1st Place

Covid, Ebola,Monkeypox, seasonal flu —Who needs Halloween?

— Paul Hughes-Cromwick

Inspiration: 24/7 ghosts, goblins, and pathogens

2nd Place

Surprise billing curbs,Like the famed headless horseman,Remain incomplete.

— Michael L. Millenson

Inspiration: “How to Avoid Surprise Bills — And the Pitfalls in the New Law”Ìý

3rd Place

Ghastly, grotesque, sick!You mask up to trick-or-treat,But not for covid?

— Micki Jackson

Inspiration: The ongoing mask-or-not masquerade

While Halloween may be coming to an end, KHN reporting continues year-round. Send us your haikus at any time for possible inclusion in our Morning Briefing: /contact-haiku/

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Experts say the response to the monkeypox virus in rural America may be affected by the patchy resources and bitter politics that are a legacy of the pandemic, challenges that some worry could allow sporadic infections to gain a foothold.

“Your embers turn into a forest fire really quickly,” said Brian Castrucci, president and CEO of the de Beaumont Foundation, a national nonprofit focused on public health policy. “The challenge is: Do we have the infrastructure in place in rural America for an adequate response to monkeypox, to covid, to whatever is next on the horizon?”

In Humboldt County, local officials galvanized quickly after monkeypox was reported. The local health board issued a encouraging residents to be cautious about physical contact and outlining what symptoms to look for — painful or itchy rashes, fever, and headache, among others.

“I don’t think this is something we should be afraid of,” Dr. Charles Stringham, the county’s health officer, said in the news release, “but instead something that each of us can avoid by taking a few relatively simple precautions.”

Local health officials are in a “primary prevention role,” Stringham said during an interview. It’s a role that includes educating the community about the virus, monitoring the person who tested positive, and checking in with local physicians.

State and local public health officials in Nevada said the response in Humboldt County, where nearly 18,000 people live, and similar efforts in other rural communities follow guidelines set by the Centers for Disease Control and Prevention. State and local health leaders meet monthly to discuss public health issues, which of late have included the monkeypox virus. They said they’re confident in local responses.

Still, some residents of rural Nevada said they have been confused about where to find vaccines or whether vaccines were available in their county.

Stevie Noyes, a resident of Winnemucca, Humboldt County’s largest city, who identifies as pansexual, said she wouldn’t know where to go to get a vaccine for monkeypox. She called a local retail pharmacy, where her family usually gets vaccines, in early September and was told the pharmacy didn’t have monkeypox vaccines. The pharmacist didn’t know where she could find one in town.

Noyes, a 34-year-old hairdresser, said she’s not urgently concerned about monkeypox because no other cases have been detected in the county. Should the virus begin to spread, however, she said, members of the local LGBTQ+ community would lean on one another, rather than local county or health officials.

County and health officials “take a lot of heat from the town” on the politics of responding to public health issues, Noyes said. “What I see a lot is that political influence to where it does curb what’s released and it does curb the steps that are taken.”

Despite the venomous discourse Noyes has witnessed, Stringham said that in his experience, the monkeypox virus has not been difficult to respond to politically, especially compared with covid.

shows that non-Hispanic Black and Hispanic men who have sex with other men are overrepresented in infections across the country. LGBTQ+ advocates have said they’re concerned that the government response wasn’t reaching their communities even though they are disproportionately affected.

In larger cities, such as Las Vegas, officials have to promote awareness and to distribute educational materials and vaccines. But there is no similar center in Humboldt County, where 57% of voters in 2020 that reversed a provision in the state’s constitution that banned same-sex marriage. Statewide, the ballot measure was approved by 62% of voters.

Noyes said she’s more concerned about prejudice than the virus and fears that because the virus has been linked to men who have sex with men, it could spark retribution against people who identify as LGBTQ+ in Humboldt County. “A lot of these people, the more you interact with them, the more emboldened and, I mean, eventually dangerous they become,” she said.

Some people in Winnemucca have been outspoken about calling monkeypox a “gay virus” and making jokes on Facebook, she said.

In late September, Noyes helped host Winnemucca’s second Pride festival. Immunize Nevada, a nonprofit organization focused on providing vaccines across the state, was there to provide information about covid-19 and monkeypox.

“We’re hoping to combat it that way,” Noyes said.

Kristy Zigenis, program manager for the state’s immunization program, said responding to the monkeypox virus in rural places requires nuance. “If we were to hold a clinic in, say, a rural area, not all of those people might be ready to share with the world that they have participated in this behavior,” Zigenis said.

She added that public health officials have encountered affected people in Clark County, the home of Las Vegas, who weren’t prepared to share their sexual partners’ names during contact tracing or couldn’t identify their partners. “I think that probably crosses a bit into the rurals as far as what’s going on with the case count,” she said.

As of Oct. 26, there were 28,087 confirmed cases of the monkeypox virus nationwide, , and 298 in Nevada, putting the state in the second-highest tier for transmission. Most of the state’s cases are in Clark County, where more than two-thirds of the state’s residents live, but cases have been reported in four rural counties.

Because it’s unclear whether monkeypox has spread beyond the one detected case in Humboldt County, Stringham said he’s trying to provide enough messaging to keep residents informed, but not too much to cause burnout.

He said he thinks resources would be better directed toward prevention of covid, adding that the situation could change.

To make matters more difficult, the community health nurse, who is responsible for distributing the vaccine from a state-run clinic in Winnemucca, retired months ago, and her replacement, a nurse from Carson City, didn’t arrive until October.

“We’re working in a bit of a deficit in that respect,” Stringham said.

