Arizona’s Efforts to Reduce Maternal Mortality and Severe Maternal Morbidity

By Mary Ellen Cunningham, AzPHA Board President

The United States ranks lower than Poland, Belarus and UAE among other nations in maternal mortality according to the CIA’s World Factbook.  A report from ACOG on maternal mortality tells us that the US Maternal Mortality rate is the only one raising among industrialized nations.  But deaths are the tip of the iceberg; it is estimated that 50-100 women experience severe maternal morbidity for every death. The CDC defines severe maternal morbidity as the unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman's health.  So, what is killing or injuring Arizona mothers?  A report published by ADHS based on available data shows us the leading causes of death or severe injury are cardiac and hypertensive disorders, hemorrhage and suicide/homicide and accidents.

In the past few years, there have been efforts nationally and within Arizona to change that trajectory.  Arizona has had a Maternal Mortality Review process, which was actually just a few lines added to the statute for Child Fatality Review, since 2011 which created a subcommittee to look into Arizona maternal deaths.  While many volunteers reviewed the cases monthly, there were no reporting requirements and never any funding attached. Additionally, the state agencies are often handicapped by the inability to hire new folks.

But all that is changing…very much for the better.  For over a year now, the Bureau of Women’s and Children’s Health, in partnership with the March of Dimes and the Arizona Perinatal Trust has been leading Arizona’s efforts to reduce maternal fatalities and severe morbidities through a collaborative process. A Severe Maternal Morbidity/Maternal Mortality Prevention Taskforce was formed on October 30, 2018 and engaged over 36 stakeholders representing the state agencies, tribes, maternal health experts, and healthcare systems.

The Task Force met a few times during the past year, reviewed data and participated in facilitated discussions.  ADHS developed a Maternal Mortality Action Plan based on the suggested strategies:

  • Sustained partnership with the Alliance for Innovation on Maternal Health (AIM)

  • Engage providers and patients

  • Secure funding

  • Expand the scope of data analysis with respect to racial disparities

  • Continuous communication with stakeholders

The Task Force is ongoing.  Information about it can be found here.

The March of Dimes, at the same time, led the effort to expand on the work of the existing Maternal Mortality Review process.  As a result of the hard work of many, and led by Senator Kate Brophy McGee, SB1040 was passed and signed by the governor at the end of the 2019 Legislative session.  SB1040 requires ADHS to gather together an advisory committee to look at the maternal mortality and morbidity review process and to report on that review to the chairs of the House and Senate Health committees by December 31, 2019 and to have a report to the governor on the incidence and cause of maternal fatalities and morbidity by December 31, 2020.

In the meanwhile, there was no grass growing under ADHS. They had applied for and were awarded a competitive grant from the CDC to support the maternal mortality efforts by standardizing the current maternal mortality review process; supporting the MMRC in developing actionable recommendations;  disseminating the findings of the MMRC to different audiences and leading and supporting the adoption of maternity safety bundles at birthing facilities.  This $450,000 a year for five years will also support needed staff. 

They also applied to become a part of the Alliance for Innovation on Maternal Health (AIM), a national effort of reducing maternal mortality and severe maternal morbidity and have started working with AIM and at the same time are awaiting to hear about an additional grant application to HRSA about maternal health.

The members of the legislatively required Advisory Committee on Maternal Mortality and Morbidity were selected from an open application process and has met once and will meet again this Monday, September 16 to continue its work. There is a very short window to accomplish much.  I was selected to represent ‘a public health organization.’ It is an Open Meeting, so anyone is welcome to attend. Here is a link to the details.

Finally, maternal mortality has become a focus of the governor’s Goal Council.  ADHS is finishing up a plan that incorporates the work and the recommendations of the multipartnered Task Force.  This Plan should be out soon.  It will not only address the acute side of maternal mortality like hemorrhage or hypertensive crisis but will address many of the social determinants of health like access to care.  As public health folk know, its what happens upstream that changes societies.

On a personal note, I have never felt so hopeful for mothers and babies in this state.  ADHS, the March of Dimes, the Arizona Perinatal Trust and countless medical personnel and health care systems both public and private have all worked tirelessly for generations to improve the outcomes for mothers and babies, but this coordinated effort is beyond anything any one group could accomplish. There is a golden opportunity right now with a mix of state and national efforts, political will and ample funding.  The battle is ours to win.  

HHS Agencies Begin to Engage on E-Cigarette Lung Injuries... and what’s the Root Policy Cause of the Vaping Epidemic?

