Wen: There are three main lessons that come to mind. First, we have seen how much the global scientific community has come together and delivered some truly incredible achievements. Less than a year after Covid-19 was declared a pandemic, we had a vaccine developed, authorized and being distributed. The scientific community has rallied on many other aspects of the response to Covid-19, including to identify treatments and improve surveillance testing.

Many of the scientific developments will last beyond this pandemic and help with other aspects of our infectious disease response. For instance, the technology behind mRNA vaccines could be used to make vaccines for other diseases. The wastewater surveillance being used to identify and track Covid-19 may be helpful for detecting other viruses.

Second, Covid-19 has unmasked many existing crises and amplified them for the world to see. The coronavirus didn’t create health disparities — these long-predated the virus — but exacerbated existing ones.

There were also many faults with the public health infrastructure that, while long known to those of us in the field, have been exposed for all to see. Data systems are not integrated between public health agencies, for example, and city and county health departments are woefully underfunded given their many responsibilities. These stem from the fragmented health care system we have in the US, as well as the ongoing lack of investment in local public health agencies.

At the same time, Covid has also demonstrated how crucial public health is. There is a saying that “public health saved your life today, you just don’t know it.” I think there is much more recognition among many that public health is essential to preventing problems that can have a major impact on people’s health and well-being.

With that said, Covid-19 occurred during a time of deep division. Virtually every aspect of the pandemic has become politicized and polarized. So thirdly, there has been rampant misinformation and disinformation that’s made the response much more challenging. We are seeing the lasting effects, such as reduced uptake of routine childhood immunizations. I’m very concerned that public health itself has become politicized in a way that could harm our response to future pandemics.

CNN: You mentioned that we’ve learned a lot scientifically. What more do we need to understand about Covid-19?

Wen: At this point in the pandemic, a lot of people have moved on from Covid-19 and no longer think about it as a major factor in their everyday lives. However, there are millions of Americans vulnerable to severe illness who remain very concerned about the coronavirus. These are people who are immunocompromised, elderly or with multiple underlying illnesses. To me, the most important research questions pertain to these individuals.

There are some antiviral medications that are effective for Covid-19 treatment, such as Paxlovid. Some patients are not eligible for Paxlovid, though, and other options are becoming more limited. The US Food and Drug Administration has revoked their authorization for monoclonal antibodies that could treat Covid-19 infection, as they no longer appear to be effective against new circulating variants. Recently, the FDA has also said that the preventive antibody Evusheld may be ineffective against some variants, including the XBB.1.5 variant that’s currently dominant in the US.

It should be an urgent priority to focus on developing better treatments for those most vulnerable to severe disease from Covid-19. I also hope that there will be much more investment into finding better vaccines. The vaccines that we have are excellent at protecting against severe disease, which is most important. However, they are not very effective at preventing infection.

The ideal vaccine would be more effective at reducing infection, and target the virus broadly so that we are not always trying to anticipate what variant will develop next — and then scrambling to find a vaccine that works against that variant. There is research being undertaken into nasal vaccines and pan-coronavirus vaccines, for example. I hope these efforts will be expedited.

CNN: We are learning more about long Covid, but is this an area that needs more research?

Wen: Absolutely. We know that many people have lingering symptoms after a Covid-19 infection. According to a large study from Israel, most symptoms resolve within the first year after infection for people with mild illness. However, there are some who have lasting symptoms, like fatigue, headache, palpitations and shortness of breath, that are so debilitating they can no longer work.

There is a lot that we don’t yet know about long Covid. The most important is how to treat patients who have it. The physiological mechanisms behind what’s causing their lingering symptoms are also unclear, along with exactly how common they are.

There are long waits to get into specialized clinics that treat this condition at present, so a lot more education needs to be done for primary care physicians and other clinicians who will probably end up being the main health care providers for many people suffering from long Covid.

CNN: What do you anticipate will happen in this coming year around Covid-19?

Wen: Right now, China is undergoing a massive surge of cases. It’s the last major country to have enforced a strict zero-Covid policy, and now that policy has been reversed. Once China’s infection numbers stabilize, Covid-19 will probably become endemic there, as it has become in most other parts of the world.

There will, no doubt, be new variants that arise. We need to keep on top of them and monitor accordingly to see if they are more deadly and/or evade the effectiveness of existing vaccines. The key, as I said earlier, is to develop vaccines that can more broadly cover variants.

And we must again remember that, while many people have resumed pre-pandemic lives, others have not. In the next year of Covid-19, I believe that the focus needs to be much more specific to these individuals who need our help the most. We should target boosters and treatments to those most vulnerable, for example.

Finally, there should be a much greater effort to rebuild our public health infrastructure. This is long overdue. Doing so is critical not just for preparing for the next pandemic, but also for improving health and well-being for all Americans.

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Recently identified inflammatory disease VEXAS syndrome may be more common than thought, study suggests | CNN

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CNN
—

David Adams spent half a decade fighting an illness he couldn’t name. He was in and out of the hospital several times per year. His inflamed joints made his hands feel like they had been squeezed into gloves – and he could no longer play his beloved classical and jazz guitars.

He had constant fevers and fatigue. He even developed pain and swelling in his genitalia, which was his first sign that something was really wrong.

“At the turn of the year 2016, I started with some really painful effects in the male anatomy,” said Adams, now 70. “After that, again, a lot of fatigue – my primary care physician at that point had blood tests done, and my white blood cell count was very, very low.”

Next, Adams, who lives in Alexandria, Virginia, saw a hematologist, a pulmonologist, a urologist, a rheumatologist and then a dermatologist. Some of them thought he might have cancer.

Adams’ symptoms continued, with even more fatigue, pneumonia and a large rash below his waist. He tried at least a dozen medications, saw about two dozen doctors, and nothing helped.

In 2019, worsening symptoms forced him to retire early from his decades-long career in clinical data systems. But he remained in the dark about what was causing the problems.

Finally, in 2020, scientists at the National Institutes of Health discovered and named a rare genetic disorder: VEXAS syndrome, which wreaks havoc on the body through inflammation and blood problems.

Adams had an appointment with his rheumatologist at the time, and when he walked into the office, he saw that his physician “was giddy like a little kid.”

In his doctor’s hands was a copy of a paper in the New England Journal of Medicine detailing the discovery of VEXAS syndrome.

Adams had his answer.

“For the first time, there was a one-to-one correlation of symptoms,” he said. “It was quite a shock.”

An estimated 1 in about 13,500 people in the United States may have VEXAS syndrome, a new study suggests, which means the mysterious and sometimes deadly inflammatory disorder may be more common than previously thought.

