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Medication-assisted treatment (MAT) is the use of medications in combination with counseling and behavioral therapies, which is effective in the treatment of opioid use disorders (OUD) and can help some people to sustain recovery.
More must be done to facilitate treatment options and the development of therapies to address OUD as a chronic disease with long-lasting effects. This means helping more people secure MAT, which requires us to break the stigma often associated with some of the medications used to treat OUD. It also requires us to find new and more effective ways to advance the use of medical therapy for the treatment of OUD.
There are three drugs approved by the FDA for the treatment of opioid dependence: buprenorphine, methadone, and naltrexone. All three of these treatments have been demonstrated to be safe and effective in combination with counseling and psychosocial support. Everyone who seeks treatment for an OUD should be offered access to all three options as this allows providers to work with patients to select the treatment best suited to an individual’s needs. Due to the chronic nature of OUD, the need for continuing MAT should be re‐evaluated periodically. There is no maximum recommended duration of maintenance treatment, and for some patients, treatment may continue indefinitely.
Bunavail (buprenorphine and naloxone) buccal film
Cassipa (buprenorphine and naloxone) sublingual film
Probuphine (buprenorphine) implant for subdermal administration
Sublocade (buprenorphine extended‐release) injection for subcutaneous use
Suboxone (buprenorphine and naloxone) sublingual film for sublingual or buccal use, or sublingual tablet.
Subutex (buprenorphine) sublingual tablet
Zubsolv (buprenorphine and naloxone) sublingual tablets
Dolophine (methadone hydrochloride) tablets
Methadose (methadone hydrochloride) oral concentrate
Vivitrol (naltrexone for extended-release injectable suspension) intramuscular
A few things are new this season:
For more information on 2019-2020 influenza vaccine recommendations: Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2019–20 Influenza Season
What flu vaccines are recommended this season?
For the 2019-2020 flu season, providers may choose to administer any licensed, age-appropriate flu vaccine (IIV, RIV4, or LAIV4).
Options this season include:
There is a table showing all flu vaccines that are FDA-approved for use in the United States during the 2019-2020 season.
What viruses will the 2019-2020 flu vaccines protect against?
There are many different flu viruses and they are constantly changing. The composition of U.S. flu vaccines is reviewed annually and updated as needed to match circulating flu viruses. Flu vaccines protect against the three or four viruses (depending on the vaccine) that research suggests will be most common. For 2019-2020, trivalent (three-component) vaccines are recommended to contain:
Quadrivalent (four-component) vaccines, which protect against a second lineage of B viruses, are recommended to contain:
FDA’s Vaccines and Related Biological Products Advisory Committee (VRBPAC) chooses the flu vaccine viruses for the United States. For 2019-2020 vaccines, they selected the H1N1 and B components on March 6, 2019.external icon Selection of the H3N2 component was delayed until March 22, 2019.
Because the timing of the onset, peak and end of flu seasons varies from year to year and cannot be predicted, it is difficult to say when is the best time to be vaccinated for any one season. In trying to balance the need to get many people vaccinated before flu activity begins with concerns about potential waning of vaccine-induced immunity during the flu season, CDC and ACIP recommend that vaccination be offered by the end of October.
Children 6 months through 8 years of age who need 2 doses should receive their first dose as soon as possible after the vaccine becomes available to allow the second dose (which must be administered at least 4 weeks later) to be received by the end of October.
For people who need only one dose for the season, vaccinating early – for example, in July or August –may lead to reduced protection against flu later in the season, particularly among older adults. While vaccination should optimally occur before the onset of flu activity in the community, providers should continue to offer and encourage vaccination as long as flu viruses are circulating and unexpired vaccine is available. To avoid missed opportunities for vaccination, vaccination can be offered during routine health care visits and hospitalizations.
Can I get a flu vaccine if I am allergic to eggs?
The recommendations for people with egg allergies are unchanged and as follows:
Why is it significant that cell-grown vaccine viruses are used to produce one flu vaccine?
Cell-grown vaccine viruses do not have changes that may be present in egg-grown reference viruses, so they should be more similar to circulating “wild-type” viruses. Vaccine effectiveness depends in part on the match between the vaccine virus and circulating flu viruses.
Is flu vaccine made using a cell-grown vaccine virus and cell-based technology more effective than vaccine made using an egg-grown vaccine virus and egg-based technology?
While the use of cell-grown vaccine viruses and cell-based technology may offer the potential for better protection over traditional, egg-based flu vaccines because they result in vaccine viruses that are more similar to flu viruses in circulation, there are no vaccine effectiveness data to support this. There is no preferential recommendation for one flu vaccine over another.
What sort of flu season is expected this year?
Influenza is unpredictable. While flu spreads every year, the timing, severity, and length of the season varies from one season to another.
Will new flu viruses circulate this season?
Flu viruses are constantly changing so it’s not unusual for new flu viruses to appear each year. More information about how flu viruses change is available.
Will the United States have a flu epidemic?
