Friday, November 30, 2018

Among the 50 states, Kentucky, which is 26th in population, ranked fourth in the death rate from drug overdoses in 2017

Kentucky had the fourth highest rate of drug overdoses among the states in 2017, fifth when the District of Columbia is added to the list, according to a new report from the federal Centers for Disease Control and Prevention.

Kentucky had 37.2 overdose deaths per 100,000 people. West Virginia had the highest rate, 57.8, and Ohio was second with 46.3. Pennsylvania and D.C. were close behind at 44.3 and 44, respectively.

Pennsylvania, the largest of those states, had the most overdose deaths, 5,388. Ohio was second with 5,111 and Florida, the third most populous state, was close behind with 5,088. Kentucky had 1,566 deaths, the 15th largest number, and West Virginia had 974. Those two states are 26th and 38th in population.

"The national report echoes many trends found in Kentucky’s annual overdose report for 2017, especially the increase in deaths due to fentanyl," a synthetic opioid that can be 50 times more potent than heroin, Linda Blackford reports for the Lexington Herald-Leader.

Kentucky's report, released in July, showed an 11.5 percent increase in drug-overdose deaths from 2016, with more than half from fentanyl. The number of heroin deaths decreased, but overdose deaths from methamphetamine surged, with meth being found in 29 percent of cases.

"Unlike opioid use, meth addiction cannot be addressed with medication assisted treatments, such as buprenorphine," Blackford notes.

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Wednesday, November 28, 2018

'It's not about losing coverage, it's about having fewer members enrolled in Medicaid,' state health secretary says of new plan

By Melissa Patrick
Kentucky Health News

The administration of Gov. Matt Bevin changed very little in the Medicaid plan that was recently re-approved by the Trump administration, which means "able-bodied" members of the program will soon have to work or participate in certain activities 80 hours a month to keep their health insurance.

Health Secretary Adam Meier and Deputy Health Secretary Kristi Putnam
speaking about the state's new Medicaid plan, Kentucky HEALTH
The new plan, called Kentucky HEALTH for "Helping to Engage and Achieve Long Term Health," also includes premiums, deductibles or co-payments, strict reporting requirements and lock-outs for non-compliance. It is tentatively set to start April 1, with the work rules and other community-engagement options to be phased in regionally.

Kentucky HEALTH will largely affect the nearly 500,000 Kentuckians who have gained health coverage through the 2014 expansion of the program to those who earn up to 138 percent of the federal poverty line ($16,653 for an individual). Kentucky has about 1.4 million people on Medicaid, but only 165,000 are expected to come under the community-engagement requirements.

Health Secretary Adam Meier told the legislature's Joint Committee on Health and Welfare and Family Services Nov. 27 that the community-engagement rules will likely roll out in Northern Kentucky first, as was scheduled before a federal judge blocked the previous version of the plan.

On June 29, two days before the rollout was to start, District Judge James Boasberg of Washington, D.C., sent then plan back to the U.S. Department of Health and Human Services for review, ruling that, among other things, HHS Secretary Alex Azar had not fully considered the state's projection that in five years the Medicaid rolls would have 95,000 fewer people with the plan than without it.

Asked if there was a chance it could be blocked again, Meier said, "There's always a chance."

After the committee meeting, Cara Stewart, an attorney with the Kentucky Equal Justice Center, one of the three organizations that filed the lawsuit on behalf of 16 Kentucky Medicaid recipients, said they were working on amending their complaint. "It's hard to expect a different result with everything the same," Stewart said.

During the meeting, several Democrats on the committee voiced concerns that thousands of Kentuckians could lose their health coverage because of the new Medicaid rules.

Rep. George Brown, D-Lexington, asked Meier exactly how many people were expected to lose coverage as a result of these new requirements.

Meier said he didn't have a "crystal ball" to determine that number, but assured him that the state has worked "diligently" with the Centers for Medicare and Medicaid Services to provide appropriate exemptions and to protect Kentuckians from any unintended consequences that could occur under the new rules.

"The same people that have access today will have access post-implementation," Meier said.

Brown noted the importance of keeping track of the numbers of Kentuckians who might fall through the cracks under the new plan. He said, “The 95,000 prospective citizens that are going to lose health care coverage is problematic. I think we have to be concerned with what happens with them."

Meier took issue with the term "losing coverage," saying, "It's not about losing coverage, it's about having fewer members enrolled in Medicaid. . . . If we can move more people to private-market insurance coverage, that’s a good thing. And that’s what this waiver is designed to do.”

Rep. Mary Lou Marzian, D-Louisville, noted that many Kentuckians who will be affected by Kentucky HEALTH are already working, but their employers don't offer health insurance. She asked what jobs were available for them to move to that offered health insurance.

Meier said that while many are expected to move to higher paying jobs that offer health insurance, others will move to higher paying jobs that will price them out of Medicaid and into what is called a qualified health plan on the federal exchange, otherwise known as Obamacare.

Kentucky Center for Economic Policy report shows that between 1980 and 2016 the percentage of Kentucky employees getting health insurance at work dropped from 80 percent to 54.5 percent respectively.

Meier said that in the last five to six months, Kentucky has seen an enrollment decline of "probably around 41,000" and attributed this to an improving economic climate. "The number one reason that people are not enrolling is because they are making too much income," Meier said after the meeting.

Meier was referring to a decline from 1,434,024 members in May to 1,392,293 in September. Most of that drop, 21,508 occurred from May to June. From September 2017 to September 2018, overall enrollment dropped by 35,571, or 2.5 percent, from about 1.43 million to about 1.39 million. Expansion enrollment, which would be much more sensitive to improvements in the economy like those Meier mentioned, dropped 5.26 percent during the period.

After the meeting, Meier assured reporters that the health cabinet will be conducting a "robust evaluation" of what happens to Medicaid beneficiaries on the new plan, including tracking of labor and wage data, reasons for disenrollment, enrollment in federally subsidized insurance, and qualitative interviews.

Rep. Joni Jenkins, D-Shively, asked what Kentucky has learned from other states, like Arkansas, where more than 12,000 people have lost Medicaid coverage since the state implemented its work requirements in June.

“We’re in a little different situation than Arkansas," Meier said. "They had utilized existing infrastructure and they operationalized very quickly. In Kentucky, we’ve been planning for several years now how to operationalize this."

In addition, Meier said it's not yet clear why Arkansas Medicaid recipients lost their coverage and that it's important to "hold our collective analysis until we have a little bit more better data to analyze what's happening and then use that data in a way that is constructive to inform policy and outreach."

Deputy Health Secretary Kristi Putnam said Medicaid members will get information about the new plan 30 days before any changes in their benefits, and that information will be posted on social media and a Cabinet for Health and Family Services website. The cabinet is working with various community partners, including the Foundation for a Healthy Kentucky, to push the information.

In addition to Arkansas and Kentucky, HHS has approved Medicaid work requirements in Indiana, New Hampshire and Wisconsin, with approvals pending for Alabama, Arizona, Kansas, Maine, Michigan, Mississippi, Ohio, South Dakota and Utah.