In comparison, the genetic disorder spinal muscular atrophy affects about 1 in 10,000 people and Huntington’s disease occurs in about 1 in every 10,000 to 20,000 people.

Since its discovery, occasional VEXAS cases have been reported in medical research, but the study reveals new estimates of its prevalence.

The research, published Tuesday in the journal JAMA, suggests that about 1 in 13,591 people in the US have mutations in the UBA1 gene, which develop later in life and cause VEXAS syndrome.

“This study is demonstrating that there’s likely tens of thousands of patients in the US that have this disease, and the vast majority of them are probably not being recognized because physicians aren’t really considering this as a diagnosis more broadly,” said Dr. David Beck, an assistant professor in the Department of Medicine at NYU Langone Health and a lead author of the study.

VEXAS syndrome is not inherited, so people who have it don’t pass the disease to their children. But the UBA1 gene is on the X chromosome, so the syndrome is an X-linked disease. It predominantly affects men, who carry only one X chromosome. Women have two X chromosomes, so if they have a mutation in a gene on one X chromosome but not the other, they are generally unaffected.

“It’s present in 1 in 4,000 men over the age of 50. So we think it’s a disease that should be thought about in terms of testing for individuals that have the symptoms,” said Beck, who also led the federal research team that identified the shared UBA1 mutation among VEXAS patients in 2020.

“The benefit of VEXAS syndrome is that we have a test. We have a genetic test that can help directly provide the diagnosis,” he said. “It’s just a question of patients who meet the criteria – who are older individuals with systemic inflammation, low blood counts, who really aren’t responding to anything but steroids – then advocating to their doctors to get genetic testing to get a diagnosis.”

Adams, who became a patient of Beck’s, said that finally getting a diagnosis – and understanding the cause of his symptoms – was life-changing.

“It really was incredibly freeing to have the diagnosis,” he said.

“You can’t fight your enemy unless your enemy has a name,” he added. “We finally had something where we could point to and say, ‘OK, we understand what’s going on. This is VEXAS.’ “

For the new study, Beck and his colleagues at the NIH, New York University, Geisinger Research and other institutions analyzed data on 163,096 patients in a health system in central and northeastern Pennsylvania, from January 1996 to January 2022, including electronic health records and blood samples.

Eleven of the patients had a disease-causing UBA1 variant, and a 12th person had a “highly suspicious” variant.

Only three of the 12 are still alive. A five-year survival rate of 63% has been previously reported with VEXAS.

Among the 11 patients in the new study who had pathogenic variants in UBA1, only two were women. Seven had arthritis as a symptom, and four had been diagnosed with rheumatologic diseases, such as psoriasis of the skin or sarcoidosis, which causes swollen lumps in the body. All had anemia or low blood cell counts.

“None had been previously clinically diagnosed with VEXAS syndrome,” Beck said.

The finding “is emphasizing how it’s important to be able to pick these patients out, give them the diagnosis and start the aggressive therapies or aggressive treatments to keep their inflammation in check,” he said.

VEXAS – an acronym for five clinical characteristics of the disease – has no standardized treatment or cure, but Beck said symptoms can be managed with medications like the steroid prednisone or other immunosuppressants.

“But the toxicities of prednisone over years is challenging. There are other anti-inflammatory medications that we use, but they’re only partially effective at the moment,” he said. “One treatment for individuals that we’ve seen that’s very effective is bone marrow transplantation. That comes with its own risks, but that’s just underscoring the severe nature of the disease.”

Although the new study helps provide estimates of the prevalence and symptoms of VEXAS syndrome, the data is not representative of the entire United States, and Beck said that more research needs to be done on a larger, more diverse group of people.

Some men might be hesitant to seek medical care for VEXAS symptoms, but Adams said that doing so could save their life.

“Eventually, it’s going to get so bad that you’ll end up like my first hospitalization, where you’re on death’s door,” Adams said. “You don’t want to be in that situation.”

Adams has been taking prednisone to ease his symptoms, and it’s helped. But because steroid use can have side effects such as cataracts and weight gain, he has been working with his doctors to find other therapies so he can reduce his intake of the medication.

Beck and his colleagues are studying targeted therapies for VEXAS syndrome, as well as conducting stem cell bone marrow transplant trials at the NIH.

“There are many different facets of the disease,” Dr. Bhavisha Patel, a hematologist and researcher in the National Heart, Lung and Blood Institute’s Hematopoiesis and Bone Marrow Failure Laboratory, said in an NIH news release last month.

“I believe that is what is challenging when we think about treatment, because it’s so heterogeneous,” said Patel, who was not involved in the new study.

“Both at NIH and worldwide, the groups that have dedicated themselves to VEXAS are looking for medical therapies to offer to other patients who don’t qualify for a bone marrow transplant,” she said. “We continue to collaborate on many projects in order to categorize this disease further and ultimately come up with the best treatment options.”

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Pediatricians are giving out free gun locks to approach the gun violence epidemic as a public health crisis | CNN

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CNN
—

In a triage waiting room of St. Louis Children’s Hospital in Missouri, a clear basket filled with gun locks sits near the walkway, just noticeable enough to those passing by.

The hospital staff calls it the “No Questions Asked” basket, to encourage gun safety without having to confront gun owners about what can be a sensitive and divisive topic. It holds an assortment of cable gun locks free of charge, available to those who need them, alongside pamphlets explaining how to properly and safely store firearms.

The initiative, aimed at reducing the stigma of addressing gun safety, is part of a growing effort by medical professionals who are treating the country’s gun violence epidemic as a public health crisis.

“It takes standing at the bedside of one child who has been shot to realize that we all have to do more and as the leading cause of death for children in this country, pediatricians need to be front and center of the solution, of all the solutions,” said Dr. Annie Andrews, a professor of pediatrics at the Medical University of South Carolina and an expert on gun violence prevention.

Over the course of two years, thousands of gun locks have been taken from the basket, according to Dr. Lindsay Clukies, a pediatric emergency medicine physician at the hospital.

In the coming weeks, baskets filled with free gun locks will be available at more than 17 locations operated by BJC HealthCare, an organization serving metro St. Louis, mid-Missouri and Southern Illinois, Clukies said. It’s a low-cost and effective way to easily distribute firearm safety devices.

“We’ve had employees as well as patients take our locks, also their families and even a grandmother who took one for her grandson. It’s for anyone who needs them,” Clukies told CNN. In recent years, a rising number of pediatricians across the country have been engaging with the topic of gun safety in medical settings by focusing on safety and prevention, already a natural aspect of their work.