Late last week the CDC issued an Advisory about their investigation of a multi-state outbreak of severe pulmonary disease associated with e-cigarette product (devices, liquids, refill pods, and/or cartridges) use. As of September 6, 2019, over 450 possible cases of lung illness associated with the use of e-cigarette products have been reported to CDC from 33 states. As of Friday, there had been 5 deaths have been confirmed in California, Illinois, Indiana, Minnesota, and Oregon.

CDC also developed a case definition to classify cases consistently.  State and county health departments will now be able to use the new case definition to determine if cases are confirmed or probable (after examining the medical records of suspected cases and consulting with the clinical care team to exclude other possible causes).

Unlike nationally reportable conditions like communicable diseases, these cases require clinicians and public health to interview patients to determine product use and individual behaviors- which means that there’s no active surveillance system to look for injuries like these.  With more health departments and emergency departments actively looking, it’s certain that more cases will be identified, and we should be able to learn more about what’s actually happening and why pretty soon.

There aren’t enough data yet to determine what specifically might be causing the cases but many of the samples tested by the states contained significant amounts of Vitamin E acetate. Vitamin E acetate is in topical consumer products or dietary supplements, but data are limited about its effects after inhalation.

While the FDA and CDC don’t have enough data presently to conclude that Vitamin E acetate is the cause of the lung injury, they urged consumers to not use vaping products that might contain Vitamin E acetate (but I couldn’t find out how consumers would be able to tell that). The statement also said that “… no youth should be using any vaping product, regardless of the substance”.

FDA “Intends to” Better Regulate Flavored Vaping Products

Today the US Department of Health and Human Services Secretary announced that: “… the FDA intends to finalize a compliance policy in the coming weeks that would prioritize the agency’s enforcement of the premarket authorization requirements for non-tobacco-flavored e-cigarettes, including mint and menthol, clearing the market of unauthorized, non-tobacco-flavored e-cigarette products. The FDA plans to share more on the specific details of the plan and its implementation soon.”  I guess we’ll learn more about that the Federal Register in the weeks to come.

Today’s announcement that FDA intends to do more came out after preliminary numbers from the National Youth Tobacco Survey showed a continued rise in the rates of youth e-cigarette use, especially among the non-tobacco flavors that appeal to kids.  In particular, the preliminary data showed that more than 25% of high school kids are current (past 30 day) e-cigarette users in 2019 and the overwhelming majority cited the use of popular fruit and menthol or mint flavors.

Sadly, nothing in the HHS or FDA materials from today suggested that they intend to use any of their authority to tightly regulate the advertising and marketing of e-cigarettes. That fact that they were silent on that makes me believe that that might not be in the cards.

Arizona Policy Interventions Last Legislative Session were Unsuccessful

One of the key public health policy interventions that could make a dent in the vaping epidemic here in Arizona was last year’s SB 1363 Tobacco Product Sales (Tobacco 21) sponsored by Senator Heather Carter.  The bill would have classified electronic cigarettes as a tobacco product (allowing it to be regulated like tobacco – including covering it in the Smoke Free Arizona Act) and moving the buying age for cigarettes and electronic cigarettes to 21 years old.  Sadly, that bill never got a hearing at the Legislature.

So, What’s the Root Policy Cause of the Vaping Epidemic?

In short, it’s judicial branch interpretations of the FDA’s authority to regulate e-cigarettes under the Family Smoking Prevention and Tobacco Control Act.

In June 2009, President Obama signed into law the Family Smoking Prevention and Tobacco Control Act, which gave the FDA the power to regulate the tobacco industry. Under the Act, nicotine and cigarettes can’t be banned but flavorings like fruit or mint can.  Additionally, the law required new tobacco products seeking to enter the market to meet FDA pre-market standards (including electronic cigarette regulation). The statutory language left open the possibility that electronic cigarettes may be able to be regulated as a nicotine delivery device- and as such could have required a prescription.

The FDA exercised that authority by directing the U.S. Customs and Border Protection to reject the entry of electronic cigarettes into the US on the basis they were unapproved drug delivery devices.

A series of lawsuits then followed FDA’s decision. In a December 2010 landmark decision in the Smoking Everywhere v. FDA case, the U.S. Court of Appeals in Washington ruled the FDA can only regulate e-cigarettes as a tobacco product (e.g. that e-cigs can’t be regulated as a nicotine delivery device- which could have included a prescription requirement). The court said that if therapeutic claims are made then the FDA might be able to regulate e-cigs as a nicotine delivery device.  That order is here and the 25-page decision is here.