During the interim, Zigenis said, Humboldt County residents who met the eligibility requirements to receive a monkeypox vaccine needed to see an administrative assistant in the Winnemucca Community Health Nursing Services office, where 100 doses of the Jynneos vaccine were available. The state agency would then dispatch someone to Humboldt County to administer the vaccine.

Experts say that gap is emblematic of the kinds of difficulties that officials in rural communities across the country face when responding to public health issues.

“The challenge is there may be people who aren’t seeking primary care, so cases aren’t getting picked up,” Castrucci said. He added that the focus of resources on covid or monkeypox can cause other health issues to fall through the cracks, especially considering the lack of investment in local public health departments in rural America compared with departments in larger cities.

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Click here for a transcript of the episode.

Congress is supposed to complete its annual appropriations bills before the start of the fiscal year on Oct. 1. But it rarely does, and this year is no different, as lawmakers scramble to pass a short-term funding bill so they can put off final decisions until at least December.

Meanwhile, with an eye to the midterms, House Republicans put out a “Commitment to America,” which includes only the vaguest promises related to health care. It’s yet another demonstration that the only thing in health care that unifies Republicans is their opposition to Democrats’ health policies. It’s notable that this latest Republican plan does not suggest repealing the Affordable Care Act.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Rachel Cohrs of Stat, and Victoria Knight of Axios.

Among the takeaways from this week’s episode:

• The short-term funding bill to keep the government open includes the five-year reauthorization of the FDA’s user fees, which are charged to drugmakers and help pay the salaries of many FDA employees. Democrats had hoped to add provisions to that measure that would create regulations on dietary supplements, cosmetics, and lab tests. The current authorization runs out Oct. 1, and Republicans insisted they would support only a clean bill that did not have new government directives.
• That government funding bill also will not include President Joe Biden’s request for $20 billion to help pay for additional covid-19 and monkeypox vaccines and testing. Democrats said they wanted to extend those programs, but Republicans balked and said the administration still has not accounted for all the previous appropriations.
• Biden’s comment on “60 Minutes” suggesting that the covid pandemic “is over” hurt administration efforts to persuade Congress to pass the extra covid funding.
• Biden took a victory lap this week and touted successes on administration priorities for Medicare. Among them, he said, was a reduction in next year’s Part B premium, which generally covers beneficiaries’ outpatient expenses. But that premium went down, primarily because Medicare charged too much in 2022.
• Medicare premiums this year saw a dramatic increase because officials anticipated that the federal health program would see higher costs associated with the use of Aduhelm, an expensive medication for some Alzheimer’s patients that received tentative approval in 2021 by the FDA. Medicare officials later said they would cover the drug only for patients who also enrolled in a clinical trial, and the expectations for use of the drug plummeted.
• Republican House members’ proposed agenda pledged to reverse the Democrats’ decision this year to allow Medicare to negotiate some drug prices. Although Democrats said the provision would help drive down costs, Republicans said they don’t like the government interfering in the private market and fear that the measure would hamper innovation.

Also this week, Rovner interviews filmmaker Cynthia Lowen, whose new documentary, “Battleground,” explores how anti-abortion forces played the long game to overturn Roe.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: KHN’s “Britain’s Hard Lessons From Handing Elder Care Over to Private Equity,” by Christine Spolar

Alice Miranda Ollstein: KHN’s “Embedded Bias: How Medical Records Sow Discrimination,” by Darius Tahir

Rachel Cohrs: The New York Times’ “,” by Paula Span

Victoria Knight: Forbes’ “,” by Jemima McEvoy 

Also mentioned in this week’s episode:

• House Republicans’ “”
• The New York Times’ “,” by Jessica Silver-Greenberg and Katie Thomas
• The New York Times’ “,” by Katie Thomas and Jessica Silver-Greenberg
• Politico’s “,” by Alice Miranda Ollstein and Daniel Payne
• Stat’s “,” by Aoife Brennan

To hear all our podcasts,Ìýclick here.

And subscribe to KHN’s What the Health? on , , , , or wherever you listen to podcasts.

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• Read de Marco’s “Children in Northern California Learn to Cope With Wildfire Trauma”

KHN Florida correspondent Daniel Chang discussed the Southern response to the monkeypox outbreak on C-SPAN’s “Washington Today” on Sept. 14.

• Read Chang’s “Southern States’ Lackluster Monkeypox Efforts Leave LGBTQ+ Groups Going It Alone”

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After about a week of searching online, he and three friends made an appointment in Wilton Manors, a city about 3½ hours south by car. DeChellis, who is gay, said he doesn’t understand why the vaccine wasn’t available closer to home or why getting answers about who was eligible from his local health department was so difficult.

“My biggest takeaway from our experience has been just the difference in the state of Florida from county to county,” said DeChellis, 30, a supply chain manager who lost a half-day of work while traveling to get his first vaccine dose.

The perception that the response to the monkeypox virus in the South has lacked coordination has rekindled familiar concerns about recent state policies that leave members of the region’s LGBTQ+ communities feeling marginalized and discriminated against. More urgently, it raises questions about whether state and local health departments are doing enough to protect the people principally affected by the virus: men who have sex with men.

States like New York and California have followed the to prioritize gay and bisexual men in outreach, vaccination, and treatment for monkeypox. Such states have declared a public health emergency and initiated aggressive, targeted vaccination campaigns. Although New York and California are the states with the highest number of cases, Florida, Georgia, and Texas are home to robust gay communities and together have just over a quarter of the country’s .