Tuesday, November 27, 2018

Hepatitis found among three more Lexington-area food workers

Lexington Herald-Leader graphic
Three more restaurant workers in the Lexington area have been found to have hepatitis A, but the state still has no food-borne cases of the disease more than 15 months into a statewide outbreak of then liver disease, health officials said.

"Anyone who ate in November at the Hardee’s at 2990 Richmond Road in Lexington, the Waffle House at 2347 Buena Vista Road in Lexington or the Waffle House at 4 Carol Road in Winchester may have been affected," Morgan Eads of the Lexington Herald-Leader reports, based on information from the Lexington-Fayette County Health Department.

The department said in a news release, “While it is relatively uncommon for restaurant customers to become infected with the hepatitis A virus due to an infected food handler, anyone who consumed food or drink at these locations during the stated time period is advised to get a hepatitis A vaccination.” It said the three employees won't return to work until they are medically cleared.

Hepatitis A can be transmitted from person to person by food or water contaminated by fecal material. Symptoms include fatigue, stomach pain, nausea, darkened urine and yellowed skin. The health department recommends getting vaccinated for the disease and carefully washing hands with warm water and soap after using the bathroom, and before making food and drinks.

Through Nov. 17, the outbreak had affected 2,769 Kentuckians, hospitalized 1,438 and killed 17, according to the state Cabinet for Health and Family Services.

Pikeville Medical Center creating children's hospital, expanding heart-care center, adding other facilities; total cost $52 million

Pikeville Medical Center announced Tuesday that it would spend $7 million to relocate and expand its inpatient pediatrics clinic into a children's hospital, and establish, expand or improve nine other facilities with price tags totaling $45 million. Officials said about 200 jobs would be created.

The hospital appears to be on a rebound. In June, CEO Donovan Blackburn laid off 130 employees, blaming mismanagement by former CEO Walter May, whom the board ousted in January. May, 81, died Nov. 2. He had overseen the growth of the former Pikeville Methodist Hospital into a medical center with 300 beds and more than 3,000 employees, who account for one-sixth of total wages in Pike County, reports Dan Klein of WSAZ-TV in Huntington, W.Va.

"We have everywhere from doctors to house-keeps, to valets, but our average rate is $60,000 a year," Blackburn told WYMT-TV in Hazard.

The number of beds planned for the children's hospital was not announced. The hospital said it is spending $32 million, supported by a federal loan, to expand its Heart and Vascular Institute. "We're one of the top heart institutions in the state by the mere numbers of operations," Blackburn said.

The other projects include new or expanded clinics in South Williamson, Martin and Whitesburg; a new network headquarters to manage services in more than 43 buildings; an expanded laboratory costing $7 million; a new primary care center; a remodeled second-floor atrium in the May Tower; and a coffee shop.

Romaine lettuce is OK to eat unless it was grown in the Central Coast region of California, federal agencies say

Romaine lettuce (Photo from Getty Images)
After urging Americans not to eat any romaine lettuce, two federal agencies have limited their warning to lettuce grown in the Central Coast region of California.

The Centers for Disease Control and Prevention and the Food and Drug Administration say romaine  grown elsewhere, or in greenhouses or hydroponically, has not been linked to the outbreak of E.coli bacterial infections.

The agencies advise consumers to check labels or store signs for the source of any romaine lettuce, and if you have already purchased romaine (or any lettuce mix containing it) and aren't sure where it was grown, throw it out and thoroughly clean your refrigerator.

No single grower, supplier or distributor has been identified as the source of the lettuce that caused the infections.

"CDC officials recommend that clinicians not prescribe antibiotics to anyone infected with this bacteria as some studies suggest that these drugs could increase a patient’s risk of developing a serious complication from the illness," Sheri Rudavsky reports for The Indianapolis Star.

Sexually transmitted diseases are on the rise, even as funding to prevent and treat them is declining

Health officials are worried about this strain of gonorrhea that
resists antibiotics. (Centers for Disease Control and Prevention  photo)
"Health officials are tracking record-breaking rates of sexually transmitted disease, including a resurgence of some infections which had been considered rare, such as gonorrhea and syphilis. These STDs are on the rise amid cuts to public health budgets dedicated to testing, prevention, and public outreach," Mary Meehan reports for Ohio Valley ReSource, which covers Kentucky, Ohio and West Virginia.

The Centers for Disease Control and Prevention reported 2.4 million new cases of STDs in 2017; about 40 percent of those were among people aged 15 to 25. In some Ohio Valley communities, chlamydia infections rose more than 200 percent and gonorrhea rose 1,000 percent or more between 2011 and 2017, Meehan reports.

The surge among younger people could stem from a greater likelihood to engage in risky sexual behavior. Jim Thacker, spokesperson for the Madison County Health Department, told Meehan that people born after the AIDS epidemic was largely contained may be less fearful about STDs. And the availability of effective, long-term birth control might make young adults and teens less prone to use condoms, he said.

Some of those affected by STDs are much younger than teens: according to a recent CDC report, more infants are dying after catching syphilis from their mothers during birth. Syphilis is easily treated with antibiotics, but an untreated pregnant woman has up to an 80 percent chance of passing it on to her baby during birth, Meehan reports. The number of babies born with syphilis increased from 362 in 2013 to 918 in 2017, mostly in Southern and Western states.

Matt Prior, spokesperson for the nonprofit National Coalition of STD Directors, told Meehan that STDs are a public health crisis often hitting areas already hurting from the opioid epidemic, such as Appalachia.  Meehan reports, "As rates go up, Prior said, funding has gone down. So while STDs have increased by 30 percent in the last five years to reach an all-time high, the amount of federal money for prevention and education has consistently gone down since 2003. Prior says that federal funding is critical for states like Kentucky, West Virginia and Ohio."

Prior told Meehan, "The federal STD prevention line is the only line or funding streams these states have so it is really the first and last line of defense."

Sunday, November 25, 2018

2017 Kentucky law to allow mentally ill to be ordered into treatment under certain circumstances isn't being used

Faye Morton, left, joined other supporters of Tim's Law, named
for her son, to push for it in 2017. (Photo: John Cheves, Herald-Leader)
"Nobody is using a heralded 2017 state law that was intended to help hundreds of Kentuckians with serious mental illness break the perilous cycle of homelessness, jail and involuntary hospitalization," John Cheves of the Lexington Herald-Leader reports, based on interviews with court officials.

"Tim’s Law, which the legislature passed despite a veto by Gov. Matt Bevin, "created a petition process so that district court judges can order seriously mentally ill people, under certain specific conditions, into supervised outpatient treatment, including medication, counseling and enrollment in public assistance," Cheves notes. The law is named for Tim Morton, "a Lexington man who was hospitalized for psychiatric treatment dozens of times over 36 years, often involuntarily and in police handcuffs, because he did not recognize that he had schizophrenia."

