WHO | Recommended composition of influenza virus vaccines for use in the 2019 southern hemisphere influenza season

27 September 2018

It is recommended that egg based quadrivalent vaccines for use in the 2019 southern hemisphere influenza season contain the following:

  • an A/Michigan/45/2015 (H1N1)pdm09-like virus;
  • an A/Switzerland/8060/2017 (H3N2)-like virus;
  • a B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage); and
  • a B/Phuket/3073/2013-like virus (B/Yamagata/16/88 lineage).

It is recommended that egg based trivalent vaccines for use in the 2019 southern hemisphere influenza season contain the following:

  • an A/Michigan/45/2015 (H1N1)pdm09-like virus;
  • an A/Switzerland/8060/2017 (H3N2)-like virus; and
  • a B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage).

It is recommended that the A(H3N2) component of non-egg based vaccines for use in the 2019 southern hemisphere influenza season be an A/Singapore/INFIMH-16-0019/2016-like virus together with the other vaccine components as indicated above.

Source: WHO | Recommended composition of influenza virus vaccines for use in the 2019 southern hemisphere influenza season

Flu View Phase 6

Source: Flu View Phase 6

CDC Interactive Map – Weekly Influenza

A Weekly Influenza Surveillance Report Prepared by the Influenza Division

Source: FluView Phase 8

Anthem’s effort to punish patients for ‘unnecessary’ ER visits has been a bust — but still burdens patients 

In the last few years, Anthem Blue Cross has made a strong bid for the award for the most heartless and senseless coverage policy in the health insurance business.

Its competition entry is a policy that penalizes patients for seeking “unnecessary” treatment at an emergency room. If Anthem concludes that the reason for the visit wasn’t an emergency after all, it can deny the claim — saddling members with bills that could exceed $10,000.

Anthem’s rationale is that the ER is the costliest venue for medical treatment; therefore, weeding out patients whose medical complaints could more appropriately be managed through a doctor’s appointment or a visit to an urgent-care clinic will save money for Anthem and for its customers base. Anthem launched this program in Kentucky in 2015 and expanded it in 2017 and this year to Indiana, Georgia, Missouri and Ohio. (The company dropped plans to expand it this year into New Hampshire.)

Now, after several years’ experience in some of those states, a few conclusions can be drawn about it. First, the program as a whole appears to be a bust. According to statistics the company provided to Sen. Claire McCaskill, D-Mo., the vast majority of claims denials under the program have been reversed on appeal. The number of initial denials has fallen this year, too, after Anthem changed the rules to broaden the exemptions — that is, cases in which the ER claim would always be approved, no questions asked.

Perhaps most important, expecting consumers to diagnose their conditions as emergent or non-emergent before going to the ER is stupid and possibly illegal, insofar as it requires them to make judgments that ER doctors often can’t make without a professional examination. Using the ultimate diagnosis as a proxy for the urgency of the original visit to the ER is an imperfect standard to the point of being nonsensical, in medical terms.

“I’m a board-certified trained doctor of emergency medicine,” Jonathan Heidt, president of the Missouri chapter of the American College of Emergency Physicians, told me in January, “and I have trouble looking at the ER note and knowing what the patient was thinking at 3 o’clock in the morning.”

But the likelihood is that Anthem doesn’t actually want to deny members’ ER claims — what it really wants is for them not to go to the ER at all. Anthem’s policy is really just another hoop for consumers to jump through, which always translates into less usage. The drawback is that these obstacles result in less unnecessary medical care, but less necessary care too. More on that in a bit.

The statistics on claims denials and reversals come from a report McCaskill issued this summer, using Anthem data (even though the company stiff-armed her on some of her data requests). The conclusions about the wisdom of the policy come from an analysis by researchers at Yale and Harvard medical schools recently published by the Journal of the American Medical Assn. The researchers concluded that anthem’s system is so flawed it “could place many patients who reasonably seek ED (emergency department) care at risk of coverage denial.”

Anthem, the nation’s second biggest health insurer, says it’s standing by its policy, though it has no current plans to expand it to more states. The company told me by email that its “Emergency Department Review” was designed to “reduce the trend in recent years of inappropriate use of EDs for non-emergencies.” It said it found that about 5 percent of all claims it received for ER care were for non-emergencies, “which is in line with findings from the Centers for Disease Control and Prevention.”

The important questions, however, are what counts as a “non-emergency,” who makes the call, and when?