During patient visits, it’s increasingly common for pediatricians to ask the patient’s parents if there are guns at home, and if so, how they are stored. Some hospitals then offer free gun locks, often sourced from donations or police departments and paired with safe storage education.

Some pediatricians, who bear witness to the effects of gun violence on children in their workplace every day, told CNN they see it as their obligation as medical professionals to be part of the solution to the epidemic.

In 2022, 1,672 children and teenagers under 17 were killed by gun violence and 4,476 were injured, according to the Gun Violence Archive, a nonprofit organization tracking injuries and deaths by gunfire since 2014.

“We have just as an important voice in this conversation as anyone else because we’re the ones who have invested our entire careers to protecting children and ensuring that children can grow up to be the safest healthiest version of themselves,” said Andrews.

“It is only natural that we see these things that we understand that they’re preventable, and we want to get involved in finding the solutions,” she added.

So far in 2023, high-profile incidents of children accessing firearms have heeded calls for stronger, more consistent laws nationwide, requiring adults to safely secure their guns out of the reach of children and others unauthorized to use them. They have also highlighted a lack of public education on the responsibility of gun owners to store their guns unloaded, locked and away from ammunition, CNN previously reported.

In early January, a 6-year-old boy was taken into police custody after he took a gun purchased by his mother from his home, brought it to school and shot his teacher at Richneck Elementary School in Newport News, Virginia, police said. Just over a week later, a man was arrested in Beech Grove, Indiana, after video was shown on live TV of a toddler, reportedly the man’s son, waving and pulling the trigger of a handgun, CNN previously reported.

Hundreds of children in the US every year gain access to firearms and unintentionally shoot themselves or someone else, according to research by Everytown for Gun Safety, a leading non-profit organization focusing on gun violence prevention. In 2022, there were 301 unintentional shootings by children, resulting in 133 deaths and 180 injuries nationally, Everytown data showed.

Firearm injuries are now the leading cause of death among people younger than 24 in the United States, according to the Centers for Disease Control and Prevention. The American Academy of Pediatrics released an updated policy statement in October 2022, stating firearms are now the leading cause of death in children under the age of 24 in the US.

The Academy’s statement urged a “multipronged approach with layers of protection focused on harm reduction, which has been successful in decreasing motor vehicle-related injuries, is essential to decrease firearm injuries and deaths in children and youth.”

The Academy has free educational modules for pediatricians to guide them on how to have what can be challenging or uncomfortable conversations about firearms with families, according to Dr. Lois Kaye Lee, a pediatrician and the chair of the Academy’s Council on Injury, Violence and Poison Prevention.

“This shouldn’t be considered as something extra; it should be considered as part of the work that we do every day around injury prevention, be it around firearms, child passenger safety and suicide prevention,” Lee said.

Dr. Georges Benjamin, executive director of the American Public Health Association, told CNN the public health approach to addressing gun violence removes the politics from the issue and “puts it into a scientific evidence-based framework.”

“Physicians have a unique opportunity to engage their patients, the parents of kids or the parents themselves as individuals to make their homes safer,” Benjamin said. “We already do this for toxins under our kitchen cabinets, razor blades and outlets in the wall.”

In the emergency department at St. Louis Children’s Hospital, all patients are screened for access to firearms and offered free gun locks, as well as safe storage education, Clukies said. Gun locks can also be mailed to families, free of cost, through the hospital’s website.

“Every patient that comes into our emergency department, whether it’s for a fever or a cold or a broken arm, is asked about access to firearms,” said Clukies, adding 5,000 locks have been given out since the initiatives were started in 2021.

In a collaborative effort between trauma nurses, physicians, social workers, violence intervention experts and family partners, the hospital created a “nonjudgmental” script for doctors to follow as they ask patients about access to firearms, Clukies said.

During the screening process, pediatricians will ask parents or caretakers questions such as: Do you have access to a firearm where your child lives or plays? How is it stored? Is it stored unloaded or loaded?

“When I first started doing this, I would say, ‘Are there any guns in the home? Yes, or no?’ But I have found and learned from other experts that if you just say, ‘If there are any guns in the home, do you mind telling me how they’re secured?’ it takes away the judgment,” said Andrews, a pediatrician whose hospital, the Medical University of South Carolina, also offers free gun locks to patients.

An assortment of cable gun locks offered free of charge by the Medical University of South Carolina.

Families are asked about firearms in the “social history” phase of a patient visit, during which pediatricians will ask who lives in the home, what grade the child is in, what activities they engage in and where the child goes to school, according to Andrews. When parents indicate their firearms are not safely stored, like on the top of a shelf or in a nightstand drawer, Andrews said those are important opportunities for intervention and education about storage devices such as keypad lockboxes, fingerprint biometric safes and other types of lock systems.

It’s also important for pediatricians to understand the parents’ or caretakers’ motivation for owning a firearm to “inform the conversation about where they’re willing to meet you as far as storage goes,” she added.

Andrews and Clukies said they were pleasantly surprised by the willingness of families to discuss firearm safety, most of whom recognize it is an effort to protect their children.

“I expected more pushback than we received, which is attributed to us really focusing on how we properly word these questions,” Clukies said. “I think it’s because we turn it into a neutral conversation, and we focus on safety and prevention.”

Andrews added it is uncommon for medical schools or residencies to discuss gun violence prevention, which she says is due to the “politics around the issue.”

“Thankfully, that has evolved, and more and more pediatricians are realizing that we have to be an integral part of the solution to this problem,” Andrews said.

At the St. Louis Children’s Hospital, pediatricians followed up with patients who received a free gun lock in a research study roughly two months after they launched the initiative in the fall of 2021 to see if their storage practices changed.

The study found two-thirds of families reported using the gun lock provided to them by the hospital and there was a “statistically significant decrease” in those who didn’t store their firearms safely, as well as an increase in those who stored their firearms unloaded, according to Clukies.

But there is still much more work to be done in the medical community to fight the gun violence epidemic and scientific research on the issue is “woefully underfunded,” Andrews contended.

According to the American Public Health Association’s Benjamin, a multidisciplinary approach by policymakers, law enforcement and the medical community is essential to fostering a safer environment for children.

“Injury prevention is a core part of every physician’s job,” Benjamin said. “It’s clearly in our lane.”

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Flu, Covid-19 and RSV are all trending down for the first time in months | CNN

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CNN
—

A rough respiratory virus season in the US appears to be easing, as three major respiratory viruses that have battered the country for the past few months are finally all trending down at the same time.