In a subsequent ruling in December 2010, the appeals court also ruled against the FDA in a 3–0 unanimous decision, finding that the FDA can only regulate e-cigarettes as tobacco products. The judges ruled that such devices would only be subject to drug legislation if they are marketed for therapeutic use – E-cigarette manufacturers had successfully proven that their products were targeted at smokers and not at those seeking to quit.

Editorial Note: Here lies the root cause of why we are where we are right now.  Had the judges found that the FDA had the authority to regulate e-cigarettes as a nicotine delivery device- they could have required a prescription (for smoking cessation purposes) on e-cigs and the marketing wildfire that resulted in the addiction of a generation of young people to high levels of nicotine could have been averted. 

Following those court rulings, in April 2011 the FDA announced it will regulate e-cigarettes like traditional cigarettes and other tobacco products under the Food Drug and Cosmetics Act, however, they never exercised their authority to regulate the marketing and advertising of e-cigarettes, and here we are…  in the middle of a teen and young adult vaping epidemic.

Michigan Health Department to Ban Sale of Flavored E-Cigarettes

This week Governor Whitmer of Michigan ordered the Michigan Department of Health and Human Services to ban the sale of flavored electronic cigarettes. 

Last week the Department declared that youth vaping constitutes a public health emergency, triggering the directive. The ban will covers both retail and online sales of flavored e-cigs as well as preventing misleading marketing of vaping products, including the use of terms like “clean,” “safe,” and “healthy”.  Besides sweet flavors, the prohibition will also apply to vaping products that use mint and menthol flavors.

The new rules will go into effect as soon as the health department issues rules later this month.  The initial ban will last 6 months.  In the mean time the health department will develop permanent regulations banning flavored e-cigarettes.  The ADHS has an ongoing social media campaign, but additional policy interventions are clearly needed.

Below is a link to a webinar series by the Western Region Public Health Training Center.  I really need to view these in the next couple of weeks- you might want to as well.

APHA Urges Congressional Leaders to Act on Firearm Violence Prevention Legislation 

APHA sent a  letter to House and Senate leaders urging Congress to take immediate action on three key proposals to address the epidemic of gun violence in the U.S. In the letter to House and Senate leaders, the letters urge Congress to enact three critical and commonsense policies already under consideration that would create major progress in reducing the toll of firearm violence. These policies include:

1) appropriating $50 million through the FY 2020 Labor, Health and Human Services, Education, and Related Agencies appropriations bill for public health research on firearm morbidity and mortality prevention;

2) enacting legislation requiring universal background checks, such as H.R. 8, the Bipartisan Background Checks Act; and

3) enacting legislation that allows the removal of firearms from those deemed potentially harmful to themselves or others through the issuance of extreme risk protection orders, or ERPO, such as H.R. 1236/S.506, the Extreme Risk Protection Order Act.

The joint letter urges Congress to work to enact these important proposals upon their return to Washington, D.C., following the summer congressional recess. We shall see.

Here's how you can urge your member of Congress to act on key gun violence prevention legislation.

UA and Pima County Launching an Academic Health Department

The UA Mel and Enid Zuckerman College of Public Health and the Pima County Health Department have created an Academic Health Department with the goals of enhancing public health education, training and research to improve community health in Pima County.

Some of the elements of the Academic Health Department will include an expansion of internship opportunities at the Health Department for UA Zuckerman College of Public Health students; research poster forums featuring projects developed by interns; training for internship preceptors, faculty advisers, graduate coordinators and undergraduate advisers; and a fellowship program.

There will also be a Mini Public Health School, which will be a monthly lecture series featuring presentations by faculty members and health department staff discussing their research and community-based projects. 

Members of the AHC core team from the UA Zuckerman College of Public Health are: Dr. Rosales and Emily Waldron, community engagement and outreach coordinator. From the Pima County Health Department: Bob England, MD, MPH, interim director; Julia Flannery, organizational development program manager; Paula Mandel, deputy director; and Kristin Barney, MA, division manager. 

For more information, about the Academic Health Department, please contact Dr. Cecilia Rosales at, (602) 827-2205.

Aligning the Roles of Medicaid and Public Health

Aligning the Roles of Medicaid and Public Health

Medicaid and public health partnerships play an important role in advancing a statewide approach to improving health and reducing health disparities. Collaboration and shared priorities between agencies can play a super important role in improving outcomes.