Anthem’s system is based on the diagnostic codes submitted by the ER with its claim — in other words, what the ER doctors ultimately judged the patient’s problem to be. In Indiana Anthem used a roster of 120 codes ranging from “abrasion” to “viral wart” and including various contusions and pain complaints; in Missouri, according to ER doctors, the list ran to more than 1,900 conditions. If the conditions appeared on the ER claim, Anthem would subject the claim to further review, with an eye to rejecting it.

Under Anthem’s original rules, the denial policy wouldn’t apply when the patient is 14 or younger, an urgent care clinic isn’t located within 15 miles, or the visit occurs on a Sunday or holiday. This year the company added several exclusions. Claims will always be paid if the patient was directed to visit the ER by a doctor; is traveling out of state; received any surgery, IV medications, or an MRI or CT scan at the ER.

The basic problem remains, however: A final diagnosis by an ER doctor isn’t very useful in judging what motivated a patient to report to the ER in the first place. That’s what the Harvard/Yale study found.

Patients aren’t diagnosticians. They don’t make decisions on whether to go to the ER based on a diagnosis, but based on their symptoms. And 90 percent of the symptoms that typically send a patient to the ER are common to both nonemergency conditions and potentially life-threatening emergencies.

Back or abdominal pain could be a muscle spasm — or herald a kidney stone or appendicitis; the researchers found that in their study sample of emergency cases from 2011 to 2015, abdominal pain resulted in hospital admission 16 percent of the time — but could result in Anthem denials in 4.3 percent of cases. Chest pain could be indigestion or a heart attack. Headache, vomiting, dizziness, cough and shortness of breath also could go either way.

In Anthem’s system, the researchers warned, “patients with acute illnesses are put in a difficult position of weighing the risk of delayed treatment for severe disease vs an uncovered medical bill.”

Anthem told me that “if a consumer reasonably believes that he or she is experiencing an emergency medical condition, then they should always call 911 or go to the ED.” But that’s just empty persiflage, if the consequence of guessing wrong is a bill for several thousand bucks.

The stakes are considerable. The Harvard/Yale study calculated that if Anthem’s policy were widely copied, nearly 1 in 6 ER visits by insured adults would result in a non-emergency diagnosis and be subject to denial.

McCaskill’s report traced the life cycle of Anthem ER claims denials and appeals in Kentucky, Georgia and her home state of Missouri. Her findings are eye-opening.

In July through December of last year, 5 percent of ER claims — 3,700 — were denied in Missouri, 4 percent (5,000) in Kentucky and 7 percent (3,500) in Georgia. Another 5 percent were initially denied but paid after appeals in Missouri, 7 percent in Kentucky and 13 percent in Georgia.

In fact, most denials were eventually overturned — and the rate of reversals rose almost every month into this year. In Missouri, the rate of reversals increased from 58 percent in July 2017 to 73 percent in November, a trend largely matched in the other two states.

Since January, when Anthem changed its standards, ER denials have plummeted — to zero in all three states by March 2018, McCaskill reports.

That points to the question of why Anthem’s program still exists at all. To begin with, it may well violate federal law, which requires insurers to cover ER services if a patient arrives with symptoms that a “prudent layperson” — one with an average knowledge of health and medicine — could reasonably expect to result in “serious impairment to his or her health.” Anthem says its physician reviews are aimed at matching ER diagnoses with the prudent layperson standard, which may explain why denials have plunged.

Even in 2017, when the company was still denying a sizable percentage of ER claims, the results appear to have fallen short of its expectations. McCaskill says Anthem had projected that its program would save $2.9 million a year via denials of unnecessary ER visits in Missouri alone; but in the last six months of 2017, the denials yielded only $1 million in savings through unpaid claims — not counting the reversals after appeal.

The statistics suggest that Anthem’s initiative might even have cost the company more than it saved. Thousands of ER claims had to be scrutinized by professionals before denials, examined again if they were appealed, and ultimately paid if the denials were reversed.

Some of these costs land on the shoulders of patients. Anthem customers face the tension of how to pay five-figure bills for ER visits they thought would be covered for a nominal co-pay, and weeks or months of lost work time or other inconveniences trying to challenge the decision. Emergency Departments face the uncertainty of getting reimbursed for their services.