But in Florida, and in other areas of the South, gay men fear that the monkeypox response is not being consistently prioritized because the virus affects the health of gay men, especially those who are . And they worry that local governments are not responding with urgency to diseases that primarily affect marginalized communities.

“They are not going to go out of their way to help us,” said Hank Rosenthal, 74, a gay man and retired emergency medicine physician who lives in Fort Lauderdale, Florida.

Jeremy Redfern, a spokesperson for the Florida Department of Health and speaking on behalf of the local health departments, said the agency is “fully integrated” to respond to public health needs across the state’s 67 counties. “There are no jurisdictional boundaries to our reach in Florida,” he said. “There is no politics with monkeypox.”

But recent laws like a Florida one that prohibits instruction on gender identity and sexual orientation in some elementary school grades — referred to as the “Don’t Say Gay” bill by opponents — and the state’s for people with Medicaid have created a hyperpoliticized atmosphere around issues related to sexual orientation and gender identity, LGBTQ+ advocacy groups say. And that has some groups feeling the need to take matters into their own hands, especially in states that downplayed the covid-19 pandemic and banned face mask and vaccine mandates to limit the spread of the virus.

“We mobilize, and we try to make stuff happen because our job is to take care of our community,” said Ricardo Martinez, CEO of Equality Texas, an advocacy group for LGBTQ+ rights. “We can’t depend on the state to provide the relief and safety that we need, so we have to organize ourselves.”

Florida’s of monkeypox was reported in Broward County in late May. Since then, the health department has reported that most of the state’s more than 2,200 cases — — have occurred in South Florida’s Miami-Dade and Broward counties, where DeChellis and his friends traveled to obtain a monkeypox vaccine.

The vaccine, called Jynneos, ships from the directly to five county health departments. From there, the state sends vaccines to doctors, hospitals, and other county health departments “as needed,” Redfern said.

The national stockpile ships vaccines to five sites per state and at first used a distribution system that was unfamiliar to state officials; it required them to track doses manually and place orders by email instead of through an automated system, creating a bottleneck. On Sept. 6, the U.S. Department of Health and Human Services announced it had awarded a $20 million contract to a private wholesale company to vaccine distribution to more sites in the coming weeks.

As government responses improve, LGBTQ+ advocates and people who have tried to get vaccinated in Florida say vaccine access and information during the first months of the virus’s spread were inconsistent. They said local health departments used different eligibility criteria, appointment scheduling systems, and public outreach.

Brandon Lopez of Orlando said that when he first tried to get vaccinated through his local health department in June, he was told that only health care workers in laboratories and those who draw blood were eligible. Lopez, 30, said he considered driving to Miami after hearing that friends there got the shots but was told appointments were only for local residents.

Some counties announced in mid-July, but many people who tried to sign up said that no slots were available or that they received an error message prompting them to create a new email account.

“I’m looking at my friends that live in Chicago, that live in San Francisco, that live in Washington, D.C., and they’re able to just walk up to a place,” said Josh Roth, 33, of Orlando, who waited nearly three weeks to get his first vaccine dose. “They may have a couple of hours to wait, but they’re able to get the shots.”

Advocates are also concerned that people with more education, money, and time might be better able to access the shots.

suggests that Black and Hispanic men are disproportionately affected by monkeypox cases, yet non-Hispanic white patients have received more first doses of the vaccine than any other group, .

More appointments began to open up in Florida in mid-August after the FDA authorized a new method of giving the vaccine that required training and special equipment but stretched the nation’s limited supply.

DeChellis did not have to drive to Wilton Manors for his second shot on Aug. 23, and Roth received his second dose as scheduled. After trying for weeks to get an online appointment, Lopez got vaccinated in early August at the Orange County health department in Orlando.

But the experience made him feel as though monkeypox was not an urgent matter for local health officials. “My expectation is that if it doesn’t affect a mass group of people, it’s not going to be a priority,” Lopez said.

After the monkeypox outbreak began, some health departments in the South began partnering with so-called trusted messengers in the LGBTQ+ community to raise awareness and host vaccine clinics.

In South Florida, for example, Broward County’s health department reached out to high-risk groups in the community for help getting people vaccinated, said Robert Boo, CEO of the Pride Center at Equality Park, a nonprofit that provides health and social services for LGBTQ+ people and that hosted a vaccine drive. In Texas, Equality Texas held a webinar with doctors and other experts who answered questions from the public.

But in other areas, gay and bisexual men said they could not get answers, not even from their local health departments.

Florida, Georgia, and Texas together make up 26% of the nearly 22,000 confirmed cases reported as of Sept. 9, but their response has been unlike California’s and New York’s, where emergency declarations from governors have allowed more health care workers to administer the vaccine and local health departments to access more money from the state for vaccinations, education, and outreach.

“An emergency declaration does nothing for the response,” said Redfern, the spokesperson at the Florida health department, which is responding to a concurrent outbreak of also primarily affecting gay and bisexual men.

“There is nothing a new state of emergency order would do for Georgians that isn’t already being done,” said Andrew Isenhour, a spokesperson for Republican Gov. Brian Kemp. He also said the Georgia Department of Public Health has been raising awareness about monkeypox and recently launched a .

In Texas, Austin and Dallas officials declared local emergencies in early August. The Texas Department of State Health Services declined to comment on whether a declaration is warranted statewide.

Some providers, like Dr. Ivan Melendez of the Hidalgo County Health Authority in South Texas, agree that because monkeypox is spreading primarily among men who have sex with men, a statewide declaration is not needed. Lab testing, vaccines, and guidance for both clinicians and the public are available.