The United States experiences annual epidemics of seasonal flu. This time of year is called “flu season.” In the United States, flu viruses are most common during the fall and winter months. Flu activity often begins to increase in October and November. Most of the time flu activity peaks between December and February, and it can last as late as May. CDC monitors certain key flu indicators (for example, outpatient visits of influenza-like illness (ILI), the results of laboratory testing and reports of flu hospitalizations and deaths). When these indicators rise and remain elevated for a number of consecutive weeks, “flu season” is said to have begun. Usually ILI increases first, followed by an increase in flu-associated hospitalizations, which is then followed by increases in flu-associated deaths.
For the most current flu surveillance information: Weekly U.S. Influenza Surveillance Report.
When will flu activity begin and when will it peak?
The timing of flu is unpredictable and can vary in different parts of the country and from season to season. Seasonal flu viruses can be detected year-round; however, seasonal flu activity often begins as early as October and November and can continue to occur as late as May. Flu activity most commonly peaks in the United States between December and February.
What should I do to protect myself from flu this season?
CDC recommends a yearly flu vaccine for everyone 6 months of age and older as the first and most important step in protecting against this potentially serious disease.
In addition to getting a seasonal flu vaccine, you can take everyday preventive actions like staying away from sick people and washing your hands to reduce the spread of germs. If you are sick with flu, stay home from work or school to prevent spreading flu to others. In addition, there are prescription medications called antiviral drugs that can be used to treat flu illness.
What should I do to protect my loved ones from flu this season?
Encourage your loved ones to get vaccinated. Vaccination is especially important for people at high risk of developing flu complications, and their close contacts. Also, if you have a loved one who is at high risk of developing flu complications and they get flu symptoms, encourage them to seek medical attention for possible treatment with a flu antiviral drug. These drugs work best if given within 48 hours of when symptoms start. CDC recommends that people who are at high risk of developing serious flu complications and who get flu symptoms during flu season be treated with flu antiviral drugs as quickly as possible without waiting for confirmatory testing. People who are not at high risk of developing serious flu complications may also be treated with flu antiviral drugs, especially if treatment can begin within 48 hours.
Do some children require two doses of flu vaccine?
As in previous seasons, some children 6 months through 8 years of age will need 2 doses of flu vaccine this season. Children in this age group who have not previously received two or more total doses of any trivalent or quadrivalent flu vaccine (including the nasal spray vaccine) before July 1, 2019, or whose vaccination history is not known, need two doses of 2019-2020 flu vaccine administered at least 4 weeks apart.
For 8-year-olds who need two doses, the second dose is recommended even if the child turns 9 years of age between receipt of dose 1 and dose 2. Children in this age group who have received two or more total doses of trivalent or quadrivalent flu vaccine before July 1, 2019 need only one dose for this season.
What can I do to protect children who are too young to get vaccinated?
Children younger than 6 months old are at high risk of serious flu complications, but are too young to get a flu vaccine. Because of this, safeguarding them from flu is especially important. If you live with or care for an infant younger than 6 months old, you should get a flu vaccine to help protect them from flu. Advice for Caregivers of Young Children is available for more information. Everyone else who is around the baby also should be vaccinated. Also, studies have shown that flu vaccination of the mother during pregnancy can protect the baby after birth from flu infection for several months.
In addition to getting vaccinated, you and your loved ones can take everyday preventive actions like staying away from sick people and washing your hands to reduce the spread of germs. If you are sick with flu, stay home from work or school to prevent spreading flu to others.
How much flu vaccine will be available this season?
Flu vaccine is produced by private manufacturers, so supply depends on manufacturers. For the 2019-2020 season, manufacturers have projected they will provide as many as 162 million to 169 million doses of flu vaccine, which is similar to projected supply for last season. Flu vaccine supply updates will be provided as they become available at Seasonal Influenza Vaccine & Total Doses Distributed.
Are any of the available flu vaccines recommended over the others?
For the 2019-2020 flu season, ACIP recommends annual flu vaccination for everyone 6 months and older with any licensed, age-appropriate flu vaccine (IIV, RIV4, or LAIV4) with no preference expressed for any one vaccine over another.
There are many vaccine options to choose from; the most important thing is for all people 6 months and older to get a flu vaccine every year. If you have questions about which vaccine is best for you, talk to your doctor or other health care professional.
Why is the nasal spray being recommended as an option this year when it has been shown to not be effective in past flu seasons?
Flu vaccine effectiveness (VE) can vary from year to year, among different age and risk groups, by vaccine type, and even by virus type and subtype. While data from 2010-2011 through 2016-2017 indicated that nasal spray vaccine lacked effectiveness among 2 through 17-year-olds against H1N1 viruses in the U.S., nasal spray vaccine was effective against influenza B viruses, and was similarly effective against H3N2 viruses as inactivated influenza vaccines. Since the 2018-2019 season, the manufacturer of nasal spray vaccine has used a new H1N1 vaccine virus in production. Some data suggest this will result in improved effectiveness of against H1N1. However, no published effectiveness estimates for this vaccine component against H1N1 viruses are available. ACIP and CDC voted to resume the recommendation for the use of nasal spray vaccines based on evidence suggesting that the new H1N1 component will result in improved effectiveness of the vaccine against these viruses. There is no expressed preference for any flu shot or the nasal spray vaccine.