So why hasn't the law been used? Cheves reports, "Part of the problem is a lack of public awareness, court officials said. But the legislature also failed to provide any money for more staff at community mental health agencies or courthouses, or — since respondents are entitled to a lawyer to represent them at hearings — public defender’s offices. All of these state-funded institutions already are struggling with their current caseloads. In fact, tucked into the nine-page law is a short note stating that it won’t take full effect until 'adequate funding' is made available." Also, "Some of the seriously mentally ill do not have responsible adults in their lives ready to intercede."

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“It breaks my heart, it really does,” Faye Morton, Tim’s mother, told Cheves. “We’re very aware of the lack of interest in this.”

Jefferson District Judge Stephanie Pearce Burke told Cheves, “The petitions are going to have to be initiated by the hospitals — by Central State and Eastern State,” which need to identify people who are frequently admitted “and then get the process started for us before their patients are discharged from an involuntary stay so we can find a better way to handle this.”

Regional mental-health agencies could play a role, Cheves reports: ", a publicly funded nonprofit that provides mental health services in Lexington, is ready to receive Tim’s Law respondents for treatment, but funding “is very tight” already, said Don Rogers, chief clinical officer. Mountain Comprehensive Care Center, a sister agency in Eastern Kentucky, has a $500,000, four-year federal grant that could be tapped, if anyone in that area ever files a Tim’s Law petition, said project manager Martin Meade."
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Saturday, November 24, 2018

Op-ed aims to inform adults about dangerous new e-cigarettes that writers say are aimed to hook a new generation on nicotine

In an effort to inform Kentucky adults about the dangers of the latest electronic cigarette devices, called mod-pods, Ben Chandler and Dr. Pat Withrow write in an op-ed for the Lexington Herald-Leader: "We encourage parents, teachers and others who work with youth to recognize them for what they are: highly effective nicotine delivery devices designed to hook a new generation."

Photo by The Sentinel-Echo, London, Ky.
Chandler is president and CEO of the Foundation for a Healthy Kentucky and Withrow is outreach director at Baptist Health Paducah.

The most popular mod-pod right now is the Juul, which looks like a large USB flash drive, and can even be plugged into a computer's USB port to charge. The authors note that knock-offs like the MarkTen Elite and the Suorin Air Pod Vaporizer are also a growing market.

Teens love them because that they are easily concealed, come in thousands of flavors (including bubble gum), don't create an odor when used, and can be personalized with "skins," which the authors call "another effective youth marketing tactic." Many of them can also be adapted to vape marijuana and other drugs.

"You may think they’ve yet to hit your home, classroom or community," they write, but add that that's likely not the case.

New data from the federal Centers for Disease Control and Prevention shows that electronic cigarette use among high-school students increased 78 percent in the past year and middle-school use went up 48 percent -- increases that the authors say coincide with the introductions of the mod pods. The U.S. Food and Drug Administration has called this upsurge an epidemic.

"Our concern is that the explosive popularity of these latest e-cig designs will reverse all the progress we’ve made in reducing smoking and related disease and death over the last 50 years," the authors write. "Kentucky already remains behind the rest of the nation in curbing tobacco use. So it behooves parents, teachers and others who work with kids to understand this dangerous new trend."

Chandler and Withrow explaining exactly what these mod-pod e-cigarettes are: battery-powered tobacco devices that heat nicotine, with pods that contain propylene glycol, other chemicals and the flavorings. When heated, the combination of nicotine, particulate matter, heavy metals and gas vapor creates an aerosol. This aerosol is inhaled into the lungs and quickly circulates into the brain.

A Juul pod contains the same amount of nicotine as in a pack of 20 cigarettes (200 puffs) -- though most teens report that they don't know there is nicotine in these devices. Multiple studies also show that kids who vape are more likely use regular cigarettes.

"We believe there’s no reason to put nicotine in these devices except to create new customers who, quite literally, can’t quit," Chandler and Withrow write. "In addition to being addictive, nicotine and other substances harm the developing brain which continues to mature until the age of 25."

The authors note that the experience is "much smoother and more addictive than previous generations of e-cigs and vapes." In fact, a Truth Initiative study found that 80 percent of 15 to 24-year-olds who try Juul continue to use the product. Use of these mod-pods has become so pervasive that teens now say they are "Juuling" instead of "vaping," they write.

They conclude: "Bottom line? There are absolutely no redeeming benefits for our youth to begin using nicotine e-cigarettes. So don’t be fooled. The latest e-cig devices pose significant health hazards for today’s youth."

Friday, November 23, 2018

Another reason to not ignore hearing loss: Study shows it will likely cost you more in health-care expenses

Untreated hearing loss in older adults affects more than just their ability to communicate. It can also increase their health-care expenses.

Medical News Today photo
A Johns Hopkins Bloomberg School of Public Health study found that older adults with untreated hearing loss pay an average of 46 percent more -- or $22,434 more -- for health care over a decade, compared to those who have no hearing loss.

“Knowing that untreated hearing loss dramatically drives up health-care utilization and costs will hopefully be a call to action among health systems and insurers to find ways to better serve these patients,” lead author Nicholas Reed said in a news release.

Reed is a member of the core faculty of the Cochlear Center for Hearing and Public Health at the Bloomberg School and an instructor of audiology in the Department of Otolaryngology-Head and Neck Surgery at the Johns Hopkins University School of Medicine.

The study, published in JAMA Otolaryngology-Head and Neck Surgery, saw differences as early as two years after diagnosis, with the patients who had untreated hearing loss showing a 26 percent increase in total health-care costs, more than half the difference found after 10 years. Of the 46 percent increase after 10 years, an average $20,403 of it was incurred by the patient's health insurer and $2,030 by the patient in out-of-pocket costs, the study found.

The findings "add to a growing body of research from Johns Hopkins and elsewhere showing the detriments of untreated hearing loss, which include a higher risk of dementia and cognitive decline, falls, depression and lower quality of life," says the release. It notes that hearing loss affects 38 million Americans, a number that’s expected to double by 2060. One in three Americans between 65 and 74 has hearing loss, and two-thirds of adults 70 and older have a clinically significant loss.

Nearly 700,000 Kentuckians have hearing loss, or about 16 percent of the commonwealth's citizens, according to the Kentucky Commission on the Deaf and Hard of Hearing. Click here to see how many people in your county have hearing loss.

How the study was done, and what might be done in response

Using data from OptumLabs Data Warehouse, the researchers identified more than 77,000 patients with likely age-related untreated hearing loss, excluding those who used a hearing aid or whose hearing loss was secondary to another condition.

An in-depth analysis found that after 10 years, "Patients with untreated hearing loss experienced about 50 percent more hospital stays, had about a 44 percent higher risk for hospital readmission within 30 days, were 17 percent more likely to have an emergency department visit and had about 52 more outpatient visits compared to those without hearing loss," the release says. And of the extra $22,434 in total health care costs, only about $600 was due solely to hearing loss-related care.

The study did not indicate why untreated hearing loss drives up health-care costs, but the release notes that a companion paper using the same data found that hearing loss is independently associated with "significantly greater" incidence of disease.