But others say an emergency declaration would signal that a threat exists, free up funding, require additional reporting, and cut bureaucratic red tape.

“It gives us a concerted response,” said Jill Roberts, an epidemiologist and associate professor at the University of South Florida. “It allows for more information: Where are vaccines going? Where are cases happening? Where are the hot spots we can hit?”

Dr. Melanie Thompson, an Atlanta physician who provides care for people living with HIV, said she would like the state and governor to play a stronger role in coordinating a uniform response across Georgia’s 159 counties. Not all local health departments are adequately staffed or funded, Thompson said.

“They’re all out there doing their own thing,” she said. “Some counties do a really good job with that. Other counties don’t.”

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Last week, the FDA told health care providers to split a one-dose vial of the monkeypox vaccine . The shift was good news for vaccine-strapped cities throughout the country because it meant what little supply is available could be stretched much further.

But then L.A. County and other cities and states were told that they would get significantly less vaccine than they’d requested. L.A. County expected to receive 14,000 vials of the vaccine this week, which would have yielded, when split, 70,000 doses for eligible residents. Instead, the county will receive 5,600 vials, which will yield only 28,000 doses.

At a news conference last week, L.A. County health officials said they expected the full shipment and with it could fully vaccinate up to 90,000 people — about half of what it believes to be the at-risk population. Now with far fewer vaccine doses, that goal may take weeks to achieve.

Monkeypox cases in L.A. County have . Most cases are among men who have sex with men. California has reported , ranking it second among states in case numbers after New York, according to the Centers for Disease Control and Prevention.

The vaccine, named , is a smallpox vaccine that can also be used to prevent monkeypox amid the ongoing outbreak. The full-vial dose is injected into muscle tissue, but giving a smaller dose between layers of the skin — known as an intradermal injection — is also effective in preventing the painful viral infection.

The shift by federal officials from allotting vials to allotting doses took local public health officials by surprise. The Administration for Strategic Preparedness and Response within the Department of Health and Human Services is responsible for .

Other places with active outbreaks also got word to expect significantly fewer vaccine vials in the next shipments. Philadelphia officials expected to receive 3,600 vials but will instead receive just over 700.

“We have thousands of people who are at risk that should be vaccinated preventively before they get exposed,” Dr. Cheryl Bettigole said Tuesday. “We are advocating to our federal partners to reconsider and restore Philadelphia’s allocation of vaccine, which is urgently needed.”

L.A. County was an early adopter of the new dosing and injection strategy.

“We communicated that Public Health would implement these changes when the next tranche of doses were received, but if providers felt ready to implement the new strategy, they could proceed,” said the department’s statement.

The L.A. County Public Health department said it received assurances from federal leadership that more doses would be available in the coming weeks. But fewer doses means will remain tight.

L.A. County has a population of 10 million people, and public health officials estimate about 180,000 are at elevated risk for monkeypox. The virus causes painful skin lesions and is spread through skin-to-skin contact with someone who has the lesions. Although anyone can contract monkeypox, gay and bisexual men who have had multiple partners in the past two weeks are at the highest risk in this outbreak. The U.S. has more than 13,500 identified cases as of Aug. 17, .

This story is part of a partnership that includes ,Ìý,Ìýand KHN.

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Antes de la pandemia de covid, se pensaba que los sedimentos de aguas residuales eran prometedores como un indicador temprano de amenazas para la salud, en parte porque las personas pueden excretar evidencia genética de enfermedades infecciosas en sus heces, a menudo antes de que desarrollen síntomas de enfermedad.

Israel ha monitoreado durante décadas las aguas residuales para la poliomielitis. Pero antes de covid, en los Estados Unidos ese control de riesgos se limitaba casi exclusivamente a actividades académicas.

Desde covid, una alianza de investigación con científicos de la Universidad de Stanford, Michigan y Emory fue pionera en los esfuerzos para recalibrar las técnicas de vigilancia para detectar el virus de covid-19: la primera vez que se utilizan aguas residuales para seguimiento de una enfermedad respiratoria.

Ese mismo equipo, , o SCAN, ahora es líder en la expansión del monitoreo de aguas residuales para detectar la viruela del simio (del mono, o símica), un virus endémico en regiones remotas de África que en cuestión de meses ha infectado a en todo el mundo, y en el país.

Hace pocos días, la administración Biden declaró el brote de viruela del simio como una , luego que se declarara en California, Illinois y Nueva York.

Y los científicos de SCAN visualizan un futuro en el que los sedimentos de aguas residuales sirvan para rastrear problemas de salud pública amenazantes. “Estamos analizando una amplia gama de cosas que podríamos evaluar”, dijo Marlene Wolfe, profesora asistente de salud ambiental en Emory.

Desde que amplió su vigilancia a mediados de junio, el equipo de SCAN ha en varias de las 11 cuencas de alcantarillado del norte de California que está monitoreando, incluidas Palo Alto, San José, Gilroy, Sacramento y dos ubicaciones en San Francisco.

Financiada por subvenciones de la National Science Foundation y la CDC Foundation, SCAN está realizando un seguimiento similar en Colorado, Georgia, Michigan y y busca ampliarse hasta a 300 sitios.

Es uno de un número creciente de proyectos de vigilancia de aguas residuales ejecutados conjuntamente por universidades, agencias de salud pública y departamentos de servicios públicos que están informando los hallazgos de covid a las agencias estatales y federales.

Los sitios de SCAN en California, Georgia, Michigan y Texas, y se encuentran entre los pocos que informaron muestras que dieron positivo para el virus de la viruela del mono.