Still, the gains Anthem may have garnered from its policy may not be obvious. If it succeeded in discouraging patients from presenting at the ER in the first place out of fear of a big bill, that wouldn’t show up in denial and appeal statistics. Anthem couldn’t be tagged for infringing the prudent layperson rule, because the decision to skip the ER would be made by its imprudent customers on their own, for their own reasons.

Perhaps it’s a bit unfair to criticize Anthem for trying to shift the costs of ER coverage to patients. After all, trying to avoid paying out on claims is what comes naturally to insurance companies. That’s what allowed Anthem to record a profit of $3.8 billion last year on revenue of $90 billion, and to pay its recently-retired chairman and CEO, Joe Swedish, nearly $50 million in 2015-2017.

Indulgent state regulators in five states have allowed Anthem to get away with this flagrantly anti-consumer practice. The blame belongs to them.

Source: Anthem’s effort to punish patients for ‘unnecessary’ ER visits has been a bust — but still burdens patients | Consumer & Retail | pilotonline.com

Antibodies in Llama Blood Might Eliminate the Need for Yearly Flu Shots | Mental Floss

Getting your yearly flu shot is an important way to protect yourself against the latest strains of the virus. But the annual practice can also be annoying, as evidenced by the more than half of all Americans who skip it. Now, BBC reports that scientists may have discovered the key to a perennial preventative flu treatment hiding in an unlikely source: llama blood.

According to a new paper published in the journal Science, the tiny antibodies produced by llamas are better equipped to fight the influenza virus than the larger ones found in humans. When the flu virus enters your body, specialized white blood cells called B lymphocytes make antibodies to attack it; they glob onto proteins on the outside of the virus, marking it so the immune system knows what to eradicate. But this only works if the shape of the antibody fits the proteins on the outside of the virus. If the exterior of the flu virus has mutated since your last flu shot, your body may not be able to recognize and stop it.

Llama antibodies work a bit differently. They’re much smaller than humans’, which means they can reach the core of an influenza virus—a.k.a. the part that looks the same from strain to strain. If scientists can make a human antibody that functions the same way, they will essentially develop a one-size-fits-all treatment that could continue to be effective as years progress.

For their study, researchers from the Scripps Institute in California made a synthetic antibody that borrowed elements from some of the strongest flu antibodies produced in llama blood. After wrapping the antibodies’ genetic information in a harmless virus and infecting flu-sickened mice with it, the flu virus was stopped in almost every case. Only one of the 60 flu strains that were tested persisted, and it was one that doesn’t infect humans.

This flu “vaccine” isn’t really a vaccine at all—it’s more like gene therapy. Unlike current flu shots, it doesn’t have to train the body’s immune system to be effective, which would make it an especially appealing option for people with weakened immune systems like elderly patients. But human trials still need to be completed before the promise of a stronger, longer-lasting flu treatment becomes a possibility.

Source: Antibodies in Llama Blood Might Eliminate the Need for Yearly Flu Shots | Mental Floss

Medicine: My Sacrifice (A Letter to my Family) — Jessica K. Willett, MD

https://jessicakwillettmd.com/rabble-rabble/2017/3/26/7mkf3gvhl665ni3k294kako7g1742t

CNBC: Here are some reasons why people don’t get the flu shot — and why they’re wrong

CNBC: Here are some reasons why people don’t get the flu shot — and why they’re wrong.
https://www.cnbc.com/2018/11/02/heres-why-people-dont-get-a-flu-shot-and-why-you-should.html

Doctors urge residents to receive flu shot -Cleburne, TX

Last year’s flu season was one of the worst in more than a decade, resulting in a “high-severity” classification that saw 172 reported child deaths and 19 consecutive weeks of record-breaking flu hospitalizations nationwide.

To avoid another hard-hitting season, local healthcare professionals are encouraging people to get flu shots.

“On the heels of what happened last year — knowing it was the most deadliest flu season and a low-vaccination year — it should have been a reminder to people to get their flu shot,” Texas Health Emergency Medicine Physician Glenn Hardesty said. “It sort of just falls off peoples radar.”

Flu season generally starts as early as October and can run through May.

“It is never too late for the flu shot,” Hardesty said. “Usually two to three days after exposure to the flu you will begin to have profound body aches. You will have a cough and cold to go along with this and run fevers. The flu will put you down and you are not functional.”

Bob Moos, public affairs officer for the U.S. Centers for Medicare and Medicaid Services, said last year’s heavy toll underscores the importance of getting a flu vaccine as soon as possible.