A new dataset from the US Centers for Disease Control and Prevention shows that the number of emergency department visits for the three viruses combined – flu, Covid-19 and RSV – have dropped to the lowest they’ve been in three months. The decline is apparent across all age groups.

Measuring virus transmission levels can be challenging; health officials agree that Covid-19 cases are vastly undercounted, and surveillance systems used for flu and RSV capture a substantial, but incomplete picture.

But experts say that tracking emergency department visits can be a good indicator of how widespread – and severe – the respiratory virus season is.

“There’s the chief complaint. When you show up to the emergency room, you complain about something,” said Janet Hamilton, executive director at Council of State and Territorial Epidemiologists. “Being able to look at the proportion of individuals that seek care at an emergency department for these respiratory illness concerns is a really good measure of the respiratory disease season.”

In the week following Thanksgiving, emergency department visits for respiratory viruses topped 235,000 – matching rates from last January, according to the CDC data.

While the surge in emergency department visits early in the year was due almost entirely to Omicron, the most recent spike was much more varied. In the week ending December 3, about two-thirds of visits were for flu, about a quarter were for Covid-19 and about 10% were for RSV.

Grouping the impact of all respiratory viruses together in this way offers an important perspective.

“There’s a strong interest in thinking about respiratory diseases in a more holistic way,” Hamilton said. “Transmission is the same. And there are certain types of measures that are good protection against all respiratory diseases. So that could really help people understand that when we are in high circulation for respiratory diseases, there are steps that you can take – just in general.”

Now, Covid-19 again accounts for most emergency department visits but flu and RSV are still the reason behind about a third of visits – and they’re all trending down for the first time since the respiratory virus season started picking up in September.

More new data from the CDC shows that overall respiratory virus activity continues to decline across the country. Only four states, along with New York City and Washington, DC, had “high” levels of influenza-like illness. Nearly all states were in this category less than a month ago.

Whether that pattern will hold is still up in the air, as vaccination rates for flu and Covid-19 are lagging and respiratory viruses can be quite fickle. Also, while the level of respiratory virus activity is lower than it’s been, it’s still above baseline in most places and hospitals nationwide are still about 80% full.

RSV activity started to pick up in September, reaching a peak in mid-November when 5 out of every 100,000 people – and 13 times as many children younger than five – were hospitalized in a single week.

RSV particularly affects children, and sales for over-the-counter children’s pain- and fever-reducing medication were 65% higher in November than they were a year before, according to the Consumer Healthcare Products Association. While “the worst may be over,” demand is still elevated, CHPA spokesperson Logan Ramsey Tucker told CNN in an email – sales were up 30% year-over-year in December.

But this RSV season has been significantly more severe than recent years, according to CDC data. The weekly RSV hospitalization rate has dropped to about a fifth of what it was two months ago, but it is still higher than it’s been in previous seasons.

Flu activity ramped up earlier than typical, but seems to have already reached a peak. Flu hospitalizations – about 6,000 new admissions last week – have dropped to a quarter of what they were at their peak a month and a half ago, and CDC estimates for total illnesses, hospitalizations and deaths from flu so far this season have stayed within the bounds of what can be expected. It appears the US has avoided the post-holiday spike that some experts cautioned against, but the flu is notoriously unpredictable and it’s not uncommon to see a second bump later in season.

The Covid-19 spike has not been as pronounced as flu, but hospitalizations did surpass levels from the summer. However, the rise in hospitalizations that started in November has started to tick down in recent weeks and CDC data shows that the share of the population living in a county with a “high” Covid-19 community level has dropped from 22% to about 6% over the past two weeks.

Still, the XBB.1.5 variant – which has key mutations that experts believe may be helping it to be more infectious – continues to gain ground in the US, causing about half of all infections last week. Vaccination rates continue to lag, with just 15% of the eligible population getting their updated booster and nearly one in five people remain completely unvaccinated.

Ensemble forecasts published by the CDC are hazy, predicting a “stable or uncertain trend” in Covid-19 hospitalizations and deaths over the next month.

And three years after the first Covid-19 case was confirmed in the US, the virus has not settled into a predictable pattern, according to Dr. Maria Van Kerkhove, the World Health Organization’s technical lead for the Covid-19 response.

“We didn’t need to have this level of death and devastation, but we’re dealing with it, and we are doing our best to minimize the impact going forward,” Van Kerkhove told the Conversations on Healthcare podcast this week.

Van Kerkhove says she does believe 2023 could be the year in which Covid-19 would no longer be deemed a public health emergency in the US and across the world, but more work needs to be done in order to make that happen and transitioning to longer-term respiratory disease management of the outbreak will take more time.

“We’re just not utilizing [vaccines] most effectively around the world. I mean 30% of the world still has not received a single vaccine,” she said. “In every country in the world, including in the US, we’re missing key demographics.”

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New 988 mental health crisis line sees ‘eye-opening’ rise in calls, texts, chats in first 6 months, data shows | CNN

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CNN
—

Since the summer launch of the 988 Suicide and Crisis Lifeline, the new three-digit number has seen a significant rise in call volume – routing more than 2 million calls, texts and chat messages to call centers, with the majority being answered in under a minute.

“The average speed to answer year-over-year was about three minutes in 2021. It’s now 44 seconds in December of 2022,” said Dr. John Palmieri, a senior medical advisor at the US Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration, who serves as 988’s deputy director.

The 988 Suicide and Crisis Lifeline, formerly known as the National Suicide Prevention Lifeline, launched last July, transitioning the former 1-800-273-TALK phone number to the three digits of 988. The new number is intended to be easy to remember, similar to how people can dial 911 for medical emergencies.

Since that transition, in the past six months, about 2.1 million calls, texts and chats to the new 988 number have been routed to a response center and, of those, around 89% were answered by a counselor, according to a CNN analysis of data from SAMHSA, which oversees 988. Many of the calls that went unanswered were due to callers hanging up before reaching a counselor.

“We know that there are many individuals in this country who are struggling with suicidal concerns, with mental health or substance use concerns, who aren’t able to access the care that they need. And in many respects, historically, because of funding limitations or other limitations, the system has let them down,” Palmieri said. “So, this is truly an opportunity with 988 – as a catalytic moment – to be able to transform the crisis care system to better meet those needs in a less restrictive, more person-centered, more treatment- and recovery-oriented way.”

Since the summer launch of 988, more than 300,000 calls, texts and chats have come in each month. SAMHSA data on the new lifeline show that in December 2022 versus December 2021, calls answered increased by 48%, chats answered increased by 263% and texts answered increased by 1,445%.