Al igual que con covid, los datos sobre la viruela del simio se pueden usar para comparar tendencias entre regiones, pero existen límites en lo que se puede lograr. El monitoreo de aguas residuales no identifica quién está infectado; solo revela la presencia de un virus en un área determinada. Y se necesita un especialista para analizar las muestras. Los investigadores consideran que la vigilancia de aguas residuales es un complemento de otras herramientas de salud pública, no un reemplazo.

“Todavía estamos en la vanguardia en términos de descubrir el potencial”, dijo Heather Bischel, profesora asistente de ingeniería civil y ambiental en la Universidad de California-Davis. “Pero lo que ya hemos visto muestra que este tipo de monitoreo es adaptable a otras amenazas para la salud pública”.

Algunas comunidades ya tomaban muestras de aguas residuales antes de la pandemia para averiguar qué tipo de opioides usaban los residentes. Más recientemente, la tecnología también se ha revelado prometedora para monitorear y el (RSV). Los Centros para el Control y Prevención de Enfermedades (CDC) están planeando estudios piloto para ver si las aguas residuales pueden revelar tendencias en infecciones resistentes a los antibióticos, infecciones alimentarias y , una infección por hongos.

Gran parte de las pruebas de aguas residuales dependieron de fondos proporcionados a través de la legislación federal de alivio de covid. En el campus de Bischel, esos fondos se combinaron con dinero de donantes universitarios para armar un programa integral de pruebas y tratamiento para la escuela y la ciudad de Davis que incluía vigilancia de aguas residuales. La prueba de aguas residuales está en curso bajo una subvención separada.

Actualmente, los CDC solo informan resultados de covid en su sistema nacional de vigilancia de aguas residuales, un reflejo del número limitado de cuencas de alcantarillado que hasta ahora están siendo analizadas para viruela del mono.

La propagación global de la viruela del simio se detectó por primera vez en el Reino Unido en mayo y se pensó que este virus también podría pasar a las aguas residuales, ya sea a través de las heces o cuando una persona infectada con una llaga abierta se ducha.

Los alcantarillados en áreas con personas infectadas podrían “iluminarse” con evidencia de la enfermedad, si las pruebas de aguas residuales pudieran identificarla.

“Y se iluminó”, dijo Brad Pollock, presidente de ciencias de la salud pública en UC Davis Health. “Actúa como un sistema de advertencia y no es necesario persuadir a las personas para que realicen pruebas individuales para poder utilizar la información; se recopila de forma pasiva, por lo que obtienes una mirada más amplia sobre esa comunidad”.

Se cree que el virus se propaga principalmente a través del contacto íntimo de piel con piel y la exposición a lesiones sintomáticas, aunque investigadores están explorando otras vías de transmisión. Por ahora, el brote aquí se concentra mayormente entre hombres que tienen sexo con hombres.

El descubrimiento de la viruela del simio en el sistema de aguas residuales de San Francisco en junio, el primer hallazgo de este tipo en el país, lanzó la alarma en una ciudad con una creciente población LGBTQ+. El 28 de julio, San Francisco declaró la viruela del simio una e instó al gobierno federal a intensificar la distribución de vacunas.

Para su vigilancia en el norte de California, SCAN se asocia con funcionarios de salud locales y universidades para recolectar muestras, que envía a analizar a Verily Life Sciences, una empresa de tecnología de salud propiedad de la empresa matriz de Google, Alphabet. En el área de Atlanta, SCAN está trabajando con funcionarios de salud de los condados de Emory y Fulton.

Pero no todas las agencias de salud pública se están moviendo tan rápido. Apenas ahora se está elaborando un plan de monitoreo de aguas residuales para el virus en el condado de Los Ángeles, que había confirmado de viruela del simio a fines de julio.

“Con cada cosa nueva que agregamos a la plataforma de prueba, estamos aprendiendo cosas”, dijo Wolfe de SCAN. “La pandemia realmente abrió nuestra imaginación para una herramienta que ya existía pero que no se había desarrollado a su máxima capacidad. Eso ahora está cambiando”.

This story was produced by KHN, which publishes , an editorially independent service of the .

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Before the covid pandemic, wastewater sludge was thought to hold promise as an early indicator of community health threats, in part because people can excrete genetic evidence of infectious diseases in their feces, often before they develop symptoms of illness. Israel has for decades monitored wastewater for polio. But before covid, such risk monitoring in the U.S. was limited largely to academic pursuits.

With the onset of covid, a research collaboration that involves scientists at Stanford University, the University of Michigan, and Emory University pioneered efforts to recalibrate the surveillance techniques for detection of the covid-19 virus, marking the first time that wastewater has been used to track a respiratory disease.

That same research team, the , or SCAN, is now a leader in expanding wastewater monitoring to detect monkeypox, a once-obscure virus endemic to remote regions of Africa that in a matter of months has infected people globally and across the U.S. The Biden administration last week declared the monkeypox outbreak a , following similar decisions by health officials in California, Illinois, and New York.

And SCAN’s scientists envision a future in which wastewater sludge serves as a reservoir for tracking a slew of menacing public health concerns. “We’re looking at a whole range of things that we might be able to test for,” said Marlene Wolfe, an assistant professor of environmental health at Emory.

Since expanding its surveillance in mid-June, the SCAN team has in several of the 11 Northern California sewersheds it is monitoring, including Palo Alto, San Jose, Gilroy, Sacramento, and two locations in San Francisco. Funded by grants from the National Science Foundation and the CDC Foundation, SCAN is doing similar monitoring in Colorado, Georgia, Michigan, and four and wants to scale up to 300 U.S. sites.