“The hospitalizations and deaths were mainly among people 65 and older,” Moos said. “As people age, their immune system typically weakens and their ability to ward off diseases declines. Moreover, the flu virus can cause complications for those already struggling with chronic health problems.

“If you’re enrolled in Medicare Part B, your flu shot won’t cost you anything, as long as your doctor, health clinic or pharmacy agrees not to charge you more than Medicare pays. There’s no deductible or co-payment.”

Hardesty said in addition to getting the flu shot, there are things people can do to stop the spread of the virus.

“Avoid contact with those who are ill,” he said. “Wash your hands. If you have the flu, minimize contact with others. Don’t go to work or school while you have symptoms. You are contagious while you are still exhibiting symptoms.”

Other measures to reduce the chances of spreading the virus include:

• Wipe down frequently touched surfaces such as doorknobs, tables, elevator buttons and faucets. Simple alcohol-based cleaning products are effective to inactivate flu.

• Coughing and sneezing into your shirt rather than your elbow or hand is a good way to keep droplets and aerosols from traveling through the air and depositing on surfaces.

• Increasing air circulation in the room can dilute flu viruses in the air and limit their spread. This can be achieved by increasing the exchange rate of building ventilation systems, turning on ceiling or portable fans, and, if possible, opening windows.

• Air purifiers designed to remove particles should be effective at removing viruses from air too, although this has not been tested directly. A purifier with a HEPA filter and a high flow rate will remove the most particles.

• Surgical masks are particularly useful if worn by sick individuals. This intervention will help keep an infected person from spreading viruses around, as they come out even when you’re just exhaling. If you’re not sick but are around people who have the flu, wearing a surgical mask can help protect you from getting infected as long as it’s tight-fitting.

Source: Doctors urge residents to receive flu shot | Local News | cleburnetimesreview.com

An earlier flu season is expected this year | 13 WTHR Indianapolis

https://www.wthr.com/article/earlier-flu-season-expected-year

The New York Times: A Sense of Alarm as Rural Hospitals Keep Closing

The New York Times: A Sense of Alarm as Rural Hospitals Keep Closing.
https://www.nytimes.com/2018/10/29/upshot/a-sense-of-alarm-as-rural-hospitals-keep-closing.html

Quartz: Opioid addiction may be the key to America’s inflation risk

Quartz: Opioid addiction may be the key to America’s inflation risk.
https://qz.com/1437456/opioids-could-be-key-to-understanding-americas-inflation-risk/

New initiative is reducing the amount of prescription drugs in circulation

http://mynorthwest.com/1162003/initiative-reducing-opioids-circulation/

At HCMC, doctors pursue new way to treat opioid addiction – StarTribune.com

Tonya Rainey, left, hugged physician assistant Kitty Earl-Torniainen after a discussion about fighting her heroin addiction.

Tonya Rainey estimates that she has cycled through hospital emergency rooms more than 50 times since she became addicted to opioids seven years ago.

Typically, Rainey, 45, who is homeless, has been given a small dose of medicine to ease her painful withdrawal symptoms and then sent back to the streets with a few numbers to call for chemical dependency treatment. Within hours, she is back to injecting heroin up to six times a day, which she says nearly took her life.

But when Rainey arrived at Hennepin County Medical Center early this month, vomiting and shaking from going two days without heroin, she had a drastically different experience: Addiction treatment specialists arrived at Rainey’s bedside in the emergency room and spoke to her about a plan for recovery and getting off the streets. Rainey also was enrolled on the spot in HCMC’s methadone program, which helps in reducing cravings and can alleviate excruciating withdrawal symptoms.

“They used to treat me like a nobody,” Rainey said of her hospital care. “This was the first time that I felt like people really cared and believed me when I said that I’m ready to turn my life around.”

Hennepin Healthcare, one of the state’s largest hospital systems, is among a small but growing number of institutions nationwide that have begun initiating treatment for opioid addiction in the emergency room, where patients often have “hit bottom” and are more receptive to treatment. Clinicians are trying to fill a longstanding gap in the health care system and stem a rising tide of admissions to hospitals by people suffering from opioid addictions. Statewide, hospitalizations for substance abuse have soared 40 percent between 2010 and 2017, reaching nearly 10,000 admissions last year.

“One of the problems with addiction treatment is that it’s generally been put on the patient to take care of on their own. We wouldn’t tell someone with cancer or heart disease to go make an appointment and hope they get better,” said Dr. James Miner, chief of emergency medicine at HCMC. “The goal now is to get people started on treatment and on the road to recovery right away.”