“We see the uptick in volume as an indicator that more people are aware of the service and able to access it,” Kimberly Williams, CEO and president of Vibrant Emotional Health, the nonprofit administrator and operator of the 988 lifeline, said in an email Thursday.

She added that Vibrant was “not surprised” by the increase in volume and has been “working strategically” with the more than 200 call centers in the 988 network to respond.

“In December of 2022 compared to December of 2021, over 172,000 more contacts were answered as part of the lifeline system,” Palmieri said.

The average amount of time counselors spent talking, chatting or texting with contacts was about 21 minutes and 55 seconds.

“It’s really eye-opening to see the increase in the texts, chats and calls that are coming in. But to see that more states have a more than 90% answer rate for contacts coming from their state – and that average speed of answering is down, so people are getting help more quickly,” said Hannah Wesolowski, the chief advocacy officer for the National Alliance on Mental Illness.

She added that before the launch of 988, there were likely many people seeking mental health support but didn’t feel like there was a call service available for them.

“With the National Suicide Prevention Lifeline, even though they did answer a range of crises, it was billed as the ‘National Suicide Prevention Lifeline.’ So a lot of people who are not feeling suicidal but were in distress didn’t feel like that was a resource for them,” Wesolowski said.

“I think awareness of 988 continues to grow each month,” she said. “This country is in a mental health crisis at large. I believe that many more people are feeling that they’re approaching a crisis situation or are in crisis.”

The 988 lifeline also has been testing a pilot program specifically for the LGBTQ+ community, in partnership with the Trevor Project, in which calls, texts or chats from LGBTQ+ youth have the option of being connected with counselors specially trained in LGBTQ-inclusive crisis care services.

The pilot program began around the end of September, and “there has been a lot of demand and a lot of utilization of that service,” Palmieri said. He added that LGBTQ+ youth are at a higher risk of suicide.

“With that pilot program, it is so important that particularly a young person who’s feeling alone, who’s feeling isolated, is able to connect to somebody that they feel can share their experience and that comes from a similar place of understanding,” Wesolowski said. “I’m very anxious to see what the data shows when the pilot ends in March, but I feel very encouraged by my conversations with the Trevor Project and others involved in this.”

Since its launch, the 988 lifeline also has increased the number of call centers taking Spanish calls from a total of three to seven. Spanish language options will increase for text and chat messaging as well, Palmieri said.

“We are also implementing video phone capabilities for people who are deaf and hard of hearing,” he said.”In addition to that, in Washington state, there’s a pilot currently providing specialized care access for individuals who are American Indian/Alaskan Natives to be able to be connected to an organization that’s focused more specifically on their needs.”

HHS announced in December that through SAMHSA, more than $130 million has been awarded in grants to support the 988 Suicide and Crisis Lifeline. The funding comes from the Bipartisan Safer Communities Act. The federal spending omnibus bill includes about $500 million for the 988 Suicide & Crisis Lifeline, according to SAMHSA.

In total, the Biden administration has invested nearly $1 billion in the 988 lifeline.

“Our country is facing unprecedented mental health and substance use crises among people of all ages and backgrounds,” HHS Secretary Xavier Becerra said in the announcement last month.

“Although rates of depression and anxiety were rising before the pandemic, the grief, trauma, and physical and social isolation that many people experienced during the pandemic exacerbated these issues. Drug overdose deaths have also reached a historic high, devastating individuals, families, and communities,” he said. “The significant additional funding provided by the Bipartisan Safer Communities Act will have a direct positive impact on strengthening the behavioral health of individuals and communities across the country.”

The 988 lifeline is just one tool in the ongoing effort to improve our nation’s mental health, which Lori Tremmel Freeman, chief executive officer of the National Association of County and City Health Officials, calls “a key concern of public health” right now.

“It is also one of the root causes of substance abuse and misuse, which is fueling the national epidemic that we have. We’re also concerned about, of course, rates of suicide and what we can do to alleviate and lower those rates,” Freeman said.

“This is very much also a primary public health crisis of concern and leads to many other public health issues that need to be addressed: homelessness, food insecurity, substance misuse, and poor health outcomes,” she said. “We need to get people healthy and well, and connected to the right resources and professionals that can help them overcome their mental health crises.”

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Decreasing rates of childhood immunization are a major concern. Our medical analyst explains why | CNN

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CNN
—

Vaccine rates for measles, polio, diphtheria and other diseases are decreasing among US children, according to a new study from the US Centers for Disease Control and Prevention.

The rate of immunizations for required vaccines among kindergarten students declined from 95% to approximately 94% during the 2020-21 school year. It dropped further — to 93% — in the 2021-22 school year.

That’s still a high number, so why is this drop in immunization significant? What accounts for the decline? What might be the consequences if these numbers drop further? If parents are unsure about vaccinating their kids, what should they do? And what can be done on a policy level to increase immunization numbers?

To help us with these questions, I spoke with CNN Medical Analyst Dr. Leana Wen, an emergency physician, public health expert and professor of health policy and management at the George Washington University Milken Institute School of Public Health. She is also author of “Lifelines: A Doctor’s Journey in the Fight for Public Health.”

CNN: Why is it a problem that childhood immunization rates are declining?

Dr. Leana Wen: The reduction of vaccine-preventable diseases is one of the greatest public health success stories in the last 100 years.

The polio vaccine was introduced in the United States in 1955, for example. In the four years prior, there were an average of over 16,000 cases of paralytic polio and nearly 2,000 deaths from polio each year across the US. Widespread use of the polio vaccine had led to the eradication of polio in the country by 1979, according to the CDC, sparing thousands of deaths and lifelong disability among children each year.

The measles vaccine was licensed in the US in 1963. In the four years before that, there were an average of over 500,000 cases and over 430 measles-associated deaths each year. By 1998, there were just 89 cases recorded — and no measles-associated deaths.

These vaccines are very safe and extremely effective. The polio vaccine, for example, is over 99% effective at preventing paralytic polio. The measles vaccine is 97% effective at preventing infection.

We can do this same analysis for other diseases for which there are routine childhood immunizations.

It’s very concerning that rates of immunization are declining for vaccines that have long been used to prevent disease and reduce death. That means more children are at risk for severe illness — illness that could be averted if they were immunized. Moreover, if the proportion of unvaccinated individuals increases in a community, this also puts others at risk. That includes babies too young to be vaccinated or people for whom the vaccines don’t protect as well — for example, patients on chemotherapy for cancer.

CNN: What accounts for the decline in vaccination numbers?