It is one of a growing number of sewage surveillance projects across the U.S. run jointly by universities, public health agencies, and utilities departments that are feeding covid findings to state and federal agencies. How many of those networks have expanded their search to monkeypox is unclear. SCAN sites in California, Georgia, Michigan, and Texas and a in Nevada are among the few that have reported sludge samples that tested positive for the monkeypox virus.

As with covid, data on monkeypox can be used to compare trends across regions, but there are limits to what this kind of monitoring can accomplish. Wastewater monitoring doesn’t pinpoint who is infected; it reveals only the presence of a virus in a given area. And it takes a specialist to analyze the samples. Researchers consider wastewater surveillance a complement to other public health tools, not a replacement.

“We’re still really on the front end in terms of discovering the potential here,” said Heather Bischel, an assistant professor in civil and environmental engineering at the University of California-Davis, which included wastewater monitoring as part of its Healthy Davis Together covid testing program for the campus and surrounding community. “But what we’ve seen already shows that this type of monitoring is adaptable to other public health threats.”

Some U.S. communities were sampling sewage before the pandemic to figure out what kinds of opioids residents were using. More recently, along with covid and monkeypox, the technology has shown promise for and respiratory syncytial virus, or . The federal Centers for Disease Control and Prevention is planning pilot studies to see whether sewage can reveal trends in antibiotic-resistant infections, foodborne illnesses, and , a fungal infection.

Much of the wastewater testing that ramped up during the pandemic’s first year was done in concert with universities or county offices and reliant on funding provided through federal covid relief legislation. On Bischel’s campus, those funds were combined with university donor money to put together a comprehensive testing and treatment program for the school and the city of Davis that included wastewater surveillance. The sewage testing is ongoing under a separate grant.

Currently, the CDC is reporting only covid results on its , a reflection of the limited number of sewersheds that so far are testing for monkeypox.

The global spread of monkeypox was first detected in the United Kingdom in May and prompted conjecture that this virus, too, might shed into wastewater, either through feces or when an infected person with an open sore takes a shower. Sewersheds in areas with infected people might then “light up” with evidence of the disease — if the wastewater testing could pinpoint it.

“It did light up,” said Brad Pollock, who chairs public health sciences at UC Davis Health. “It acts as a warning system, and you don’t have to persuade people to take individual tests in order to use the information; it’s collected passively, so you get a more broad community look.”

The virus is thought to be spreading primarily through intimate skin-to-skin contact and exposure to symptomatic lesions, although researchers are exploring other potential means of transmission. For now, the U.S. outbreak is concentrated largely in gay communities among men who have sex with men.

The discovery of monkeypox in San Francisco’s wastewater system in June, the first such finding in the nation, set off alarms in a city with a thriving LGBTQ+ population. On July 28, San Francisco declared monkeypox , urging the federal government to step up its distribution of vaccines.

For its Northern California surveillance, SCAN partners with local health officials and universities to collect samples and then sends them to Verily Life Sciences — a health tech company owned by Google’s parent company, Alphabet — for analysis. In the Atlanta area, SCAN is working with Emory and .

Not all public health agencies are moving as fast. A wastewater monitoring plan for the virus is only now being put together in Los Angeles County, which had confirmed cases of monkeypox by the end of July.

And though California is collecting monkeypox data from its surveillance partners, it’s not available for all regions, underscoring that wastewater monitoring for viruses is still an emerging methodology.

“With every new thing that we add to the testing platform, we are learning things,” said SCAN’s Wolfe. “The pandemic really cracked open our imagination for a tool that already existed but that hadn’t been developed to its full capacity. That’s changing now.”

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Click here for a transcript of the episode.

Voters in Kansas told the rest of the country this week that they don’t want their state to ban abortion. In a nearly 60%-40% split, voters turned back an effort by anti-abortion activists to amend the state constitution to remove its right to abortion, which would have allowed the legislature to ban the procedure.

Meanwhile, in Washington, Congress is in its pre-recess push to pass legislation. A bill to provide health benefits to veterans injured by breathing in toxic substances from military burn pits finally made it to President Joe Biden’s desk. But talks continue on the Democrats’ health care-climate-tax bill that would, among other things, allow Medicare to negotiate some prescription drug prices and extend expanded subsidies for insurance under the Affordable Care Act.

This week’s panelists are Julie Rovner of KHN, Tami Luhby of CNN, Sandhya Raman of CQ Roll Call, and Rachel Cohrs of Stat.

Among the takeaways from this week’s episode:

• At least four other states — California, Kentucky, Montana, and Vermont — will have abortion questions on their ballots in November. Michigan is likely to have one, too, but the petitions required are still being certified.
• The Department of Justice has sued Idaho, arguing that its nearly-total abortion ban — set to take effect later in August — conflicts with federal law guaranteeing patients access to emergency medical care. If the case were to be appealed all the way to the Supreme Court, it could endanger the emergency care law, which has not faced that sort of legal challenge before.
• Biden signed an executive order this week that among other things could allow Medicaid to cover the travel expenses of women seeking out-of-state abortion care if their state restricts it. But the White House did not provide many details about how such a program would work or be paid for. The so-called Hyde Amendment, named for abortion opponent Rep. Henry Hyde, who died in 2007, forbids federal funding of most abortions. Supporters of the president’s move suggested that restriction applies only to medical care and not transportation, but any effort by Medicaid to set up such a transportation program would likely be litigated.
• New data released this week by the Department of Health and Human Services finds that the number of uninsured Americans has fallen to an all-time low of 8%. That estimate comes as the Senate is considering funding to continue enhanced premium subsidies for people who buy insurance on the Affordable Care Act’s marketplaces. If that legislation falters, the number of people without insurance is expected to rise sharply, as premiums will become unaffordable for many.
• Biden’s rebound of covid-19 symptoms reminds the country that the standards on when a patient has recovered are not firm and raises questions about how patients should handle reentry after battling the disease.