The Association of State and Territorial Health Officials recently put together this interesting and easy to listen to 30 minute podcast that highlights opportunities to  leverage each agency's respective roles and resources through the CDC’s 6|18 Initiative.  Here are some links to additional resources regarding these kinds of partnerships:

U.S. Surgeon General’s Advisory:

Marijuana Use and the Developing Brain

The US Surgeon General (Jerome Adams MD) Issued  a concise advisory this week  that emphasizes the health risks of marijuana use in adolescence and during pregnancy. He released the Advisory in response to recent increases in access to marijuana and in its potency, along with misperceptions of safety of marijuana endanger our most precious resource, our nation’s youth.

Doula Services Improve Maternal and Child Health Outcomes

Medicaid Programs Increasingly Reimbursing for Doula Services

Doulas are professionals who provides physical, emotional, and informational support to a woman throughout pregnancy, childbirth, and postpartum. Doula’s act as a facilitator between the laboring women and her physician by ensuring that mom and dad get the information they need in a way that they understand so they can make informed decisions. 

Evidence suggests that support from doulas is linked to lower c-section rates and fewer complications. Medicaid finances more than half of all births each year in 25 states, indicating that Medicaid reimbursement policy can be a particularly effective lever to improve maternal health outcomes. Two states have enacted legislation to provide reimbursement for care by doulas as a way to improve maternal health outcomes and address existing maternal mortality disparities.

Currently, Minnesota and Oregon take advantage of the fact that doulas can reduce healthcare costs while improving outcomes in their state Medicaid programs. In the 2018 budget, Minnesota increased the reimbursement rates for doulas.  The new law also requires Oregon’s coordinated care organizations (which deliver Medicaid services) to provide information about how to access doula services online and through any printed explanations of benefits. The law tasked Oregon Medicaid with facilitating direct payments to doulas, which was addressed through rulemaking.  

New Jersey recently enacted legislation to improve maternal health among disproportionately affected groups of women by permitting the state to seek a state plan amendment or waiver that establishes Medicaid reimbursement for doula services. The legislation follows a recently piloted state doula program aimed at reducing health disparities in communities with high infant mortality rates.

Indiana also enacted legislation ensuring that pregnancy services covered by Medicaid also include reimbursement for doulas. The law incorporates doula services into the state’s obstetrician navigator program through the department of health, as well as the family and social services administration, allowing Medicaid reimbursement for services provided by doulas. Like in New Jersey, this legislation allows the state to apply for a state plan amendment or waiver necessary to implement doula reimbursement in Medicaid.

There's growing momentum to conduct comprehensive reviews of maternal mortality data, which could help better understand the underlying causes of health disparities. Using a health equity lens to develop policy and design clinical interventions could also prove valuable by ensuring that services are culturally competent, affordable, and accessible by populations who need them most. 

Twenty-nine states (including Arizona) have committees that review maternal deaths and make public policy recommendations.  Arizona took a big step forward this last legislative session with the passage of SB 1040 Maternal Mortality Report which establishes a Maternal Fatalities and Morbidity Advisory Committee to explore public health policy interventions to improve maternal outcomes.

Perhaps the Advisory Committee, which meets on Friday August 30 from 9:30am to 12:30 pm at the Arizona State Laboratory, will explore the role that Doulas can play in improving birth outcomes and make some evidence based recommendations to better use their services in Arizona's care network (our Board President Mary Ellen Cunningham will be representing AzPHA on the committee).

Addressing Postpartum Depression with Public Health Policy

As Arizona embarks on an in-depth look at maternal mortality in the coming months no doubt that postpartum depression will be part of the discussion.  

Moms with postpartum depression can have feelings of sadness, anxiety, and exhaustion that may make it difficult to care for themselves and their kids.  Data from the CDC’s Pregnancy Risk Assessment Monitoring System (PRAMS) show that one in nine U.S. women experience symptoms of postpartum depression.

While there's not a single cause of postpartum depression—it likely results from a combination of physical and emotional factors—women are at greater risk for developing postpartum depression if they have one or more of the following risk factors:

  • Symptoms of depression during or after a pregnancy.

  • Previous experience with depression or bipolar disorder.

  • A family member who has been diagnosed with depression or other mental illness.

  • A stressful life event during pregnancy or shortly after giving birth.

  • Medical complications during childbirth.