Where can I get a flu vaccine?
Flu vaccines are offered by many doctor’s offices, clinics, health departments, pharmacies and college health centers, as well as by many employers, and even by some schools.
Even if you don’t have a regular doctor or nurse, you can get a flu vaccine somewhere else, like a health department, pharmacy, urgent care clinic, and often your school, college health center, or work.
The HealthMap Vaccine Finderexternal icon helps you to locate where you can get a flu vaccine.
What is flu vaccination using a jet injector?
FDA has approved one flu vaccine (Afluria Quadrivalent) for administration by a jet injector device (the PharmaJet Stratis 0.5ml Needle-free Jet Injector) for people 18 through 64 years of age. These are the only two flu vaccines approved for administration by jet injector. People aged 18 through 64 years may receive this vaccine either by jet injector or needle. A jet injector is a medical device used for vaccination that uses a high-pressure, narrow stream of fluid to penetrate the skin instead of a hypodermic needle. More information about Flu Vaccination by Jet Injector is available.
What is adjuvanted flu vaccine?
The FDA licensed a seasonal flu vaccine containing adjuvant for adults 65 years of age and older. An adjuvant is an ingredient added to a vaccine to create a stronger immune response to vaccination. FLUAD™Cdc-pdfpdf icon[155 KB, 13 pages]external icon was licensed in November 2015 and will be available during the 2019-2020 flu season. It includes the MF59 adjuvant, an oil-in-water emulsion containing squalene oil. FLUAD™ is the first adjuvanted seasonal flu vaccine marketed in the United States.
Can I get vaccinated and still get flu?
Yes. It’s possible to get sick with flu even if you have been vaccinated (although you won’t know for sure unless you get a flu test). This is possible for the following reasons:
How effective will flu vaccines be this season?
It’s not possible to say in advance exactly how well the flu vaccine will work this season. How well it works can vary by season, virus type/subtype, the kind of vaccine, and age and other host factors of the people being vaccinated. At least two factors play an important role in determining the likelihood that flu vaccines will protect a person from flu illness: 1) characteristics of the person being vaccinated (such as their age and health), and 2) the similarity or “match” between the flu viruses in the vaccine and those spreading in the community.
During years when the viruses in the flu vaccine and circulating flu viruses are well matched, it’s possible to measure substantial benefits from flu vaccination in terms of preventing flu illness. However, even during years when the vaccine match is good, the benefits of flu vaccination will vary across the population, depending on host factors like the health and age of the person being vaccinated and even potentially which flu vaccine was used.
Recent studies by CDC researchers and other researchers suggest that flu vaccination usually reduces the risk of influenza illness by 40% to 60% among the overall population when the vaccine viruses are like the ones spreading in the community.
For more information about vaccine effectiveness, click here.
Will this season’s flu vaccine be a good match for circulating viruses?
It’s not possible to predict with certainty if a flu vaccine will be a good match for circulating flu viruses. A flu vaccine is made to protect against the flu viruses that research and surveillance indicate will likely be most common during the season. However, scientists must pick which flu viruses to include in a flu vaccine many months in advance in order for flu vaccines to be produced and delivered on time. Also flu viruses change constantly (called “drift”). They can change from one season to the next or they can even change within the course of one flu season. Another factor that can impact vaccine effectiveness, especially against influenza A(H3N2) viruses, are changes that can occur in vaccine viruses as they are grown in eggs, which is the production method for most current flu vaccines. Because of these factors, there is always the possibility of a less than optimal match between circulating flu viruses and the viruses in a flu vaccine.
Over the course of flu season, CDC studies samples of circulating flu viruses to evaluate how close a match there is between viruses used to make the flu vaccine and circulating flu viruses.
One of the ways that helps CDC evaluate the match between flu vaccine viruses and circulating flu viruses is with a lab process called ‘genetic and antigenic characterization’. Results of genetic and antigenic characterization testing are published weekly in CDC’s FluView.
Can a flu vaccine provide protection even if the flu vaccine is not a “good” match?
Yes, antibodies made in response to vaccination with one flu virus sometimes can provide protection against different but related flu viruses. A less than ideal match may result in reduced vaccine effectiveness against the flu virus that is different from what is in the flu vaccine, but it might still provide some protection against flu illness.
In addition, it’s important to remember that a flu vaccine contains three or four flu viruses (depending on the type of vaccine you receive) so that even when there is a less than ideal match or lower effectiveness against one virus, a flu vaccine may protect against the other flu viruses.
For these reasons, even during seasons when there is a less than ideal match, CDC continues to recommend flu vaccination for everyone 6 months and older. Vaccination is particularly important for people at high risk for serious flu complications), and their close contacts.
What happens in the body when someone has flu?