Wen: There are probably many factors. First, there has been substantial disruption to the US health care system during the Covid-19 pandemic. Many children missed routine visits to the pediatrician during which they would have received vaccines due to pandemic restrictions. In addition, some community health services offered also became disrupted as local health departments focused on Covid-19 services.

Second, disruption to schooling has also played a role. Vaccination requirements are often checked prior to the start of the school year. When schools stopped in-person instruction, that led to some families falling behind on their immunizations.

Third, misinformation and disinformation around Covid-19 vaccines may have seeded doubt in other vaccines. Vaccine hesitancy and misinformation were already major public health concerns before the coronavirus emerged, but the pandemic has exacerbated the issues.

According to a December survey published by the Kaiser Family Foundation, more than one in three American parents said vaccinating children against measles, mumps, and rubella shouldn’t be a requirement for them to attend public schools, even if that may create health risks for others. This was a substantial increase from 2019, when a similar poll from the Pew Research Center found only 23% of parents opposed school vaccine requirements.

CNN: What are some consequences if immunization rates drop further?

Wen: If immunization rates drop further, we could see more widespread outbreaks. Diseases that were virtually eliminated in the US could reemerge, and more people can become severely ill and suffer lasting consequences or even die.

We are already seeing some consequences: Last summer, there was a confirmed case of paralytic polio in an unvaccinated adult in New York. It’s devastating that a disease like polio has been identified again in the US, since we have an extremely effective vaccine to prevent it.

There is an active measles outbreak in Ohio. As of January 17, 85 cases have been reported. Most of the cases involved unvaccinated children, and at least 34 have been hospitalized.

CNN: If parents are unsure of vaccinating their kids, what should they do?

Wen: As parents, we generally trust pediatricians with our children’s health. We consult pediatricians if our kids are diagnosed with asthma and diabetes, or if they have new worrisome symptoms of another illness. We should also consult our pediatricians about childhood immunizations; parents and caregivers with specific questions or concerns should address them.

The national association of pediatricians, the American Academy of Pediatrics, “strongly recommends on-time routine immunization of all children and adolescents according to the Recommended Immunization Schedules for Children and Adolescents.”

CNN: What can be done to increase immunization numbers?

Wen: There needs to be a concerted educational campaign to address why vaccination against measles, mumps, rubella, chickenpox, polio and so forth is so crucial. One of the reasons for vaccine hesitancy, in my experience, is that these diseases have been rarely seen in recent years. Many people who are parents now didn’t experience the devastation of these diseases growing up, so may not realize how terrible it would be for them to return.

Specific interventions should be targeted at the community level. In some places, low immunization levels may be due to access. Vaccination drives at schools, parks, shopping centers, and other places where families gather can help increase numbers. In other places, the low uptake may be because of vaccine hesitancy and misinformation. There will need to be different strategies implemented in that situation.

Overall, increasing immunization rates for vaccine-preventable childhood diseases needs to be a national imperative. I can’t underscore how tragic it would be for kids to suffer the harms of diseases that could be entirely prevented with safe, effective and readily available vaccines that have been routinely given for decades.

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Study shows convalescent plasma works for immune-compromised Covid-19 patients, but it can be hard to find | CNN

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CNN
—

Convalescent plasma – a once-celebrated treatment for Covid-19 that has largely fallen out of favor – does work well for people who are immune-compromised, according to a study published Thursday.

The report in the journal JAMA Network Open analyzed the results of nine studies and found that immune-compromised Covid-19 patients were 37% less likely to die if they got convalescent plasma, an antibody-rich blood product from people who’d recovered from the virus.

Although it’s legal to use convalescent plasma to treat Covid patients who are immune-compromised, as inpatients or outpatients, government guidelines are neutral about whether the treatment works, so some hospitals offer it but others do not.

“Our concern is that many patients who need [convalescent plasma] are not getting it,” said Dr. Arturo Casadevall, an infectious disease expert at Johns Hopkins University and a co-author of the new study. “This is really important because these people can be treated, and they could have better outcomes with this material if we can just get the word out.”

He said it’s to everyone’s advantage to treat immune-compromised patients quickly.

Immune-compromised people sometimes have “smoldering Covid” for months because they lack the antibodies to fight it off, which gives the virus plenty of opportunities to mutate in the person’s body.

“These immune-compromised patients are essentially variant factories,” said Dr. Michael Joyner, an anesthesiologist at the Mayo Clinic and another study co-author. “And you do not want a bunch of people running around out there making weird variants.”

There are about 7 million immune-compromised people in the US, and treating them if they contract Covid-19 has proved challenging.

Many of them can’t take the antiviral drug Paxlovid because it interferes with other medicines they take.

Monoclonal antibodies, once popular for prevention and treatment for this group, aren’t used anymore because coronavirus variants have changed over time. One of the advantages of convalescent plasma is that as long as it’s been donated recently, there’s a high likelihood it will have antibodies to currently circulating variants, according to advocates for the treatment.

But the National Institutes of Health’s Covid-19 treatment guidelines say there’s not enough evidence to recommend either for or against the use of convalescent plasma in people with compromised immune systems.

Three times last year – in May, August and December – Casadevall, Joyner and dozens of other doctors from Harvard, Stanford, Mayo, Columbia and other academic medical centers wrote emails to scientists at the National Institutes of Health, sending them research materials and urging them to revise the guidelines. They say they have not received a response.

Joyner said he’s “frustrated” with the NIH’s “bureaucratic rope-a-dope,” calling the agency’s guidelines a “wet blanket” that discourages doctors from trying convalescent plasma on these people.

Some patient advocates say they’re angry.

“This lack of response to the researchers is infuriating,” said Janet Handal, co-founder of the Transplant Recipient and Immunocompromised Patient Advocacy Group.

Several large randomized clinical trials on the general population, including one in India and one in the UK, have found that convalescent plasma did not reduce Covid-19 deaths or prevent severe illness, and the treatment is no longer authorized in the US for people who have healthy immune systems.

The nine studies analyzed in the new report are much smaller and looked only at immune-compromised patients.

Dr. Peter Horby, a professor at the University of Oxford and the co-principal investigator of the large UK study, said that a large randomized clinical trial should be done on immune-compromised patients before clinical practice guidelines for this group are changed.

He said that support for convalescent plasma to treat Covid-19 has been based on “an emotional feeling that something had to be done.”

“We’ve seen time and again that people’s beliefs and emotions about what works can be wildly wrong, and so the best thing to do is to evaluate these things properly in trials,” he said.