"For example, compared to those without hearing loss, those with untreated hearing loss had 3.2 more dementia diagnoses, 3.6 more falls and 6.9 more depression diagnoses per 100 people over 10 years.
Over 10 years, those with untreated hearing loss had an estimated 50 percent greater risk of dementia, 40 percent greater risk of depression, and almost 30 percent higher risk for falls compared to those without hearing loss," says the release.

“We don’t yet know if treating hearing loss could help prevent these problems,” Jennifer A. Deal, co-author and assistant scientist in the Bloomberg School’s Department of Epidemiology, said in the release. “But it’s important for us to figure out, because over two-thirds of adults age 70 years and older have clinically significant hearing loss that may impact everyday quality of life."

Deal also said poor communication could play a role in the higher costs for patients with hearing loss, noting that they may have trouble communicating their symptoms or hearing what their provider is saying about their care. One solution, she said, is increased access to "amplification devices," which the release notes will become more readily available in 2020, when a federal law authorizing certain types of over-the-counter hearing aids will go into effect.

The study was done in collaboration with AARP, the University of California San Francisco, and OptumLabs.

Study finds genes linked to body's use of cholesterol and fat, and risk for heart disease, also increase the risk for Alzheimer's

A study of more than 1.5 million people found that some of the genes that increase the risk for heart disease also increase the risk for Alzheimer's disease. It might mean, eventually, that managing cholesterol and fat in the diet could lower some people's risk for Alzheimer's.

Illustration by Michael Worful
The study, published in the journal Acta Neuropathologica, looked at the differences in the DNA of people with factors that contribute to heart or Alzheimer's disease and identified 90 points across the genome that were associated with risk for both diseases. It is the largest genetic study of Alzheimer's disease, according to the news release.

“These findings represent an opportunity to consider repurposing drugs that target pathways involved in lipid metabolism,” the medical term for the storage of fats or their breakdown for energy, said Celeste M. Karch, senior co-author and an assistant professor of psychiatry at Washington University School of Medicine in St. Louis. “Armed with these findings, we can begin to think about whether some of those drugs might be useful in preventing or delaying Alzheimer’s disease. . . . We really need to think about these risks more holistically.”

The findings are important for Kentucky. Nearly 7 percent of the state's adults have some form of heart disease, and around 70,000 Kentuckians 65 and older have been diagnosed with Alzheimer's. Heart disease is the second leading cause of death in Kentucky, and Alzheimer's is sixth.

Researchers from Washington University and the University of California, San Francisco focused on specific risk factors for heart disease, such as obesity, Type 2 diabetes and high cholesterol, to see if any of those well-recognized risk factors for heart disease also were genetically related to risk for Alzheimer’s.

Genes that influenced metabolism of fats “were the ones that also were related to Alzheimer’s disease risk,” Karch said. “Genes that contribute to other cardiovascular risk factors, like body mass index and Type 2 diabetes, did not seem to contribute to genetic risk for Alzheimer’s.”

Dr. Rahul S. Desikan, co-senior author and an assistant professor of neuroradiology at UC San Francisco, added that while more research is needed, "The new findings suggest that if the right genes and proteins could be targeted, it may be possible to lower the risk for Alzheimer’s disease in some people by managing their cholesterol and triglycerides," says the release.

Thursday, November 22, 2018

Ky. has a high premature birth rate, but 2 programs are reducing it; one stresses home visitations; the other uses data analysis

By Melissa Patrick
Kentucky Health News

One in nine Kentucky babies are born prematurely, one of the nation's highest rates – so high that the March of Dimes gave the state a "D" on its 2018 Premature Birth Report Card.

A baby is premature if born before 37 completed weeks of pregnancy, four weeks short of full-term. In 2017,  just over 11 percent of Kentucky babies were born preterm. The national average is just under 10 percent, a rate that has risen three years in a row.

Because important growth and development happens during the last weeks of pregnancy, preterm babies are at an increased risk of neurologic, respiratory and digestive problems. Complications from being born early is the main cause of newborn death, says the March of Dimes.

Preterm babies are also at risk for long-term challenges, including behavioral and social-emotional problems, learning difficulties, and increased risk of conditions like attention deficit-hyperactivity disorder and increased risk of Sudden Infant Death Syndrome. As adults, they are more likely to have chronic diseases such as heart disease, high blood pressure and diabetes, says UK Healthcare.

The March of Dimes says that while the cause of about half of premature births is unknown, there are common risk factors, including a multiple pregnancy (twins), smoking or drug use during pregnancy, being underweight, having diabetes or having preeclampsia, a condition that is characterized by high blood pressure and the presence of protein in the mother's urine.

What's Kentucky doing about it?

Several programs work to lower the number of preterm births in Kentucky.

One is a voluntary home-visitation program called Kentucky Health Access Nurturing Development Services. Kentucky's HANDS  serves first-time, high-risk mothers through local health departments. It received a $7.5 million federal grant in October.

The HANDS program provides assistance to overburdened parents from the prenatal period to the child's third birthday. It served about 4,000 people in more than 2,000 homes through nearly 56,000 home visits in 2017, according to a Cabinet for Health and Family Services news release.

Research published in the journal Maternal Child Health, shows that participants in the HANDS program had fewer preterm births and low-birthweight babies, and decreased incidences of child abuse and neglect, especially among those who received seven or more prenatal home visits.

The data shows the rate of preterm births among expectant mothers who received one to three prenatal visits was 12.1 percent, above the state's relatively high average, while the rate for those who received seven or more visits was 9.4 percent, below the national average. Similarly, the rate of low-birthweight babies dropped to 6.5 percent among mothers with seven or more visits, compared to 8 percent who had only one, two or three visits.

The study also found that women in the program had increased access to prenatal care and decreased maternal complications during pregnancy.

The home-visitation program provides the at-risk mother with a family support worker who tailors a plan to meet her needs, including linking participants to community services needed to support a healthy pregnancy and birth. And after the child is born, the program helps families nurture healthy growth and development in the child and teaches them how to create safe homes.

Courtney Embry, a nurse from the Grayson County Health Department, said a family support worker provides education about nutrition in pregnancy and can help expectant mothers sign up for the Women, Infant and Children nutrition program, help them find resources to quit smoking, or help them find transportation to get to their prenatal appointments.

"We see a lot of moms who don't have transportation, so therefore they are not actually getting to their OB appointments," she said. "So we will help them find transportation." She said they do that through community transportation programs, programs that offer gas vouchers or helping them to find employment.

"The HANDS acronym sums up what we do," said Shelly Lambert, director of early-childhood services for the Lincoln Trail District Health Department. "We are a helping hand for parents. We are there to support them, to help them, to nurture them and help with the development of their child."

Carter County HANDS coordinator Jana McGlone said one reason the program is so successful is because it explains the "why" of it all, Lisa Gillespie reported for Louisville's WFPL in October.

“Their doc might say, ‘You need to take your prenatal vitamin,’ but he may not tell them, ‘OK, this is why you should take this’,” McGlone told Gillespie. “When they get that understanding and knowledge, it makes them want to do it more."