Flu viruses usually infect the respiratory tract (i.e., the airways of the nose, throat and lungs). As the infection progresses, the body’s immune system responds to fight the virus. This results in inflammation that can trigger respiratory symptoms such as cough and sore throat. The immune system response also can trigger fever and cause muscle or body aches. When infected people cough, sneeze, or talk, they can spread flu viruses in respiratory droplets to people who are nearby. People might also get flu by touching a contaminated surface or object that has flu virus on it and then touching their own mouth or nose.
Most people who become sick will recover in a few days to less than two weeks, but some people may become more severely ill. Following flu infection, moderate complications such as secondary ear and sinus infections can occur. Pneumonia is a serious flu complication that can result from either flu virus infection alone or from co-infection of flu virus and bacteria. Other possible serious complications triggered by flu can include inflammation of the heart (myocarditis), brain (encephalitis) or muscle (myositis, rhabdomyolysis) tissues, and multi-organ failure (for example, respiratory and kidney failure). Severe complications can happen to anyone, but may be more likely to happen to people who have certain chronic medical conditions, or in elderly persons.
What should I do if I get sick with flu?
Most people with flu have mild illness and do not need medical care or antiviral drugs. If you get sick with flu symptoms, in most cases, you should stay home and avoid contact with other people except to get medical care.
If, however, you have symptoms of flu and are at high risk of flu complications, or are very sick or concerned about your illness, contact your health care provider. There are drugs your doctor may prescribe for treating flu called antivirals. These drugs can make you better faster and may also prevent serious complications.
Antiviral drugs are prescription drugs that can be used to treat flu illness. People at high risk of serious flu complications recommended for prompt antiviral treatment include children younger than 2 years of age (although all children younger than 5 years are considered at higher risk for complications from flu, the highest risk is for those younger than 2 years of age), adults 65 years of age and older, pregnant women, people with certain long-term medical conditions, and residents of nursing homes and other long-term care facilities). Antiviral treatment as early as possible is also recommended for people who are very sick with flu (such as those with complicated, progressive illness or people hospitalized because of flu). Other people can be treated with antivirals at their health care professional’s discretion. Treating high risk people or people who are very sick with flu with antiviral drugs is very important. Studies show that prompt treatment with antiviral drugs can prevent serious flu complications. Prompt treatment can mean the difference between having a milder illness versus very serious illness that could result in a hospital stay.
Treatment with antivirals works best when begun within 48 hours of getting sick. However, treatment can still be beneficial when given later in the course of illness. Antiviral drugs are effective across all age and risk groups. Studies show that antiviral drugs are under-prescribed for people who are at high risk of complications who get flu. Four FDA-approved antiviral medications are recommended for use during the 2019-2020 flu season: oseltamivir (available in generic versions and under the trade name Tamiflu®), zanamivir (Relenza®), peramivir (Rapivab®), and baloxavir marboxil (Xofluza®). More information about antiviral drugs can be found at Treatment – Antiviral Drugs. This guidance is consistent with the 2019-2020 flu season recommendationsexternal icon published by the Infectious Diseases Society of America (IDSA) on December 19, 2018, in Clinical Infectious Diseases.
What is baloxavir marboxil?
Baloxavir marboxil (trade name Xofluza®) is a flu single-dose antiviral drug approved October 24, 2018 by the FDA. Baloxavir is approved for the treatment of acute uncomplicated flu in people 12 years and older who have had flu symptoms for less than 48 hours. In clinical randomized trials, baloxavir was similar to oseltamivir, a currently recommended flu antiviral drug, in alleviating flu symptoms.
More information regarding baloxavir is available: Influenza Antiviral Drug Baloxavir Marboxil.
How does CDC track flu activity?
The Epidemiology and Prevention Branch in the Influenza Division at CDC collects, compiles and analyzes information on flu activity year round in the United States and produces FluView, a weekly flu surveillance report, and FluView Interactive, which allows for more in-depth exploration of flu surveillance data. The U.S. flu surveillance system is a collaborative effort between CDC and its many partners in state, local, and territorial health departments, public health and clinical laboratories, vital statistics offices, healthcare providers, clinics, and emergency departments. Information in five categories is collected from eight different data sources that allow CDC to:
For more information, visit “Overview of Influenza Surveillance in the United States”.
What will CDC do to monitor flu vaccine effectiveness for the 2019-2020 season?
CDC collaborates with partners each season to assess how well the seasonal flu vaccines are working. During the 2019-2020 season, CDC is planning multiple studies on the effectiveness of flu vaccines. Researchers conduct these studies each year to measure how well flu vaccines work in order to continually assess and confirm their value as a public health measure.
Part of the need for this continued assessment is that flu viruses that circulate each year tend to change and evolve, and so the components of the flu vaccine are changed relatively frequently to protect against these new circulating viruses. A summary of CDC’s latest vaccine effectiveness estimates is available at Seasonal Influenza Vaccine Effectiveness, 2005-2018.
What is CDC doing to monitor antiviral resistance in the United States during the 2019-2020 season?