  • Mixed feelings about pregnancy.

  • Lack of strong emotional support from a partner, family, or friends.

  • Alcohol or other drug use problems.

Legislative approaches to address maternal mental health conditions and postpartum depression include increasing awareness of risk factors for and effects of postpartum depression, increasing access to prenatal and postpartum screening for these risk factors, and increasing access to treatment and support services for women at high risk for postpartum depression.

Below is an overview of state legislative activity in 2019 to address the screening and treatment for maternal mental health conditions and postpartum depression.

Texas passed 2 bills addressing postpartum depression. One (HB 253) requires their health and human services commission to develop and implement a five-year strategic plan to improve access to postpartum depression screening, referral, treatment, and support services.  The other bill (SB 750) instructs the commission to develop and implement a postpartum depression treatment network for women enrolled in the state’s medical assistance program.

In Oklahoma, SB 419, directs the state licensing boards to work with hospitals and healthcare professionals to develop policies and materials addressing education about and assessment of perinatal mental health disorders in pregnant and postpartum women.

Illinois passed HB 2438 which requires that mental health conditions occurring during pregnancy or postpartum be covered by insurers.  HB 3511 (the Illinois Maternal Mental Health Conditions, Education, Early Diagnosis, and Treatment Act) requires their department of human services to develop educational materials for health care professionals and patients about maternal mental health conditions and requiring birthing hospitals to supplement the materials with relevant resources to the region or community in which they are located.

Virginia passed HB 2613, which adds information about perinatal anxiety to the types of information licensed providers providing maternity care must provide to each patient (including postpartum blues and perinatal depression).

Arizona will be exploring strategies to improve maternal health outcomes as part of the implementation of SB 1040 Maternal Mortality Report - which established a Maternal Fatalities and Morbidity Advisory Committee to explore public health policy interventions to improve maternal outcomes.

Perhaps the Advisory Committee, which meets on Friday August 30 from 9:30am to 12:30 pm at the Arizona State Laboratory, will explore the role public policy can play in reducing the public health impact of post-partum depression. Our Board President Mary Ellen Cunningham will be representing AzPHA on the committee.

Immigration Status, Public Benefits & Access to Care

Medicaid generally limits eligibility (for immigrants) to qualified legal immigrants with refugee status, veterans, and people lawfully present in the US for 5 years or more. State Medicaid programs can elect to provide coverage to legally present immigrants before the 5-year waiting period ends (Arizona does not).

States get matching funds from CMS when they choose to provide Medicaid coverage to legally present immigrants who are children or pregnant before the end of the 5-year waiting period.  33 states have elected to cover lawfully residing immigrant children and 25 states cover legally present pregnant women (Arizona does not).

The Affordable Care Act made it possible for the legally present immigrants who are ineligible for Medicaid (due to being in the five-year waiting period) to qualify for commercial coverage and subsidies on the Federal health insurance marketplace.

Immigrants eligible for Medicaid or employer-sponsored insurance face several coverage and service barriers.  As I mentioned above, immigration officials consider the likelihood of individuals and families becoming a “public charge,” which can result in denied admission to the US or status as a lawful permanent resident. 

The criteria that will be considered beginning 10/15/19 will include whether applicants receive Medicaid (AHCCCS), the Medicare Part D Low Income Subsidy, the Supplemental Nutrition Assistance Program (food stamps), and Section 8 Housing program. The existing Rule only considered participation in Temporary Assistance for Needy Families.

Fear that using safety net services will mean that they’ll be considered a public charge contributes to some families of mixed immigration status avoiding use of services like TANF, Medicaid, SNAP etc.  Some eligible immigrants avoid services because they think family members will become involved in immigration enforcement actions.

Research findings by the Kaiser Family Foundation found that changes in healthcare use and decreased participation in Medicaid and the Children’s Health Insurance Program because of this immigration policy.

Anyway, it’s a complicated system but I hope this makes it a little clearer.

Federal Court Decision Allows Implementation of the New Title X Family Planning Rules

The new regulations eliminate Title X’s long-standing requirement for non-directive pregnancy options counseling and requires a “bright line” of physical and financial separation between the provision of family planning and abortion services

Title X is a super important public health program that provides folks with comprehensive family planning and related preventive health services. It's designed to prioritize the needs of low-income families or uninsured people. Its overall purpose is to promote positive birth outcomes and healthy families by allowing individuals to decide the number and spacing of children.