CDC photo
Another effort to reduce preterm births in Kentucky is a Passport Health Plan program that uses a maternity-analytics platform to identify at-risk mothers. Passport manages the care of more than 310,000 Kentuckians on Medicaid. The analytics were developed by Lucina Health, a Kentucky-based obstetric data management firm.

In just six months, Passport was able to identify 85 percent of its high-risk pregnant mothers during their first two trimesters and provide them with a personalized care plan designed to reduce their risks, according to a Lucina news release. It says the program has reduced early deliveries by 13 percent, earning Passport millions of dollars.

"Identifying and communicating with at-risk mothers as soon as possible is critical to reducing preterm birth rates in the United States," the release says. "Reducing preterm birth, a national public health priority, can be accomplished by implementing strategies that target modifiable risk factors and provide access to care with potentially high social and financial impact."

November is Prematurity Awareness Month.

Beshear sues 9th opioid maker, says it makes him the most aggressive attorney general, based on number of suits

Filing his ninth lawsuit against a maker of drugs that have contributed to the opioid epidemic, Attorney General Andy Beshear said "This lawsuit makes Kentucky the most aggressive state in pursuing these companies in the nation."

The lawsuit, against Arizona-based Insys Therapeutics, "alleges the company exacerbated Kentucky’s opioid epidemic by placing profits over the health of Kentuckians," a news release from Beshear's office said. "Kentucky now leads the nation in the number of individual opioid lawsuits filed by an attorney general." Some suits by other attorneys general have multiple defendants.

Beshear announces suit (Photo by Josh James, WUKY Radio)
The Hardin County suit claims the company fraudulently persuaded physicians to prescribe Subsys, a fentanyl-based mouth spray, to treat chronic pain. The Food and Drug Administration allows the drug only for "breakthrough pain in cancer patients," the release said. The suit "alleges the company accomplished its scheme by fraudulently acquiring insurance coverage approvals, giving kickbacks to doctors, and incentivizing its salesforce to engage in unlawful and deceitful conduct. The lawsuit cites numerous company emails and promotional materials that describe the company’s alleged illegal behavior."

Beshear, who is seeking the Democratic nomination for governor in the May primary election, is not the first law-enforcement official to go after Insys. His release notes, "Between 2016 and 2017, federal prosecutors indicted and arrested Insys founder John Kapoor and several Insys executives alleging they conspired to bribe prescribers, many of whom operated pain clinics, to prescribe Subsys off-label. . .. Insys’ illegal and deceptive marketing practices were described in detail in a 2018 U.S. Senate report."

"Insys defended its promotion of Subsys against similar charges in New York, saying it made up a 'very small percentage' of opioid prescriptions in that state," Josh James reports for Lexington's WUKY. The company told the Palm Beach Post, in response to being added to a lawsuit in Florida, that it is about "allegations of misdeeds by former employees," and the firm has new management and staff.

The release said "Beshear has sued three national opioid distributors, Pennsylvania-based AmerisourceBergen, Ohio-based Cardinal Health and San Francisco-based McKesson Corp., which together are responsible for supplying 85 percent of opioids in Kentucky; distributor and retail pharmacy Walgreens; and pharmaceutical manufacturers Johnson and Johnson, Mallinckrodt, Endo Pharmaceuticals and Teva. Beshear’s office has won fights to keep four of his current opioid lawsuits in Kentucky courts. Three of the four additional suits are also pending in state court."

Wednesday, November 21, 2018

CDC says don't eat any romaine lettuce while it investigates a multi-state outbreak of E.coli infections related to it

The Centers for Disease Control and Prevention is advising Americans to not eat any romaine lettuce, and retailers and restaurants to not sell it, while it investigates the multi-state outbreak of Shiga toxin-producing E.coli infections that have been linked to the lettuce.

CDC photo
The CDC warning includes all types of the lettuce, including whole heads, hearts, bags of pre-cut romaine and salad mixes that contain it. If you are unsure, the CDC says, "Do not eat it, and throw it away. It also suggests washing and sanitizing drawers and shelves where romaine was stored.

The warning comes after 32 people in 11 states have become sick from eating the contaminated product. None of the cases have been in Kentucky. Also of concern, Canada has reported 18 people infected with the same strain of E.coli. The illnesses range from Oct. 8 to Oct. 31 and no deaths have been reported.

The CDC notes that symptoms of Shiga toxin-producing E.coli vary, but often include severe stomach cramps, diarrhea (often bloody), vomiting, and sometimes a low-grade fever. Most people will get better in five to seven days, but others can have severe, life-threatening infections. The illness can start anywhere from one to 10 days of infection.

If you believe you have an E.coli infection, call your health-care provider, write down what you ate in the week before you got sick, report your illness to the health department, and be prepared to answer questions about your illness.

The current outbreak is not related to another recent multistate outbreak of E.coli related to romaine lettuce, says the CDC.

Trial of lawsuit challenging legislature's attempted ban of most common type of second-trimester abortion ends after five days

A five-day trial over a Kentucky law that bans the most common method of second-trimester abortion is over. U.S. District Judge Joseph McKinley, who heard the case without a jury, did not hear closing arguments, but asked the lawyers to submit written statements within 45 days and said he would rule after reviewing them. Meanwhile, Gov. Matt Bevin's administration is not enforcing the law.

The procedure is called "dilation and evacuation," or D&E, and involves dilating the cervix and removing the fetus using suction and surgical tools. About 500 women underwent this procedure last year at the state's only abortion clinic, the EMW Women's Surgical Center in Louisville, Deborah Yetter reports for the Louisville Courier Journal.

State Rep. Addia Wuchner spoke to abortion foes outside
the U.S. Courthouse in Louisville Nov. 13, as trial began on
the suit challenging her legislation. (CJ photo by Matt Stone)
The legislation to ban the procedure at 11 weeks or after, except in medical emergencies, was filed by Rep. Addia Wuchner, R-Florence. It passed the Senate 31-5 and the House 75-13. The state was enjoined from enforcing it after the American Civil Liberties Union filed the lawsuit challenging its constitutionality.

Generally, a D&E is done after the 14th week of pregnancy. Earlier in pregnancy, a woman can take a medication to induce an abortion, or undergo a procedure in which suction is used to remove the contents of the uterus.

"Supporters of the law called the procedure, in which the fetus is removed with instruments, 'gruesome and brutal'," Yetter reports. "Opponents of the law say it would prohibit a safe and medically proven procedure, barring for many women in Kentucky their right to terminate a pregnancy."

Yetter reports that Bevin General Counsel M. Stephen Pitt said in his opening statement that women seeking the procedure could go out of state, or EMW doctors could comply with the law, which requires them to inject a solution to kill the fetus first, before performing the procedure.

The ACLU lawyers said Kentucky can't dodge a constitutional obligation by telling women to go out of state and the "proposed fetal demise procedure is unnecessary and brings risk of infection and complications including cardiac arrest to the patient," Yetter reports.