Antiviral resistance means that a virus has changed in such a way that antiviral drugs are less effective or not effective at all in treating or preventing illnesses with that virus. CDC will continue to collect and monitor flu viruses for changes through an established network of domestic and global surveillance systems. CDC also is working with the state public health departments and the World Health Organization to collect additional information on antiviral resistance in the United States and worldwide. The information collected will assist in making informed recommendations regarding use of antiviral drugs to treat flu.
How does CDC estimate the burden of seasonal flu on the United States?
The burden of flu on the United States can vary widely from season to season and is determined by a number of factors including the characteristics of circulating viruses, the timing of the season, population immunity to circulating viruses, how well flu vaccines are working, and how many people have gotten vaccinated. While the impact of flu varies, it places a substantial burden on the health of people in the United States each year.
CDC uses a model to estimate the numbers of flu illnesses, medical visits, and hospitalizations in the United States (as well as the impact of flu vaccination on these numbers). The same model is also extended to estimate flu-related deaths in the United States. This methodology has been used to retroactively calculate flu burden, including deaths, going back to 2010.
Beginning with the 2018-2019 flu season, CDC began reporting cumulative, in-season estimates of the burden of flu. These Preliminary In-Season Burden Estimates will be provided when activity has been sufficient to generate a stable estimate, and will be updated weekly over the course of the flu season.
How does CDC classify flu season severity?
In 2017, CDC adopted and outlined a new methodology for determining flu season severity. Based on data from past flu seasons, CDC researchers used key flu indicator data to develop intensity thresholds (ITs) to classify the severity of flu seasons.
Based on the intensity thresholds, CDC researchers classified seasonal severity from 2003-2004 through the 2018-2019 flu seasons. Overall, four seasons were classified as low severity, eight as moderate, three as high, and none as very high.
What is flu forecasting?
Flu places a significant disease burden on the U.S. population each year, but the magnitude and timing varies from season to season, making the annual impact difficult to predict at the beginning of each season. Flu forecasting may help predict when the start, peak, and increases in flu activity will occur. Unlike CDC’s traditional influenza surveillance systems, which measure flu activity after it has occurred, flu forecasting offers the possibility to look into the future and better plan ahead, potentially reducing the impact of flu and can potentially be used to prepare for and prevent illness, hospitalization, and death, as well as the economic burden, experienced during a flu epidemic. When forecasts accurately predict flu activity, the ability to more effectively plan for public health responses to seasonal flu epidemics and future influenza pandemics is possible.
Flu forecasting aims to predict the characteristics of influenza seasons before disease activity occurs and is captured by the U.S. influenza surveillance system. Since the 2013-2014 flu season, the Influenza Division at CDC has worked with CDC’s Epidemic Prediction Initiative (EPI) and external researchers to improve the science and usability of flu forecasting by coordinating flu forecasting challenges. Recently, these challenges have been extended to state-level predictions and forecasting hospitalization rates.
During 2018-2019, CDC began summarizing and publicly posting flu forecasts. For the 2019-2020 flu season, CDC will continue to display weekly the forecasts received through the EPI.
Learn more about flu forecasting by visiting https://www.cdc.gov/flu/weekly/flusight/index.html.
Page last reviewed: November 5, 2019
(adapted from E.M.Today)
NEJM | August 25, 2010 | Topics: Implementation, Public Health
Howard K. Koh, M.D., M.P.H., and Kathleen G. Sebelius, M.P.A.
Too many people in our country are not reaching their full potential for health because of preventable conditions. Moreover, Americans receive only about half of the preventive services that are recommended1 — a finding that highlights the national need for improved health promotion. The 2010 Affordable Care Act2 responds to this need with a vibrant emphasis on disease prevention. Many of the 10 major titles in the law, especially Title IV, Prevention of Chronic Diseases and Improving Public Health, advance a prevention theme through a wide array of new initiatives and funding. As a result, we believe that the Act will reinvigorate public health on behalf of individuals, worksites, communities, and the nation at large (see table) — and will usher in a revitalized era for prevention at every level of society.
Major Sections Related to Prevention in the 2010 Affordable Care Act.
First, the Act provides individuals with improved access to clinical preventive services. A major strategy is to remove cost as a barrier to these services, potentially opening new avenues toward health. For example, new private health plans and insurance policies (for plans or policy years beginning on or after September 23, 2010) are required to cover a range of recommended preventive services with no cost sharing by the beneficiary. These services include those rated as “A” (strongly recommended) or “B” (recommended) by the U.S. Preventive Services Task Force (USPSTF), vaccinations recommended by the Advisory Committee on Immunization Practices (ACIP), and preventive care and screening included both in existing health guidelines for children and adolescents and in future guidelines to be developed for women through the U.S. Health Resources and Services Administration (HRSA). Examples of covered services include screening for breast cancer, cervical cancer, and colorectal cancer; screening for human immunodeficiency virus (HIV) for persons at high risk; alcohol-misuse counseling; depression screening (when systems are in place to ensure accurate diagnosis, effective treatment, and follow-up); and immunizations.