At the beginning of the pandemic, there was great enthusiasm for convalescent plasma as Covid-19 survivors sought to save lives, donating antibodies against the virus to people who were sometimes at death’s door.

In August 2020, the US Food and Drug Administration granted emergency use authorization for the treatment, but some questioned whether it was politically motivated and whether the data really showed that it worked.

Then, the large clinical trials suggested convalescent plasma didn’t work.

“We didn’t see a benefit,” said Horby, director of Oxford’s Pandemic Sciences Institute.

But there was one exception.

Horby said his study did find “some evidence of some benefit” in Covid-19 patients who had not developed antibodies against the virus. This would most likely include immune-compromised patients because their faulty immune systems don’t always generate antibodies the way they should, even after infection.

When this group of patients received convalescent plasma, Horby said, they had a slightly shortened hospital stay and a slightly lower risk of ending up on a ventilator compared with similar patients who did not receive convalescent plasma.

Joyner and Casadevall, the Mayo and Hopkins doctors, point to that finding – and a similar one in a large trial in Australia, Canada, the UK and the US, as well as results of smaller studies – as an indication that convalescent plasma is worth trying in immune-compromised patients.

Immune-compromised patients who catch Covid-19 can get convalescent plasma relatively easily if they’re patients at Hopkins, Mayo or several other medical centers.

But many other people might have a difficult time accessing it.

It took Bernadette Kay of Manhattan Beach, California, months to get it, and she had to be “relentless” and call in the help of several “angels” in New York, Maryland, Minnesota and California to finally make it work.

Kay, 64, who has a compromised immune system because of a drug she takes for rheumatoid arthritis, got Covid-19 in July. She took two monoclonal antibodies, as well as remdesivir and Paxlovid – twice. But she still tested positive on and off for months and had fatigue, congestion and headaches.

“I felt like half a person,” she said. “I was not an able-bodied person. I was disabled because of lack of energy. It feels dark – a heavy feeling in your forehead and your face.”

Kay said she saw several doctors and none of them suggested convalescent plasma. That’s where her first angel came in: her daughter, who had signed her up for the Transplant Recipient and Immunocompromised Patient Advocacy Group.

That group, as well as the CLL Society, an advocacy organization for cancer patients, have been helping immune-compromised people when they get infected with Covid-19, connecting them with experts and offering guidance on how to arrange to have the plasma ordered.

Kay says Handal, the co-founder of the immune-compromised patients’ group, was her second angel, because she pointed her to angels No. 3 and 4: Joyner, the Mayo doctor, and Dr. Shmuel Shoham, an infectious disease expert at Hopkins.

Joyner and Shoham pointed Kay to her fifth angel: Chaim Lebovits, a businessman, leader in the New York’s Hasidic Jewish community and co-founder of the Covid Plasma Initiative.

Lebovits reached out to a hospital and blood bank near Kay that could procure the plasma once a doctor ordered it. Kay then reached out to six local doctors, most of them infectious disease experts, inquiring about convalescent plasma, but she didn’t make any progress.

“I think they thought it was quack medicine,” she said.

By this time, it was November, four months after she initially tested positive for Covid. She sought out a seventh doctor, sending him information from plasma experts, including a slide presentation by Joyner and Casdevall. She said that doctor, after conferring with someone at the blood bank that Libovits had suggested, agreed to order the plasma.

That’s where her sixth angel came in: Robert Simpson, vice president for hospital services at the San Diego Blood Bank, who arranged to have the blood flown in from Stanford University Medical Center.

“Robert watched the flight on Flight Tracker and had a courier waiting to bring it to the hospital,” Kay said, adding that she calls her angels collectively her “circle of love.”

Two to three weeks after her infusion, she began to feel better. She tested negative on January 4 and has continued to feel well and test negative since then.

“My energy level is back to normal. I don’t feel like half a person,” she said.

She said she’ll never know for sure exactly what spurred her recovery, but “I think it was plasma that made the difference, because in six months, nothing else made a difference.”

Kay, who works in health care, said most other people wouldn’t have known how to navigate the system like she did or might have given up in frustration.

“With the help of Janet [Handal] and her team of scientists, I’ve been able to get where I am today,” she said. “But it was not easy. This was driven by my bullheaded advocacy, because that’s who I am. I think I’m a total anomaly. No one has the persistence that I have.”

Joyner said that while he and his colleagues wait for a response from their emails to the NIH, they’ve formed the National Covid-19 Convalescent Plasma Project, and they have a phone meeting every Thursday night to discuss their progress.

“We’ve encountered many roadblocks,” said Dr. Liise-anne Pirofski, chief of the Division of Infectious Diseases at the Albert Einstein College of Medicine. “It’s just not viewed as part of the Covid-19 treatment armamentarium, and it should be.”

Pirofski, Joyner and Casadevall say they receive no financial benefit from convalescent plasma. They think one reason convalescent plasma isn’t more widely used is that there isn’t a pharmaceutical company spending money to advocate for it.

Handal, who runs the Facebook group for people who are immune-compromised, said that after she sent several emails to the NIH, agency scientists wrote back, inviting her and other leaders of her group to a meeting next week.

She plans to tell them that they need to review their Covid-19 plasma guidelines and fund more research on the coronavirus and the immune-compromised, as they have few treatment options and so often isolate at home with their families to avoid the virus.

“It is unconscionable that the NIH has let stand for months its guideline on Covid convalescent plasma, which says there is not enough information to make a recommendation, while we who are immune-compromised see our treatments dwindle,” she said. “The NIH needs to speak to the clinician researchers who are experts, prioritize the immune-compromised and fund the research needed to keep us safe.”

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Pandemic fueled alcohol abuse, especially among women, but there are treatment options | CNN

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Editor’s Note: In the final two episodes of “This Is Life With Lisa Ling,” the series explores alcoholism in America (at 9 p.m. ET Sunday) and interracial marriages (at 10 p.m. ET Sunday).

CNN
—

Brook was 34 years old when her use of alcohol escalated, a way of coping with a breast cancer diagnosis.

“I just decided I’m not gonna go through this straight,” she told Lisa Lang in an episode of “This Is Life With Lisa Ling,” airing at 9 p.m. ET Sunday on CNN.

“I would drink before I went to my chemo sessions. It became more and more of a coping mechanism,” said Brook, who did not want to use her last name.

Brook survived the bout with cancer but says she became dependent on alcohol — and the pandemic only made it worse.

“When Covid started and I was home, I started drinking more and more and more,” said Brook, now 42. “I started not being able to eat, I started throwing up more often, and then I started throwing up blood.”