"ACLU lawyer Alexa Kolbi-Molinas said in her opening statement that none of the 'fetal demise' methods proposed by the state are medically acceptable, describing them as 'invasive, unfeasible, unreliable and in some cases, experimental.' Dilation and evacuation, she said, 'is the safest method that can be used' after the 14th week of pregnancy'," Yetter writes.

In September, Rewire reported, "Dilation and evacuation bans have been signed in nine states: Alabama, Arkansas, Kansas, Kentucky, Louisiana, Mississippi, Oklahoma, Texas, and West Virginia. Laws banning D&E procedures have been blocked or temporarily enjoined in seven states: Alabama, Arkansas, Kansas, Kentucky, Louisiana, Oklahoma, and Texas."

Also this week, a law to ban almost all abortions after 15 weeks of pregnancy was blocked in Mississippi, with U.S. District Judge Carlton W. Reeves writing that it disregards the 14th Amendment's "promise of due process and defied the United States Supreme Court's existing precedents on abortion rights," Alan Blinder reports for The New York Times.

“With the recent changes in the membership of the Supreme Court, it may be that the state believes divine providence covered the Capitol when it passed this legislation,” Reeves wrote. “Time will tell. If overturning Roe [v. Wade] is the state’s desired result, the state will have to seek that relief from a higher court. For now, the United States Supreme Court has spoken.”

Tuesday, November 20, 2018

Federal officials re-approve state's plan for changes in Medicaid; gradual rollout could start April 1, but more litigation looks likely

By Al Cross
Kentucky Health News

Federal health officials have again approved Gov. Matt Bevin's plan to revamp the state Medicaid program by introducing work requirements, premiums, co-payments and other changes for "able-bodied" members who weren't covered until then-Gov. Steve Beshear expanded the program in 2014.

The previous version of the plan was blocked in late June by a federal judge in Washington, D.C., who said the officials had not dealt with the state's projection that the changes would leave the Medicaid rolls with 95,000 fewer members in five years than they would have without the changes.

Gov. Matt Bevin welcomed President Trump to Lexington
on Oct. 13. (Photo by James Crisp for the Courier Journal)
District Judge James Boasberg said the officials "never adequately considered whether" the plan "would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid." Now he is likely to hear more arguments from state and federal officials and lawyers for the 16 Kentuckians who filed the lawsuit. Just what will be litigated remains unclear; the language of the Centers for Medicare and Medicaid Services approval is likely to be a major point.

The lengthy letter "makes clear that the version CMS just approved is substantially the same as the original with a few different nuances, such as a more explicit monitoring requirement about its effects," reports Amy Goldstein of The Washington Post.

CMS said in the letter that the changes are being made to encourage people to work or get education and training, not to reduce Medicaid coverage.

“There is little intrinsic value in paying for services if those services are not advancing the health and wellness of the individual receiving them, or otherwise helping the individual attain independence,” the latter. “Therefore, we believe an objective of the Medicaid program, in addition to furnishing services, is to advance the health and wellness needs of its beneficiaries, and that it is appropriate for the state to structure its demonstration project in a manner that prioritizes meeting those needs.”

CMS said in a news release that the state could begin rolling out the program regionally no earlier than April 1, the state Cabinet for Health and Family Services said in a news release. The state calls the plan Kentucky HEALTH, for "Helping to Engage and Achieve Long Term Health." It would operate under an administrative waiver of normal Medicaid rules, and after more than a year of debate is often called "the waiver." 

State Health Secretary Adam Meier said in the release that the plan “offers a customized path based on individual needs that will help beneficiaries gain better health, engagement in their communities, improved employability, and success through long-term independence.” He said it has “flexibility and procedural protections that will ensure Medicaid is able to provide beneficiaries access to services and opportunities, while utilizing a holistic approach to addressing barriers and challenges that affect overall health.”
The plan calls for beneficiaries to pay small, income-based premiums, and has "community engagement" requirements for "able-bodied" beneficiaries who are not primary caregivers: work, volunteering, job training or drug treatment at least 80 hours a month. Failure to pay premiums or report community engagement would result in loss of eligibility, which could be regained by taking a course in financial or health literacy.

“Reapproving a waiver that makes hard-working Kentuckians jump through hoops to keep their coverage will no doubt have the opposite effect," said Emily Beauregard, executive director of Kentucky Voices for Health, a coalition of interest groups. “Kentucky’s historic gains in health coverage have led to real progress in our economic recovery and our health – especially in struggling rural areas – and CMS’s decision today turns the clock back on those gains.”

Deborah Yetter of the Louisville Courier Journal notes that CMS's decision "comes as advocates have expressed increasing concern about the impact in Arkansas, which introduced work requirements earlier this year and has seen thousands cut off Medicaid enrollment as a result." Boasberg is also hearing a case challenging the Arkansas plan, the only one with work requirements in effect.

Marcie Timmerman, executive director of Mental Health America of Kentucky, said in the Vice for Health news release, “I continue to be concerned with the complexity of Kentucky HEALTH’s many administrative requirements. Kentucky quickly moved the proverbial needle on substance abuse and behavioral treatment access when we adopted Medicaid expansion. Single adults without dependents were finally able to access care. Many sought help for the first time in their life. I’m concerned many will fail to understand the new requirements and so will not be able to maintain their coverage, putting them back where they started – in our jails and on our streets instead of in treatment.”

Other stakeholders were more equivocal. Terry Brooks, executive director of Kentucky Youth Advocates, said in a release, “When it comes to this – or any policy – our question is always the same – 'Is it good for kids?" And the key to this significant policy change's success or failure lies in its implementation. Kentucky HEALTH's initial rollout and ongoing management must be family-centric." While the plan doesn't have new rules for children, pregnant women, and transition-aged youth in foster care, he said, research shows that insured parents are likelier to have insured children.

Brooks said the Bevin administration "has shown a commitment to children and families, and, as a result, we hope for and expect a family-friendly roll-out. The success story for Kentucky's kids of late has been more and more gaining access to health insurance coverage, and this plan's implementation must be a catalyst rather than an inhibitor to that trajectory of progress."

The Foundation for a Healthy Kentucky said it "remains committed to assisting Medicaid beneficiaries with their efforts to understand and comply with the waiver's requirements." In May, the foundation and the Bevin administration announced a partnership in which the foundation would pay premiums for those who cannot afford them, and work with employers and others to expand the availability of community-engagement activities in all areas of the state.

"It will take a collective effort by the state, providers, community organizations, and all those involved with the new Medicaid waiver to ensure Kentuckians are successful in meeting its requirements, so they do not lose health coverage," foundation President and CEO Ben Chandler said in a news release.

This story may be updated.

Sunday, November 18, 2018

Ky. has 78 confirmed flu cases and 2 deaths from it this season; there's no cure, so officials advise shots for all over 6 months old

Kentucky is one of three states under an influenza threat defined as "regional," with confirmed cases in 11 of the state's 17 regions. During the 2018-19 flu season, Kentucky has had 78 laboratory-confirmed cases of the flu and two deaths from it, according to the state Department for Public Health's weekly influenza surveillance report. The flu killed 325 Kentuckians in last year's season.