Also this week, Rovner interviews KHN’s Bram Sable-Smith, who reported and wrote the latest KHN-NPR “Bill of the Month” installment about a single-car accident that resulted in three wildly different ambulance bills. If you have an enormous or outrageous medical bill you’d like to send us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: KHN’s “They Lost Medicaid When Paperwork Was Sent to an Empty Field, Signaling the Mess to Come,” by Brett Kelman

Rachel Cohrs: The Washington Post’s “,’” by Joseph Menn and Lenny Bernstein

Tami Luhby: KHN’s “Hospices Have Become Big Business for Private Equity Firms, Raising Concerns About End-of-Life Care,” by Markian Hawryluk

Sandhya Raman: KHN’s “Nursing Homes Are Suing the Friends and Family of Residents to Collect Debts,” by Noam N. Levey

To hear all our podcasts,Ìýclick here.

And subscribe to KHN’s What the Health? on , , , , or wherever you listen to podcasts.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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“Todo empeoró rápidamente”, dijo el residente de Emeryville. “Aparecieron más manchas, en la cara, y empezaron a salir fluidos. La erupción se extendió a mis codos, manos y tobillos”.

Después de seis citas virtuales con médicos y enfermeras, una llamada a una línea de atención de enfermería, una visita a una clínica de urgencias, dos a una sala de emergencia y dos diagnósticos incorrectos, un especialista en enfermedades infecciosas le diagnosticó a Kwong, de 33 años, viruela del simio (del mono o símica) a principios de julio.

A pesar de hacerse dos pruebas, nunca dio positivo.

Como el número de casos se ha disparado en Estados Unidos en el último mes, el sistema de salud pública se esfuerza por difundir el peligro del virus y distribuir un .

Pero el problema va más allá. Las personas que pueden estar infectadas se enfrentan a callejones sin salida, retrasos, diagnósticos incorrectos y tratamientos inadecuados mientras navegan por un sistema de atención de salud poco preparado y mal informado.

Este virus, poco conocido, hace que los hospitales se apresuren a enseñar al personal de urgencias a identificarlo y analizarlo correctamente. El doctor Peter Chin-Hong, especialista en enfermedades infecciosas de la Universidad de California-San Francisco que finalmente diagnosticó a Kwong, dijo que su caso fue un punto de inflexión para su hospital.

“Kevin llegó en mitad de la noche, cuando no había muchos recursos disponibles. Así que creo que después de su caso, nos estamos educando mejor sobre la enfermedad. Pero creo que los médicos no siempre saben qué hacer”, señaló Chin-Hong.

La viruela del simio es causada por , aunque no es tan transmisible ni mortal. Normalmente, los pacientes tienen fiebre, dolores musculares y luego una erupción en la cara, la boca, las manos y posiblemente los genitales que puede durar varias semanas.

El brote actual se propaga por , como tocar una herida o intercambiar saliva u otros fluidos corporales. Las personas también pueden infectarse al tocar objetos o superficies, como juguetes sexuales o sábanas, compartidos con alguien con la enfermedad.

El primer caso de viruela del simio en Estados Unidos se notificó el 17 de mayo, y desde entonces el número se ha elevado hasta probables o confirmados que representan a casi todos los estados, además de Washington, DC, y Puerto Rico.

El gobernador de California, Gavin Newsom, declaró el 1 de agosto el para coordinar la respuesta y reforzar las iniciativas de vacunación del estado. Alrededor de en California se han concentrado en la zona de la Bahía de San Francisco.

Aunque cualquiera puede infectarse, el brote parece haber afectado en gran medida a los hombres que tienen relaciones sexuales con hombres. Kwong explicó que probablemente contrajo la viruela del mono en un encuentro sexual durante los eventos del New York Pride.

“Este es el primer brote multicontinental de la historia, así que no va a desaparecer sin más”, afirmó , profesor de la Universidad de California-Irvine que estudia las enfermedades infecciosas.

“Esto no va a explotar como covid, pero este brote va a tener su recorrido”, añadió. “Puede que sea como la sífilis y permanezca”.

Pero la mayoría de los médicos no saben cómo reconocerlo. A finales de junio, cuando Kwong empezó a experimentar los síntomas, la mayoría de los médicos y enfermeras con los que habló durante las visitas virtuales ni siquiera mencionaron la viruela del mono. Eso no le sorprende al , profesor de medicina y epidemiología de la UCLA.

“Aunque he trabajado de forma intermitente en varios países del África subsahariana durante los últimos 25 años, nunca he tratado un caso de viruela del simio”, explicó Brewer. “Antes de este brote, era una enfermedad muy inusual”.

Una erupción limitada a la zona genital o rectal puede confundirse con una infección de transmisión sexual. Pero, según Brewer, incluso si los médicos no han sido capacitados para reconocer la viruela del simio, sus consejos a los pacientes podrían ayudar a contener la propagación.

“Deberían aconsejar que no se tenga actividad sexual hasta que sus lesiones estén curadas y tratadas”, apuntó Brewer.

Aunque muchos casos son leves y se resuelven por sí solos, algunos se agravan rápidamente, como el de Kwong.