The services provided by Title X grantees (the funding comes from the federal government) include family planning and contraception, education and counseling, breast and pelvic exams, breast and cervical cancer screening, screenings and treatment for sexually transmitted infections and HIV.  It also focuses on counseling, referrals to other health care resources, pregnancy diagnosis, and pregnancy counseling. Title X funding does not pay for abortions.

Back in March of this year, the US Department of Health & Human Services published in the Federal Register a final rule making changes to the federal regulations governing the Title X national family planning program. The final rules dramatically change the existing Title X family planning program nationally and in AZ.  The changes include:

  • Eliminating Title X’s long-standing legal and ethical requirement for non-directive pregnancy options counseling; and

  • Requiring a “bright line” of physical and financial separation between the provision of family planning and abortion services.

Numerous provider groups, state attorneys general and non-profit organizations sued and sought an injunction after the new Rules were announced in March (seeking an injunction to stop the rule from taking effect while the courts decide the legality of the rule). 

Legal History of the Case

Multiple federal district court judges blocked the new restrictive rules from going into effect. On June 20, 2019, a three-judge panel of the Ninth Circuit Court of Appeals granted the Trump Administration’s request to lift the preliminary injunctions, allowing the new Title X rules to be enforced. In early July, the 9th Circuit court ordered the cases be reheard en banc (meaning by all the judges on the 9th circuit versus a three-judge panel).

On July 11, the en banc court refused to block the new Title X rules from taking effect, rejecting 20 states, the District of Columbia, and reproductive right advocates request to impose an emergency stay (indefinitely or temporarily suspend or stop proceedings).

So, what’s the bottom line then?  For now- the new April Title X Rules that eliminate Title X’s long-standing legal and ethical requirement for non-directive pregnancy options counseling, and requiring a “bright line” of physical and financial separation between the provision of family planning and abortion services stand.  There have been mixed signals from HHS whether Title X grantees will be contractually required to immediately comply with the new rules or not. 

Earlier last week, published accounts suggested that HHS would be requiring immediate compliance with the new rules by their Title X contractors (including the Arizona Family Health Partnership).  Later in the week, journalists quoted anonymous HHS sources suggesting that Title X grantees wouldn’t be immediately required to adjust their business processes. Late Saturday night grantees got a letter saying the HHS “does not intend to bring enforcement actions against clinics (grantees) that are making good faith efforts to comply” with the new rules. Perhaps grantees (including the Arizona Family Health Partnership) will hear something more specific this week.

Most likely there will be an appeal and rehearing of the challenge to the April Rules in the coming weeks.

A big thanks to AzPHA members Hannah Fleming, Leila Barraza and James Hodge for helping to straighten out this complicated legal case!

Sign on to this Letter to Support Policies that Encourage Vaccination

We invite you to express your support for immunization requirements for public school attendance, vaccine education and informed use of appropriate vaccine exemptions by signing a letter of support to the Governor. The letter includes the Arizona Medical Association Resolution adopted in 2015. Practicing physicians, nurses and pharmacists from across the State of Arizona believe vaccine education is essential to the health of our children and our communities.

CLICK HERE and add your name to the growing list of Arizonans that believe that we must protect Arizona children against vaccine preventable diseases and protect community immunity that protects the most vulnerable among us.  Here’s a copy of the letter you’d be signing on to:

Dear Governor Ducey,

We, the undersigned, want to express our full support for this resolution adopted by the Arizona Medical Association (ArMA):

“ArMA supports adopting requirements that parents (or guardians) who do not wish to have their children vaccinated receive public health-approved counseling that provides scientifically accurate information about the childhood diseases, the available vaccines, the potential adverse outcomes from catching diseases, the risks unvaccinated children pose to children who cannot be vaccinated for medical reasons, the risks of vaccine side effects, and the procedures that are implemented to exclude unvaccinated children if an outbreak of disease occurs in the area administered by the local or state public health agency.

ArMA also supports adopting requirements that parents annually sign an affirmative statement that acknowledges the risks they are accepting for their own children and the children of others by claiming a personal exemption from mandatory vaccination requirements.”

As residents of Arizona, we actively support and encourage you to work with the Arizona Department of Health Services (ADHS), all County Health Departments, and longstanding partners of The Arizona Partnership for Immunization (TAPI) to maintain high levels of immunization coverage rates in our schools and our communities…to keep your constituents safer and healthier.