Flu is a very contagious disease caused by the influenza virus. There is no treatment for it, so health officials encourage everyone six months and older to get a flu shot, even if for those who are generally considered healthy -- including children.

A Centers for Disease Control and Prevention study looked at flu-related deaths in children younger than 18 over the course of six flu seasons from October 2010 through September 2016 and found that half of the deaths happened in otherwise healthy children, with most of them younger than 2. The report also shows that antiviral treatment was only given in about half of the children's deaths. The report notes that only 22 percent of the children were vaccinated.

Antiviral drugs can shorten the course of the illness or reduce its severity, but must be taken within two days of a person getting the flu.

"This study stresses how quickly the flu can become life-threatening for children. Nearly two-thirds of children died within seven days of developing symptoms. Over one-third died at home or in the emergency department prior to hospital admission. . . . This is a reminder that parents should seek prompt medical care for young children and children at high risk for flu complications with flu symptoms," says the CDC news release about the study.

Part of the problem in deciding whether to seek treatment or not is that flu symptoms are similar to cold symptoms, making it hard to differentiate between the two different viruses.

Dr. Charles Patrick Davis offers some advice on this and more in MedicineNet.

Davis notes that in general, flu symptoms are more intense than cold symptoms and can include fever, body aches, chills, and headaches, and can develop nausea and vomiting. He adds that while colds usually don't require medical care, if you suspect you have the flu you should see your health care provider.

He adds that unless you have a medical problem, most people don't need to seek care for a cold, and offers tips on when to seek medical care for flu. Here they are:
  • Fever that is continual or becomes high
  • Shaking chills
  • Coughing that produces bloody sputum and/or a greenish-yellow color
  • Difficulty breathing
  • Chest pain or chest pressure
  • Repeated nausea and vomiting
  • Confusion
  • Facial pain
  • Any uncertainty to whether you have a cold or flu during flu season
Davis also notes that if you have the flu you are typically contagious for about one to four days, though some can be contagious from about one day before the onset of symptoms for up to two weeks. For colds, most are contagious a day before the symptoms start and remain so for about five to seven days. He adds that children may be contagious for up to two weeks.

If you're looking for a place to get your flu shot, the CDC offers an interactive "flu vaccine finder" that allows you to type in your zip-code to find nearby locations that offer flu shots. Local health departments also offer the vaccine.

Saturday, November 17, 2018

Weather preparedness tips for hypothermia, carbon monoxide poisoning and food safety

By Melissa Patrick
Kentucky Health News

As the full brunt of winter approaches, the state Department for Public Health offers tips on cold-weather preparedness to prevent hypothermia, carbon-monoxide poisoning and unsafe food from power outages. The message is part of a "First 72 On You" campaign to remind Kentuckians to be prepared to manage without help for at least three days in the event of a weather emergency.

Hypothermia happens when your body loses heat faster than it can produce heat, causing a dangerously low body temperature. If left untreated, it can affect the brain, making the victim unable to think clearly or move well. It can also lead to heart and lung failure, and even death.

Hypothermia is often caused by immersion in cold water, but can also be a result of exposure to extremely cold temperatures. The Centers for Disease Control and Prevention says it can also happen during cool temperatures (40 degrees) if a person is wet (from rain, sweat or cold water) and becomes chilled.

Symptoms include shivering; an altered speech pattern; abnormally slow rate of breathing; cold, pale skin; and lethargy. In infants, the symptoms include bright red or cold skin and very low energy levels. The health department advises that you seek medical attention if you or a loved one experiences the signs of hypothermia.

Here are the health department's tips to prevent hypothermia:
  • Wear appropriate clothing, including layers of synthetic and wool fabrics, hats, coats, scarves and gloves. The best outerwear is water-resistant.
  • Avoid consuming alcohol if outdoors, which can speed the loss of heat from the body.
  • Avoid activities that cause excessive sweat, which leads to damp clothing, and chilling.
  • Stay as dry as possible
  • Outdoor workers should take special precautions to stay warm and dry.
  • The CDC recommends making a car emergency kit that among other things includes extra hats,coats and mittens, blankets, a cell phone and portable charger, water, snacks, a working flashlight and jumper cables.
Carbon monoxide: State health officials warn Kentuckians that using alternative heating sources like portable generators, kerosene heaters, propane gas stoves and ovens heated with gasoline can lead to carbon-monoxide poisoning.
CDC graphic
Carbon monoxide is an odorless, invisible gas produced when gasoline, natural gas, propane, kerosene and other fuels are not completely burned during combustion. Breathing in carbon monoxide prevents the body from using oxygen normally, and can result in death.

Early symptoms of carbon-monoxide poisoning include headache, nausea, vomiting and fatigue. If you are experiencing symptoms or if you have questions, call the Poison Control Hotline at 1-800-222-1222.

On a Facebook live event on this topic, Dr. Ardis Hoven, a consultant with the department, noted that about 170 people die every year in the U.S. from carbon-monoxide poisoning and that the state has upwards of 180 cases reported each year. "And this is something that is preventable," she said.

Here are tips for avoiding carbon-monoxide poisoning:
  • Install battery-operated carbon-monoxide detectors in your home and replace the battery and device as required. If the detector sounds, leave your home and immediately call 911. It is recommended that a detector be placed outside each bedroom, on each level of the house, and in the basement.
  • Don’t use a generator, charcoal grill, camp stove or other gasoline or charcoal-burning device inside your home, basement or garage or near a window.
  • Don’t run a car or truck inside a garage attached to your house, even if you leave the door open.
  • Don’t burn anything in a stove or fireplace that isn’t properly vented. Have your chimney checked or cleaned yearly.
  • Don’t use a gas oven to heat your house.
  • Don’t place a portable heater within reach of children or pets, and don’t use a power strip or extension cord with it. Look for an Underwriter’s Laboratories (UL) safety label, and carefully read instructions before use.
  • Seek immediate medical attention if you suspect carbon-monoxide poisoning
Food safety: Power outages during extreme weather are something to plan for, especially when it comes to food safety and avoiding foodborne illness. photo
The symptoms of foodborne illness include vomiting, diarrhea, abdominal pain, and flu-like symptoms such as fever, headache and body aches. The U.S. Food and Drug Administration says foodborne illness usually occurs within one to three days of eating the contaminated food, but can also occur within 20 minutes or up to six weeks later.

Here are some food safety tips:
  • Make sure you have appliance thermometers in your refrigerator and freezer.
  • Refrigerated foods should be safe as long as power is out for no more than four hours.
  • If the thermometer in the freezer reads 41 degrees Fahrenheit or below, or the food still contains ice crystals, the food is safe and may be refrozen.
  • Throw out any perishable food in your refrigerator, such as meat, poultry, lunch meats, fish, dairy products, eggs and any prepared or cooked foods that have been above 41 degrees Fahrenheit for four hours or more.
  • Fresh fruits and vegetables are safe as long as they are still firm and have no evidence of mold or sliminess.
  • Freeze refrigerated items that you may not need immediately to keep them at a safe temperature longer.
  • Have coolers on hand to keep essential items refrigerated if the power will be out for more than four hours.
  • Keep the refrigerator and freezer doors closed to maintain the cold temperatures.
Other advice  includes having about three days of non-perishable food on hand in case of an emergency, refill medications before the bottle is empty during the winter months, and to make sure to have working flashlights in the home.