“Tu cuerpo está siendo invadido por esta cosa que no entiendes. Y no tienes a dónde ir, así que es doloroso y aterrador”, dijo Kwong.

Al principio, Kwong trató la erupción con los esteroides tópicos que utiliza para el eczema. Cuando eso no funcionó, tuvo una cita en línea con una enfermera que le diagnosticó herpes y le recetó un medicamento antiviral.

En las horas siguientes, la erupción se extendió rápidamente a más partes de su cuerpo. Alarmado, Kwong fue a una clínica de urgencias. El médico coincidió con el diagnóstico de herpes y añadió otro: sarna, . “Mis manchas se concentraban en las manos, las muñecas, los pies y los codos, que son lugares privilegiados para la sarna”, contó Kwong.

Este médico pensó en la viruela del mono, pero las manchas de Kwong estaban agrupadas y tenían un aspecto diferente al de las imágenes de la erupción con las que este médico estaba familiarizado. “Dependiendo de dónde estuviera con mis síntomas, y de con quién hablara, recibía respuestas diferentes”, dijo Kwong.

Durante el fin de semana del 4 de julio, “intenté contactar a médicos, conocía a amigos de amigos que eran dermatólogos”, agregó. “Cada vez que hablaba con alguien, empeoraba rápidamente. Y era realmente extraño”.

Durante otra cita virtual, en mitad de la noche, una enfermera se dio cuenta de que la erupción se había extendido hacia los ojos y le dijo que fuera a la sala de emergencias de inmediato. Fue allí, en el Alta Bates Summit Medical Center de Oakland, donde los médicos dijeron que Kwong podría tener viruela del simio.

“Estuvieron investigando mientras yo estaba en la habitación, y llamaron a los Centros para el Control y la Prevención de Enfermedades (CDC). Como paciente, sentía que no sabía qué me estaba pasando, pero no me di cuenta de la poca información con que contaban los profesionales y de lo poco preparados que estaban ellos también”, expresó.

Pasó 12 horas en la sala de emergencias, donde las enfermeras le hicieron una prueba de viruela del simio. Le dijeron que volviera si tenía fiebre o empezaba a vomitar.

“En ese momento, me sentía muy mal. Tenía llagas en la parte posterior de la garganta, en la boca, por todo el cuerpo”, dijo. “Simplemente deliraba porque no podía dormir más de una o dos horas seguidas”.

Más tarde, esa misma noche, Kwong decidió ir al (UCSF). Se había enterado por un amigo de que el UCSF Health estaba tratando casos de viruela símica, y una enfermera de atención virtual le había dicho que fuera allí.

Cuando llegó, lo separaron de los demás pacientes, le dieron oxicodona para el dolor y le hicieron una prueba de viruela del simio.

Al día siguiente, Chin-Hong empezó a tratar a Kwong de viruela del simio. “Pensé, vaya, esta es una enfermedad muy, muy extendida”, contó Chin-Hong. “He visto otros casos de viruela del mono antes, pero muy concentrados. Diría que Kevin está probablemente en el 5% superior de la gravedad de las enfermedades”.

Como la erupción estaba cerca de los ojos de Kwong, Chin-Hong temía que pudiera quedarse ciego si no se trataba la enfermedad. Le recetó Tecovirimat, un medicamento antiviral con la marca TPOXX, que ha recibido la autorización especial de la FDA para tratar la viruela del mono en determinadas circunstancias.

Tras el primer día de tratamiento, Kwong notó que la erupción había dejado de extenderse. En los dos días siguientes, los cientos de manchas hinchadas se aplanaron en discos rojos. “Me sorprendió lo rápido que mejoró Kevin. Era como un turbo-cohete en el camino de la recuperación”, explicó Chin-Hong.

Cuando Kwong empezó a curarse, recibió el primer resultado de la prueba: negativo. Luego el segundo: negativo.

Chin-Hong dijo que era posible que losque tomaron las muestras de las lesiones no hubieran frotado con la suficiente fuerza como para obtener células vivas para la prueba.

“Como médico, es muy difícil obtener una buena muestra en este tipo de lesiones porque el paciente suele sentir dolor. Y no te gusta ver a la gente sufrir”, comentó Chin-Hong.

Casos como el de Kwong pueden pasar desapercibidos si las pruebas no se realizan correctamente. El para los médicos que proporcionan los CDC es adecuado, dijo Brewer, pero solo si se toma el tiempo para leer las 59 páginas.

Los médicos necesitan recoger al menos dos muestras de varios lugares del cuerpo del paciente, añadió. Según Brewer, la clave es tomar muestras de las lesiones “en diferentes etapas de desarrollo” y no concentrarse solo en los primeros bultos.

Durante dos semanas, Kwong tomó seis pastillas antivirales al día para eliminar el virus de su cuerpo. Ya no necesita medicación para el dolor. “Mi cara fue la primera en curarse, lo que me ayudó mucho a ser capaz de reconocerme en el espejo”, dijo Kwong.

Contó que, ahora que ha pasado más de un mes desde que comenzó su calvario, las manos y los pies se están curando por fin. Las cutículas y la piel de las manos se desprendieron y están en proceso de regeneración, mientras que las uñas se han vuelto negras y han empezado a caerse.

Kwong dijo que el daño psicológico tardará más en superarse. “Me siento menos invulnerable, porque fue una enfermedad que me debilitó muy rápidamente. Así que sigo trabajando en mi estado mental más que en el físico”.

Esta historia es parte de una alianza que incluye a KPCC, NPR y KHN.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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