She recently ended up in the hospital, diagnosed with cirrhosis of the liver and a bad bleed from ulcers, which doctors said could take her life if not quickly treated.

“When they were talking to me afterwards, they said, ‘If you keep going like this, you’ll be dead in a year,’ ” Brook told Ling.

Alcohol use disorder is defined as compulsively using alcohol despite negative consequences on relationships and one’s ability to function at work, school or in the community. Over time, excessive alcohol use may even rewire the brain, making booze as desirable as natural rewards such as food or sex, experts say.

Researchers at University of California, Los Angeles showed pictures of alcoholic drinks to people who are and are not addicted while scanning their brains. Regions of the brain associated with craving, pleasure and reward lit up significantly more in those with an alcohol use disorder.

“It’s much more of a medical and brain disease than we initially thought,” Lara Ray, a clinical psychologist who runs the UCLA Addictions Lab, told Ling.

In addition, just one pint of beer or average glass of wine a day may begin to shrink the overall volume of the brain. The brains of nondrinkers who began consuming an average of one alcohol unit a day showed the equivalent of half a year of aging, according to a study published in March.

The damage worsens as the number of daily drinks rises, the study found — drinking four alcohol units a day aged a person’s brain by more than 10 years.

Alcohol use disorder is a growing problem in the United States, which experts say has been enhanced by the pandemic, especially among women.

“Last year, I took care of two women who were in their early 20s who had cirrhosis and needed liver transplants, and I’ve never seen that before in my entire career,” Dr. James Burton, medical director of liver transplantation at the University of Colorado School of Medicine in Aurora, told Ling.

A recent study found a significant increase in alcohol-associated liver disease and a 15% higher rate of waiting lists and subsequent liver transplants between 2020 and 2021 — the greatest increase occurred in young adults.

Since the pandemic’s onset, statistics show an overall 14% increase in the number of drinking days per month, but a “41% increase in heavy drinking days among women,” Dr. Sarah Wakeman, medical director of the Substance Use Disorders Initiative at Massachusetts General Hospital, told CNN in January.

Why? Pre-pandemic mom wine culture, which “normalized and even glorified” drinking, is partly to blame, said Dr. Leena Mittal, chief of the women’s mental health division in the department of psychiatry at Brigham and Women’s Hospital in Boston.

In addition, “studies have shown the complexities of balancing home, work and caregiving responsibilities during the pandemic have fallen disproportionately on women,” Mittal said earlier.

Women are especially sensitive to the effects of alcohol, according to the National Institute on Alcohol Abuse and Alcoholism. Alcohol-related problems appear sooner and at lower drinking levels than in men, said the institute, part of the US National Institutes of Health.

Women are more susceptible to alcohol-related brain damage and heart disease than men, and studies show women who have one drink a day increase their risk of breast cancer by 5% to 9% compared with those who abstain.

Pandemic lockdowns also forced many people to live and work from home — sometimes alone. A July study found drinking alone during adolescence and young adulthood can strongly increase the risk for alcohol abuse later in life, especially if you are a woman.

Victoria, who also did not want to use her last name, told Ling she began drinking as a teenager. Now 55, she still “can’t control it. It’s like a tension that builds up. And so then when I do drink, it’s like, ‘Ah! I’m drinking,’ you know, so it’s way too much, way too fast.”

Victoria says she continues to crave alcohol but goes regularly to support meetings for addiction recovery after moving in with her mother during the pandemic.

Binge drinking — defined as more than four drinks for women and five for men within a few hours — is on the rise. According to a study published in June, even older people who consider themselves moderate users of alcohol are downing multiple drinks in one sitting.

People who binged were about five times more likely to experience numerous alcohol problems, including injuries, emotional or psychological issues, and alcohol dependence at work or school or while caring for children, the study found.

“What this means is that an individual whose total consumption is seven drinks on Saturday night presents a greater risk profile than someone whose total consumption is a daily drink with dinner, even though their average drinking level is the same,” study coauthor Charles Holahan, professor of psychology at the University of Texas at Austin, told CNN previously.

The US Food and Drug Administration has approved only three drugs designed to reduce alcohol use since 1951: disulfiram, which causes headaches, nausea and vomiting when mixed with alcohol; acamprosate, which works on the reward centers of the brain to reduce alcohol cravings; and naltrexone, which reduces cravings and appears to help with heavy drinking.

There is help. Find it here

The National Institute on Alcohol Abuse and Alcoholism has a tool called the NIAA Alcohol Treatment Navigator that “helps adults find alcohol treatment for themselves or an adult loved one.” For teens, the institute recommends these resources.

The Substance Abuse and Mental Health Services Administration has a free, confidential National Helpline active 24/7/ 365 days a year to provide information and treatment referrals to local treatment facilities, support groups and community-based organizations: 800-662-HELP (4357) and 800-487-4889 (TTY option).

All three have significant side effects that can deter people from using them consistently.

Researchers continue to experiment with various drugs to see if they can help cure cravings without major side effects. While not FDA-approved, the anticonvulsant drug topiramate has shown promise in some clinical trials but may affect cognition and memory. Other anticonvulsant drugs, such as zonisamide and gabapentin, and a smoking cessation drug called varenicline have shown mixed results.

At Ray’s lab at UCLA, small clinical trials have found promising results from the neuromodulator ibudilast, which hindered cravings and reduced the odds of heavy drinking for some people by 45%.

For Billy Flores, 45, the change happened quickly.

“In the first two days, I was upset in the stomach, but by the third day I was on it, I was off of alcohol, which is pretty amazing I thought,” he told Ling about using ibudilast.

Bill has struggled with alcohol but says he has found hope with a clinical trial.

Additional studies are needed to see if the benefits hold true for larger populations.

In the meantime, there are gold standard treatments for alcohol use disorder that don’t involve medications. Those include Alcoholics Anonymous and Self-Management and Recovery Training 12-step programs, cognitive behavioral treatments and mindfulness-based approaches.

A large 2006 clinical trial found behavioral interventions can be as effective as drugs — in fact, most of the medication clinical trials done to date have also included some form of social or behavioral treatment in combination with drugs.

Having support is critical to keeping a positive mindset that will ultimately win the battle with alcohol, experts say.

Brook agrees.

“When I was doing my therapy intake for rehab, one of the questions was, ‘What made you decide to do this?’ And I said, ‘I’m better than this,’ ” she told Ling.

“I still like to think that even with the relapses, I’m gonna still be that person who gets right back up and tries again.”

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Pandemic fueled alcohol abuse, especially among women, but there are treatment options | CNN

There is help. Find it here