A.D. Jacobson, M.D.
Steering Committee Chair
The Arizona Partnership for Immunization

WHO Declares the DRC Ebola Outbreak a Public Health Emergency

Decision will Amplify Intervention Efforts

The WHO declared the Ebola virus disease outbreak in the Democratic Republic of the Congo a Public Health Emergency of International Concern this week. The declaration follows several decisions in the last few months to not make that call. 

The WHO cited recent developments in the outbreak in making its recommendation, including the first confirmed case in Goma (a city of almost 2M and a major transportation hub).  The outbreak has been underway for more than a year now and there have been insufficient resources including funding to fight the outbreak - impairing the effectiveness of the public health interventions. 

Policy interventions for controlling Ebola are dicey because of the need to protect livelihoods of the people most affected by the outbreak by keeping transport routes and borders open. Interventions that effect travel and trade can have negative economic consequences, but not implementing some restrictions can impair the public health response.

The WHO made the following recommendations that relate to the declaration:

Strengthen community awareness, engagement, and participation, including at points of entry to identify and address cultural norms and beliefs that are barriers to the response.

Improve cross-border screening and screening at main internal roads to ensure that no contacts are missed and enhance screening through improved sharing of information with surveillance teams.

Enhance coordination with the UN and partners to reduce security threats to enable public health operations.

Strengthen surveillance and reduce the time between detection and isolation and implementing interventions.

Optimal vaccine strategies that have maximum impact on curtailing the outbreak should be implemented rapidly (they are using a ring-vaccination strategy).

The public health tools are available to eliminate the transmission of Ebola in the DRC. The challenge is really getting the resources deployed and implementing the proven intervention methods. Plus, and important new tool- an Ebola vaccination- is now available (it was not widely available during the 2014 West African epidemic). Security concerns, local and regional infrastructure, cultural practices and access to care are all important factors that need to be addressed in order to stop the on-gong transmission of the virus.

In an example of what the Declaration can do- the Congolese government this week tasked the military and policy with enforcing hand-washing and fever checks in Kivu Province.

Maricopa County Seeking Hepatitis A Intervention Strike Team Volunteers 

AHCCCS Policy Change Assisting the Response

Maricopa County is part of a statewide hepatitis A outbreak mostly affecting folks experiencing homelessness, substance use and/or recent incarceration. 229 people have been reported with the disease and more than 80% have been hospitalized. The Maricopa County Department of Public Health is working with community partners to vaccinate the people at highest risk...  both to protect them from getting sick and to stop the disease from spreading further.  

The public health response consists of: 1) vaccinating everyone in the county jail system for the next 8 months; 2) deploying vaccination and service strike teams (with other organizations); and 3) partnering with cities and parks to go to homeless encampments and offer vaccination in Strike Teams.

They're recruiting volunteer healthcare providers and screeners (no healthcare experience needed) for the vaccine outreach events. If you're interested in volunteering, please contact

In addition, AHCCCS now covers medically necessary covered immunizations for people 19 years of age and up when the vaccines are administered by AHCCCS registered providers through county health departments. Immunizations are covered even if the AHCCCS registered provider isn't in the member’s health plan network. The list of covered vaccinations includes (but isn't necessarily limited to) Hepatitis A & B and Measles.

Policy changes like this make a big difference in the effectiveness of public health interventions like the ones associated with this Hep A outbreak - and they also sets up a system that will be better able to prevent future outbreaks.

New USPSTF Recommendations for HIV Will Have a Powerful Public Health Impact

Ever since the passage of the Affordable Care Act, a prevention model of health has been increasingly weaving its way into the fabric of traditional models of care.  That's because the ACA expanded the role of preventive services in the US health care delivery system via various incentives. 

For example, the “Category A & B” preventive services that are recommended by the United States Preventive Services Task Force (USPSTF) are now included (at no cost to consumers) in all Qualified Health Plans. In addition, many employer-based and state Medicaid programs routinely cover Category A & B services once they're recommended by the USPSTF. 

The USPSTF is an independent, volunteer panel of experts in prevention and evidence-based medicine. The Task Force works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications.

The Task Force analyzes priority preventive health services and assigns the a letter grade (an A, B, C, or D grade or an "I Statement") based on the strength of the evidence and the balance of benefits and harms of the preventive service.

Currently, the USPSTF recommends 51 Category A & B Preventive Health Services - which include things like screening tests, counseling, immunizations, and preventive medications for adults, adolescents, and children. 

The preventive services that have an A or B grade are presented in alphabetical order and by the date they were recommended on the Task Force website.