The prevention theme also affects individuals covered by public insurance programs. A number of policy changes will be phased in over time. For example, starting January 1, 2011, Medicare will cover, without cost sharing, an annual wellness visit that includes a health risk assessment and a customized prevention plan. Full coverage of many USPSTF-recommended services will also be available under Medicare with no cost sharing. Similarly, in 2013 and beyond, state Medicaid programs that eliminate cost sharing for preventive services recommended by the USPSTF or ACIP may be eligible for enhanced federal matching funds for providing those services.
Second, the law promotes wellness in the workplace, providing new health promotion opportunities for employers and employees. For example, the Act authorizes funds for grants for small businesses to provide comprehensive workplace wellness programs. The law also requires the secretary of health and human services to assess existing federal health and wellness initiatives and directs the Centers for Disease Control and Prevention (CDC) to survey worksite health policies and programs nationally.
Third, the Act strengthens the vital role of communities in promoting prevention. New initiative opportunities are designed to strengthen partnerships between local or state governments and community groups. For example, new Community Transformation Grants promise to improve nutrition, increase physical activity, promote smoking cessation and social and emotional wellness, and prioritize strategies to reduce health care disparities. Also, in further recognition that immunization is a foundation for public health, the Act authorizes states to use their funds to purchase vaccines for adults at federally negotiated prices. Grants for states will also support demonstration projects to improve vaccination rates.
Fourth, the Act elevates prevention as a national priority, providing unprecedented opportunities for promoting health through all policies. For example, a newly established National Prevention, Health Promotion, and Public Health Council, involving more than a dozen federal agencies, will develop a prevention and health promotion strategy for the country. The council will build on the foundation of preceding prevention initiatives, such as Healthy People (which has set the country’s health promotion and disease prevention agenda for the past 30 years),3 as well as efforts of expert groups such as the USPSTF, the Community Preventive Services Task Force, and the ACIP. A new Prevention and Public Health Fund, with an annual appropriation that begins at $500 million in fiscal year 2010 and increases to $2 billion in fiscal year 2015 and beyond, will invest in a range of prevention and wellness programs administered by the Department of Health and Human Services. Initial funds have already been invested in strengthening public health infrastructure, prevention research, surveillance, integration of primary care into community-based behavioral health programs, HIV prevention, obesity prevention, and tobacco control. Reinvigorated planning will also involve a national strategy to improve the quality of health care, improved data collection on health disparities,4 and authorization of a host of other new programs. Most newly authorized programs await appropriations and future funding as available through the annual budget process (exceptions are noted in the table).
The Act authorizes heavy investment in bolstering a primary care workforce that can promote prevention. For example, the law appropriates up to $1.5 billion for the National Health Service Corps between fiscal years 2011 and 2015 to place health care professionals in underserved areas, complementing other new investments for community health centers administered through HRSA. To guide future placements of health care professionals, a new National Health Care Workforce Commission will analyze needs.
Since tobacco dependence and obesity represent substantial health threats, the Act addresses these specific challenges in a number of ways. For example, the directives for the new health plans established after September 23, 2010, also include coverage, with no cost sharing, of tobacco-use counseling and evidence-based tobacco-cessation interventions, as well as obesity screening and counseling for adults and children. Starting this year, pregnant women on Medicaid will receive coverage, without cost sharing, for evidence-based tobacco-dependence treatments; in 2014, states will be forbidden from excluding from Medicaid drug coverage any pharmaceutical agents for smoking cessation, including over-the-counter medications, that have been approved by the Food and Drug Administration. To promote healthy weight for populations, the Act appropriates funds for fiscal years 2010 through 2014 for demonstration projects to develop model programs for reducing childhood obesity. And on the policy front, menu-labeling provisions require the disclosure of specified nutrient information for food sold in certain chain restaurants and vending machines. Collectively, these complementary actions in the clinic and the community will benefit individuals as well as populations.
In short, to prevent disease and promote health and wellness, the Act breaks new ground. We believe the law reaffirms the principle that “the health of the individual is almost inseparable from the health of the larger community. And the health of each community and territory determines the overall health status of the Nation.”3 Moving prevention toward the mainstream of health may well be one of the most lasting legacies of this landmark legislation.
This article (10.1056/NEJMp1008560) was published on August 25, 2010, at NEJM.org.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
Dr. Koh is Assistant Secretary for Health, and Ms. Sebelius is the Secretary for Health and Human Services, Department of Health and Human Services, Washington, DC.
1. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348:2635-2645
2. The Patient Protection and Affordable Care Act, P.L. 111-148, 23 March 2010.
3. Koh HK. A 2020 vision for healthy people. N Engl J Med 2010;362:1653-1656
4. Siegel B, Nolan L. Leveling the field — ensuring equity through national health care reform. N Engl J Med 2009;361:2401-2403
Having travelled from Coeur d’ Alene through London, to Ireland, we found the land of green…and my ethnic and my heritage. In County Cork, 20 or so miles from City Cork, a few miles south of the small area of Mallow, near the Mourne Parrish, whe the Bishop was coming to confirm the next generation, was a small farm…after we found an ol’ Irish gal pushing a stroller, a great-granddaughter perhaps, then to an ol’ gentleman who had heard and met some Owens in the past…”not many around now…” and then a young lad…5-7 years who said, he didn’t know, but, “was it important!” And he added, the yound lady with him was “Polish” and she wouldn’t know…to the old possibly bachealor dairy farmer, pushing a wheelbarrow full of cow manure with a three prong pitchfork laid across, working so hard to see us through the coke-bottom thickened glasses with nails of a working farmer…skeptical to come close perhaps firstly, then, offering the Gealic version of Gealic or a mix, sure to confuse a traveler. But, he knew the name, lahakaneen or lakahaneen, and knew the farm and the name. And he knew just down the hill and the most two important turns of the travel. For this was my homeland, Ireland, through County Cork, across the ocean, the Ellis Isle and New York, and later, MinnEsOtaH. Kiss the ol’ farmhouse for all the Owens, alive and passed, for this was THE homeland, in Ireland, on this day. God bless all Irish!
Dr. Jim Winter (Owens of County Cork)
Today is now. Now is current. It is what is. Yesterday is a trail of previous now. Tomorrow is a feeling of now coming to be, but it is not. Now is the moment. Worry less by focusing on now. Now is the mind not thinking but of the now. Remember as in an emergency, only the focus is the emergency. All past and future stop. Focus is now. Time leaves as focus intensifies to the now. Less anxiety happens when focus is on the now moment. Now…
Music is the soul. Music is the release of life. Music is the now. Do not wonder how the musician can create but wonder why. Music is not the future, nor the past. Music is the now. Be bold musicians. Be brave musicians. Wonder only beyond the noise, create only beyond the universe. drjpw
Recently an article on “Scary Skinny” appeared in a tabloid which included many of the female movie stars and entertainers. This article was not a prelude to Halloween; however some of the eating problems at Halloween may be of note. Most of the stars highlighted are anorexic, or shall I say anorexic-appearing – so eating Halloween candy is out. Purging the calories is also a problem for the eating disordered patient.
Jessica Alba appeared in the photo with the shoulder girdle (shoulder, shoulder blade, collarbones) quite concave. It estimated her 5’6” body to be at a possible 110 pounds is all. Her supposed 15 pound weight loss was after a love breakup.
Now the world savior Angelina Jolie was more ill appearing. Her cachectic body with all front side ribs, collarbones, and breastbone sticking out was quite shocking to see. The article highlighted her weight at 105 pounds for this 5’8”. Brad Pitt was begging her to eat according to the article – a common loved one’s frustrating request in eating disorders. According to the article, she was eating under 1000 calories, which is a weight losing diet, as her needs would be 1500 to 2000 or more calories per day, depending on baseline activity and that beyond. Eating a daily small meal or a drink of lemon impregnated water is not a normalized diet for an active mother.
The actress, Renee Zellweger, at about 38 years old, should not be showing ligaments and tendons in her arms and legs. This star struggles with the fact she’s is getting older, and will struggle with weight as she ages, according to this article. This is a finding in eating disorders.
Other stars, Keira, Kate Bosworth, and even prior, Eva Longoria are intermittently grossly underweight. Their bony gauntness is a similar finding in eating disordered patients.
Eating disorders involve serious disturbances in eating behavior, such as extreme and unhealthy reduction of food intake or severe overeating, as well as feelings of distress or extreme concern about body shape or weight.
Eating is controlled by many factors, including appetite, food availability, family, peer, and cultural practices, and attempts at voluntary control. Dieting to a body weight leaner than needed for health is highly promoted by current fashion trends, sales campaigns for special foods, and in some activities and professions.
The main types of eating disorders are anorexia nervosa and bulimia nervosa. A third type, binge-eating disorder, has been suggested but has not yet been approved as a formal psychiatric diagnosis. Eating disorders frequently develop during adolescence or early adulthood, but some reports indicate their onset can occur during childhood or later in adulthood.
Eating disorders frequently co-occur with other psychiatric disorders such as depression, substance abuse, and anxiety disorders.
Females are much more likely than males to develop an eating disorder. Only an estimated 5 to 15 percent of people with anorexia or bulimia and an estimated 35 percent of those with binge-eating disorder are male.
An estimated 0.5 to 3.7 percent of females suffer from anorexia nervosa in their lifetime.1 Symptoms of anorexia nervosa include:
Resistance to maintaining body weight at or above a minimally normal weight for age and height
Intense fear of gaining weight or becoming fat, even though underweight
Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight
Infrequent or absent menstrual periods (in females who have reached puberty)
People with this disorder see themselves as overweight even though they are dangerously thin. The process of eating becomes an obsession.
The mortality rate among people with anorexia has been estimated at 0.56 percent per year, or approximately 5.6 percent per decade, which is about 12 times higher than the annual death rate due to all causes of death among females ages 15-24 in the general population
The most common causes of death are complications of the disorder, such as cardiac arrest or electrolyte imbalance, and suicide.