"Remember, the first 72 is on you," Doug Hogan, spokesman for the Cabinet for Health and Family Services, said on Facebook.

For more information, you can re-watch a Facebook live event that is archived on the CHFS Facebook page. More information on this topic can be found at

Friday, November 16, 2018

FDA cracks down on e-cigs, noting use by youth more than doubled in a year, and proposes to ban menthol in cigarettes

Centers for Disease Control and Prevention graphic
By Melissa Patrick
Kentucky Health News

The U.S. Food and Drug Administration proposed Thursday to ban menthol-flavored cigarettes and cigars, and restrict the sales of some flavored electronic-cigarette liquids, some flavored cigars and the removal of e-cigarettes that are marketed to youth.

The proposals are aimed at curbing teen use of e-cigarettes and follow the release of data showing that teen use of these products increased 78 percent among high-school students and 48 percent among middle-school students in the past year.

The 2018 National Youth Tobacco Survey found that 3.6 million middle and high schools students are using e-cigarettes -- up from 1.5 million last year -- with more than 3 million, or 21 percent, of the students in high school and 570,000, or nearly 5 percent of them in middle school.

"It’s clear we have a problem with access to, and appeal of these products to kids, and we’re committed to utilizing the full range of our regulatory authorities to directly target the places kids are getting these products and address the role flavors and marketing are playing in youth initiation,” Dr. Scott Gottlieb, the FDA commissioner, said in a news release.

Explaining the menthol/mint ban, Gottlieb said it's not fair to create a market difference by limiting menthol and mint flavors in e-cigarettes when they are still allowed in combustible products.

The researchers attribute the surge in e-cigarette use to the popularity of the Juul and similar devices, because they resemble USB flash drives, allowing them to be used discreetly; have a high nicotine content; and come in kid-friendly flavors.

The new restrictions would require all vaping liquids flavored with anything other than tobacco, mint or menthol be sold only in stores that have strict age-checking practices. And if sold online, the flavored liquids must be sold under more stringent age verification rules, which will be forthcoming.

Gottlieb said the FDA would proceed with a proposed regulation banning flavored cigars, would issue a proposed rule to ban menthol cigarettes and cigars and will seek to remove any e-cig products that are marketed to youth, including those using cartoon or animated characters on the packaging.

Gottlieb said the package "reflects a careful balancing of public health considerations" between adults having access to a less harmful alternative than combustible cigarettes to quit smoking and preventing teen use. "But make no mistake," he warned. "If the policy changes that we have outlined don’t reverse this epidemic, and if the manufacturers don’t do their part to help advance this cause, I’ll explore additional actions."

Michigan Education Association photo
Juul Labs, which controls more than 70 percent of the market, announced earlier this week that, among other things, it will stop selling its mango, fruit, creme and cucumber pods in convenience stores and vape shops, and would shut down its social-media promotions and keep monitoring third-party accounts.

More bad news in youth tobacco survey

The jump in e-cigarette use supports the fears of health officials who have long been concerned that e-cig use by teens will reverse the declines in overall youth tobacco use. Multiple studies show that teens who use e-cigs are more likely to transition to cigarettes.

The youth tobacco survey found that in the last year, overall tobacco-product use among high-school students increased by 38 percent, rising to 27.1 percent from 19.6 percent, and among middle-school students by 29 percent, rising to 7.2 percent from 5.6 percent.

Not only is use of the products increasing, so is the frequency of use, which could indicate development of a habit that may be hard to stop. The survey found that the number of high-school students reporting they had used e-cigs on 20 or more of the past 30 days increased from 20 percent to nearly 28 percent in the past year.

More high school students reported having used flavored e-cigarettes in the past year; that figure rose to 68 percent from 61 percent. And current use of menthol- or mint-flavored e-cigs rose to 51.2 percent from 42.3 percent. Teens and young adults have told researchers that the flavors are the primary reason for their e-cig use.

Proposals spark debate

Gottlieb is getting some push-back from conservatives, but has held firm to his commitment to stop the teen use of these products.

“My former friends in the libertarian community who think this is emblematic of nanny-state government intervention and denying adults access to legal pleasures — I hope that when they sit and think about the data we’re seeing they’re willing to accept modest speed bumps in terms of the access adults will have to these products to hopefully close off the access of these products to kids,” Gottlieb told Paige Winfield Cunningham of The Washington Post.

In a detailed story in The Wall Street Journal about menthol products and "Big Tobacco," a spokesman for Reynolds American Inc., which makes Newport, the leading U.S. menthol brand, said banning menthols could possibly result in a legal battle, and a ban would also expand the underground market for these products, Jennifer Maloney and Tom McGinty report.

Matthew L. Myers, president for the Campaign for Tobacco Free Kids said in a news release that the menthol ban would "have a greater impact in reducing tobacco use by youth and the African-American community than any regulatory measure ever undertaken by the federal government."

But Myers argued that the FDA's e-cigarette proposal doesn't go far enough, because it stops short of banning many flavors that are highly popular with young people, noting that the menthol and mint flavors used by 51 percent of teen e-cig users will still be available.

"With these flavors still widely available, it is doubtful that this plan will stem the tide of youth e-cigarette use, and it will be critical for the FDA to quickly supplement the steps announced today," Myers said. "In addition, the Juul device itself and other e-cigarettes that deliver exceptionally high levels of nicotine will continue to be sold in convenience stores and gas stations."

Bonnie Hackbarth, a spokeswoman for the Foundation for a Healthy Kentucky, noted that the proposed regulatory changes can take years to implement and that there has already been "unnecessary delays" in the e-cigarette regulations, which have allowed new products to "flourish."

"We’re heartened by the FDA’s stepped-up enforcement and by what appears to be a clear-minded attempt to balance the absolute necessity of keeping tobacco products out of the hands of kids while allowing adults who smoke access to products that may help them quit tobacco completely," she said. "But we can’t wait two more years or even another six months, only to find that e-cig flavors and easy access have hooked millions more kids to a deadly habit."

Ben Chandler, president and CEO of the foundation, said, "Flavored cigarettes were banned in 2009 largely because the colorful packaging and names appealed to youth, which is the age most smoking habits are established. The explosive growth in teen use of Juul and other pod e-cigarettes in recent months, in conjunction with research showing that most youth try flavored e-cigarettes first . . . just proves the point. Flavors are a powerful tool in the tobacco business-model toolbox that relies on addicting new customers to stay in business. Unless and until it's proven that flavored e-cigs actually do help adult smokers quit, they shouldn't be allowed on the market."