This month they added 2 new recommendations related to HIV: 

You can browse the USPHS website and check out the preventive services that they have evaluated but got a lower grade. Most of the services are broken down by age, gender and other risk factors.

Arizona Policies, Resources and Recent Investments are Addressing Rural Healthcare Workforce Shortages

Healthcare workforce shortages often contribute to health disparities in rural AZ.  That’s because rural communities tend to have fewer physicians, nurses, specialists, and other healthcare workers…  and at the same time face higher rates of chronic disease, mental illness, and obesity than urban areas. Having enough healthcare personnel in shortage areas can contribute to those health disparities. 

Additionally, health care providers working in shortage areas can experience isolation from their peers and burnout from seeing a greater number of patients and working longer hours than those in non-shortage areas.

A critical element to ensuring an adequate healthcare workforce is to improve the reach of provider recruitment programs, which can build a strong and diverse healthcare workforce that represents the population served. 

This year was particularly successful at the Legislature as they approved an additional $750K for the state loan repayment program (bringing the total budget to $2.75M) as well as more resources for rural Graduate Medical Education ($1.6M for rural Graduate Medical Education -$5.5M w the federal match)  - which can be use to bolster graduate training in rural AZ (this GME training is really important because it’s a key factor in where a provider practices over the course of her or his career- improving rural networks). There was also an additional $750K that was invested in the North Country GME program.

Arizona Primary Care Office

Arizona is fortunate to have an effective Primary Care Office program at the ADHS’ Bureau of Women and Children’s Health along with public policies that have been passed in the state legislature that help to improve the state program’s effectiveness. 

Our in-AZ resources to improve workforce capacity and access to care in rural and underserved AZ include the Arizona State Loan Repayment Programs, J-1 Visa Waiver Program, and at the national level, the National Health Service Corps and Nurse Corps.

Our state Primary Care Office also manages data collection regarding healthcare provider shortage areas (HPSAs) and information like Primary Care Area Statistical Profiles as well as maps and a host of additional data resources.

UA Center for Rural Health

We also have terrific programs at the UA Center for Rural Health which has rural health programs like the Rural Hospital Flexibility Program (AzFlex), the Small Rural Hospital Improvement Program (AzSHIP), Arizona First Responders Initiative (FR-CARA), The Rural Health Professions Program (RHPP), Workforce Data & Analysis (CRHWorks), Arizona Rural Recruitment and Retention Network (Az3RNet), Students Helping Arizona Register Everyone (SHARE), the Prescription Drug Overdose Program, and Health Insurance Assistance.

Arizona Area Health Education Centers

Arizona also has a unique system of AZ Area Health Education Centers that are established under state law (voter approved) “… enhance access to quality healthcare, particularly primary and preventive care, by improving the supply and distribution of healthcare professionals through educational partnerships between academic and community organizations in rural and urban medical underserved areas.” 

The Program has a state office at the UA and several local AHECs that promote community and educational partnerships to enhance access to quality health care with an emphasis on the needs of rural and urban underserved communities and populations. Their missions also include educational programs in partnership with academic institutions, communities, health care agencies, and other organizations that promote the health of Arizona residents.

Arizona Rural Health Association

We're also fortunate to have the Arizona Rural Health Association (AzRHA) in our state doing advocacy for rural health.  The AzRHA was established in 1994 as an independent organization after serving as the Advisory Committee of the University of Arizona Rural Health Office (RHO) for many years. While AzRHA continues to serve as the RHO advisory body, its functions have been expanded to cover many areas involving advocacy for rural healthcare programs.

Access to healthcare is an essential component of health and wellness. By providing financial incentives for clinicians to practice and train in rural areas and by collecting data on provider shortages and using that data to make policy adjustments, Arizona is increasingly poised to make measurable improvements in rural networks as a result of this year’s legislative session decisions.

Yuma County Captures 2019 Spotlight Award

Blue Cross Blue Shield of Arizona and fitness icon Jake “Body by Jake” Steinfeld have teamed up to shine a light on people and programs that are making Arizona healthier. The 2019 Spotlight Awards honor leaders across our state who are inspiring health and wellness in their communities, where it matters most.


Business of the Year: Chicanos Por La Causa
City of the Year: City of Phoenix
County of the Year: Yuma County
Tribal Nation of the Year: Tohono O’odham
School District of the Year: Tempe Elementary School District #3
School of the Year:  Brunson-Lee Elementary