An estimated 1.1 percent to 4.2 percent of females have bulimia nervosa in their lifetime.1 Symptoms of bulimia nervosa include:
Recurrent episodes of binge eating, characterized by eating an excessive amount of food within a discrete period of time and by a sense of lack of control over eating during the episode
Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting or misuse of laxatives, diuretics, enemas, or other medications (purging); fasting; or excessive exercise
The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months
Self-evaluation is unduly influenced by body shape and weight
Because purging or other compensatory behavior follows the binge-eating episodes, people with bulimia usually weigh within the normal range for their age and height. However, like individuals with anorexia, they may fear gaining weight, desire to lose weight, and feel intensely dissatisfied with their bodies.
People with bulimia often perform the behaviors in secrecy, feeling disgusted and ashamed when they binge, yet relieved once they purge.
Community surveys have estimated that between 2 percent and 5 percent of Americans experience binge-eating disorder in a 6-month period. Symptoms of binge-eating disorder include:
Recurrent episodes of binge eating, characterized by eating an excessive amount of food within a discrete period of time and by a sense of lack of control over eating during the episode
The binge-eating episodes are associated with at least 3 of the following: eating much more rapidly than normal; eating until feeling uncomfortably full; eating large amounts of food when not feeling physically hungry; eating alone because of being embarrassed by how much one is eating; feeling disgusted with oneself, depressed, or very guilty after overeating
Marked distress about the binge-eating behavior
The binge eating occurs, on average, at least 2 days a week for 6 months
The binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise)
People with binge-eating disorder experience frequent episodes of out-of-control eating, with the same binge-eating symptoms as those with bulimia. The main difference is that individuals with binge-eating disorder do not purge their bodies of excess calories.
Therefore, many with the disorder are overweight for their age and height. Feelings of self-disgust and shame associated with this illness can lead to bingeing again, creating a cycle of binge eating.
Because of their complexity, eating disorders require a comprehensive treatment plan involving medical care and monitoring, psychosocial interventions, nutritional counseling and, when appropriate, medication management. At the time of diagnosis, the clinician must determine whether the person is in immediate danger and requires hospitalization.
(1) restoring weight lost to severe dieting and purging; (2) treating psychological disturbances such as distortion of body image, low self-esteem, and interpersonal conflicts; and (3) achieving long-term remission and rehabilitation, or full recovery.
The primary goal of treatment for bulimia is to reduce or eliminate binge eating and purging behavior. To this end, nutritional rehabilitation, psychosocial intervention, and medication management strategies are often employed.
Several family and twin studies are suggestive of a high heritability of anorexia and bulimia, and researchers are searching for genes that confer susceptibility to these disorders. Scientists suspect that multiple genes may interact with environmental and other factors to increase the risk of developing these illnesses. Identification of susceptibility genes will permit the development of improved treatments for eating disorders.
Some insurers and their plans still make it difficult for patients to see the doctor of their choice. The “Any Willing Provider Law” in Idaho mandates that all insurance companies open their doors to any provider, granted the provider apply and follow the terms of the contractual agreement. It still seems some insurances companies restrict access to doctors and hospitals and make it difficult to get through that open door.
In the emergency rooms of America, EMTALA took care of that. It’s definition now is the “layperson’s view of the emergency.”
One case in Idaho went to the Supreme Court already, where the Supremes overruled the lower court, and award costs and a new appeal to a group of cardiologists.
Isn’t it time all companies and groups representing themselves as gatekeepers to care – that insure patients in Idaho – obey the law? Patients need to be pro-active knowing their rights.
AWP laws come in a variety of forms but the most common type prohibits managed care networks from excluding physicians, pharmacists, hospitals, and other health care providers who are willing to accept the network’s terms and conditions from participation. As the term implies, AWP laws require managed care network sponsors to include any provider who agrees to abide by the terms of their contract and accept their payment schedule.
AWP laws adopted around the country differ considerably. Some permit managed care plan subscribers freedom of choice to select any provider in general, and others have choice with respect to pharmacies or even narrow categories of specialists such as chiropractors, optometrists, or psychiatrists. Some AWP laws apply to institutional providers such as hospitals and still others require network sponsors to merely notify subscribers of plan practices.
As best as we can determine at least 17 states have passed some form of AWP law. But, the governors of Maine, Massachusetts, and Vermont vetoed their respect AWP legislation. The laws in nine states apply only to pharmacies and pharmacists. Among these is the Massachusetts proposal which the governor vetoed. The Massachusetts legislature voted to override the veto.
California has an open-panel requirement with respect to health maintenance organizations (HMOs). Minnesota adopted a law that requires managed care plans to expand network providers
and Virginia has an open-panel requirement for preferred provider organizations (PPOs) networks that permit chiropractors, optometrists, podiatrists, and psychologists to join if they agree to terms and conditions.
Idaho enacted an AWP law and grievance procedure. The law includes provisions that specify that (1) any provider who is qualified and willing to meet plan terms and conditions must be allowed to participate as a network provider; (2) termination or nonrenewal of a provider may occur only after written notice of intended breach of contract, and (3) all insurers must have a grievance procedure in place that includes arbitration or other reasonable due process features (HB 886). (Adapted from: olr@po. state. ct. us)