Traditionally, doctors in busy urban emergency rooms like the one at HCMC have focused on stabilizing patients with urgent medical concerns and referring them elsewhere for follow-up care.

But as the opioid epidemic has deepened, hospitals have become overwhelmed with addicted patients. At HCMC, doctors in the ER are responding to four to five opioid overdoses a day involving people who would die if they did not receive emergency medical care, officials said.

HCMC officials estimate that, on any given day, as many as a third of the hospital’s 484 beds are occupied by people with substance-use problems. In the past, such patients could cycle through the emergency rooms without ever being seen by professionals who specialize in substance abuse or assessed for treatment programs in the community.

To break this cycle, HCMC in May became the first hospital in the state to embed licensed drug and alcohol counselors in its emergency room to evaluate people for treatment and to connect patients with substance-use problems to community providers.

And for the first time, emergency room physicians at HCMC have begun prescribing patients with several days’ worth of a medication known as Suboxone that can ease withdrawal symptoms and suppress cravings. The medication acts as a bridge, helping patients to manage their symptoms until they are seen in an addiction treatment clinic for ongoing care.

HCMC physicians said they hope such efforts will reduce the number of people who suffer relapses after being discharged from the hospital. The Star Tribune in August reported dangerous delays in getting opioid-addiction medications into the hands of patients struggling with addiction.

Doctors across the state said patients would sometimes relapse because they could not access such drugs promptly and would go back to using heroin or prescription painkillers as a way to cope with painful withdrawal symptoms.

In some cases, physicians say, patients die waiting for treatment. The state recorded 401 opioid-related deaths in 2017, a sixfold increase since 2000. Some 40 percent of those deaths, or 162 fatalities, occurred in Hennepin County, records show.

“This has the very real potential to save lives,” said Kitty Earl-Torniainen, a physician assistant and specialist in addiction medicine at HCMC. “It allows for really vulnerable people to get help right away before the window of opportunity shuts.”

The new consultation service could also result in significant cost savings by reducing ER admissions, hospital administrators said. According to HCMC, one year of treatment through the hospital’s methadone program costs less than $5,500, while a single day in the hospital or a visit to the ER can cost more than $1,500.

“We need to be able to jump on that motivation for change immediately,” said Emily Bastian, director of housing and case management at Avivo, a drug recovery center near downtown Minneapolis. “Hospitals routinely discharge patients who are still suffering from withdrawal, and the first thing that patients do is run out and get a chemical to relieve their pain.”

For Rainey, the descent into addiction began seven years ago, when she was diagnosed with rheumatoid arthritis and was prescribed heavy doses of prescription painkillers for the often-crippling pain. Eventually, a friend taught her to shoot up heroin because it was cheaper than taking painkillers and the pain relief was more immediate, she said. Before long, Rainey said she was buying up to four $50 bags of heroin each day. The mother of eight children lost her home, became alienated from her family and began sleeping in public parks in south Minneapolis.

From her third-floor hospital room, Rainey recalled the day when she finally decided to seek help for her addiction. She was sitting outside her friend’s tent at the large homeless camp along Hiawatha Avenue in south Minneapolis, waiting for a delivery of heroin.

While there, Rainey saw paramedics carry away a young man who had overdosed, and she saw the mother of the man wailing in agony as the ambulance departed the camp. “I took that as a sign that it was time to make a change,” Rainey said. “I didn’t want to die.”

When she arrived at HCMC, shaking and barely able to stand from withdrawal, a nurse quickly rushed her to an available hospital bed. Soon after, she was given medication to ease her pain, and a team of counselors and recovery specialists began talking to her about a treatment plan.

“I’ve never cried as much as I did that day,” Rainey said, rubbing away tears. “There were so many people here [at HCMC] who had faith in me that I began to have faith in me, too.”

This week, Rainey is expected to be discharged from HCMC after three weeks of round-the-clock care and counseling. She’s now enrolled in an intensive outpatient treatment program, where she will attend therapy four times a week while receiving daily doses of methadone to manage her withdrawal symptoms.

Feeling healthy and clearheaded for the first time in months, Rainey said her first order of business upon leaving the hospital will be to visit her eight grandchildren in south Minneapolis.

“I feel ashamed that I’ve let my family down all these years,” she said. “I’ve been away too long.”

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