The Georgia Department of Public Health has recently updated its resources on Monkey Pox.  Resources and guidance can be found here: 

Information for Providers | Georgia Department of Public Health

Monkeypox Home Isolation Guidance

Monkeypox and Pregnancy

Recording of the August 8^th lecture that was held with key state officials on Monkey Pox that discussed information that included testing, diagnosis, treatment, and vaccine availability in the State.

Please review this key information as the state continues to send information to all of Georgia’s clinicians.

CDC HEALTH UPDATE

Distributed via the CDC Health Alert Network

May 11, 2022, 12:15 PM ET  

CDCHAN-00465

Summary

The Centers for Disease Control and Prevention (CDC) is issuing this Health Alert Network (HAN) Health Update to provide clinicians and public health authorities with updated information about an epidemiologic investigation of pediatric cases of hepatitis of unknown etiology in the United States. This investigation focuses on collecting information to describe the epidemiology, etiology, clinical presentation, severity, and risk factors related to illness and to identify any relationship between adenovirus infection or other factors and hepatitis. As of May 5, 2022, CDC and state partners are investigating 109 children with hepatitis of unknown origin across 25 states and territories, more than half of whom have tested positive for adenovirus with more than 90% hospitalized, 14% with liver transplants, and five deaths under investigation. Because this investigation is ongoing and includes reviewing cases of hepatitis of unknown cause with onset since October 2021, patients under investigation are not limited to current or newly diagnosed pediatric hepatitis illnesses.

This HAN Health Update also provides updated recommendations for testing specimens from patients under investigation. It is an update to a HAN Health Advisory that CDC issued on April 21, 2022, that initially notified clinicians and public health authorities of children identified with hepatitis of unknown origin and adenovirus infection.

Background

A cluster of pediatric cases of hepatitis without an apparent etiology was identified and reported to CDC in November 2021. A possible association between pediatric hepatitis and adenovirus infection is under investigation after laboratory testing identified adenovirus infection in all nine patients in the initial cluster; the five specimens that could be typed were all adenovirus type 41. Investigators continue to examine the role of other possible causes and identify contributing factors.

Recommendations for Clinicians

• Clinicians should continue to follow standard practice for evaluating and managing patients with hepatitis of known and unknown etiology.
• Clinicians are recommended to consider adenovirus testing for patients with hepatitis of unknown etiology and to report such cases to their state or jurisdictional public health authorities.
• Because the potential relationship between adenovirus infection and hepatitis is still under investigation, clinicians should consider collecting the following specimen types if available from pediatric patients with hepatitis of unknown cause for adenovirus detection:  
• Blood specimen collected in Ethylenediaminetetraacetic Acid (EDTA) (whole blood, plasma, or serum); whole blood is preferred to plasma and serum)
• Respiratory specimen (nasopharyngeal swab, sputum, or bronchioalveolar lavage [BAL])
• Stool specimen or rectal swab; a stool specimen is preferred to a rectal swab
• Liver tissue, if a biopsy was clinically indicated, or if tissue from native liver explant or autopsy is available: 
• Formalin-fixed, paraffin embedded (FFPE) liver tissue
• Fresh liver tissue, frozen on dry ice or liquid nitrogen immediately or as soon as possible, and stored at ≤ -70°C

Nucleic acid amplification testing (NAAT), such as polymerase chain reaction (PCR), is preferred for adenovirus detection (currently not available for FFPE liver biopsy or native liver explant). Testing whole blood by PCR is more sensitive to and is preferred over testing plasma by PCR. 

Were possible, clinical specimens should be tested locally to ensure timely results for patient care. For any diagnostic testing needs beyond the local capacity, CDC recommends that clinicians contact their state public health laboratory. For More Information

• Expanded testing guidance: Clinical Guidance for Adenovirus Testing and Typing of Patients Under Investigation
• Information for state health departments and laboratories: Instructions for Adenovirus Diagnostic Testing, Typing and Submission  
• Email ncirddvdgast@cdc.gov with additional questions

The Centers for Disease Control and Prevention (CDC) protects people’s health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national, and international organizations.

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Categories of Health Alert Network messages:

Health Alert          Requires immediate action or attention; highest level of importance

Health Advisory   May not require immediate action; provides important information for a specific incident or situation

Health Update      Unlikely to require immediate action; provides updated information regarding an incident or situation

HAN Info Service Does not require immediate action; provides general public health information

The proposed rule(www.gpo.gov), titled “Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models,” was published in the May 9 Federal Register.

Nearly every day since the proposed rule was first released, a team of AAFP payment and policy experts has scoured the details of this complicated proposal looking for ways to ease family physicians’ transition into a variety of new payment models. The fruits of that combined effort are evident in a 100-plus page letter(1014 KB PDF) brimming with recommendations for CMS Acting Administrator Andy Slavitt to consider. Family physicians looking for a simpler, slimmed-down version of the AAFP’s comments can explore the high points in an executive summary.(8 page PDF)

AAFP Board Chair Robert Wergin, M.D., of Milford, Neb., began the June 24 letter by expressing the AAFP’s overall support for MACRA. “We believe it was intended to strengthen primary care and make primary care a strong foundation” on which to build health care payment and delivery reform, he said. “But the importance of a successful implementation of the final rule cannot be overstated,” he added. With that in mind, CMS needs to “step back and reconsider” its approach to a proposed rule that is “overly complex and burdensome” for all physicians, said Wergin.“The implementation of MACRA will impact our health care system for years to come, and it must be done thoughtfully, carefully and as simply as possible.”This proposed rule “falls short of these goals,” he concluded.The Academy covered a lot of ground in its response to CMS’ proposed rule; a few red-hot issues most pertinent to family physicians are covered here.

Virtual Groups

The AAFP came down hard on CMS’ plan to delay implementation of virtual groups until 2018. The concept of virtual groups — as related to MIPS — would allow individual physicians or group practices of 10 or fewer eligible professionals to join forces as a virtual group during a MIPS performance period. Wergin pointed out that CMS would run afoul of MACRA by not having this process in place by 2017. But more importantly, lack of the virtual group option in 2017 would negatively affect many family physicians. This inaction on the part of CMS means that “solo and small-group physicians who had been counting on the virtual group option to be successful under MIPS will not have the opportunity,” said Wergin. He noted that more than a few family physicians had expressed enthusiasm for this opportunity, and from their conversations with the AAFP, it was clear that members “viewed it as an option to band together to share resources while maintaining their independence.” Taking this option off the table in 2017 will harm practices that were otherwise ready to engage with MACRA, said Wergin. “We are concerned they will be the hardest hit when CMS implements MIPS in 2017,” he added. The AAFP strongly urged CMS to create a “safe harbor” to exempt solo and small group practices (defined by the AAFP as five or fewer clinicians) from MIPS until the framework for virtual groups is in place.

MIPS Performance Period

The AAFP reiterated an earlier appeal to CMS regarding the initial performance period start date for MACRA. “The AAFP urgently and strongly calls on CMS to consider using 2018 as the initial assessment period for MACRA, and under no circumstances should the initial performance period start any earlier than July 1, 2017,” said Wergin. Wergin pointed out that if the final rule is issued around Nov. 1, 2016, with a start date of Jan. 1, 2017, physicians would have only two months to do a lot of prep work, including selecting quality measures and identifying clinical practice improvement activities. He suggested that 2017 be designated as a reporting preparation year and 2018 “be a year of judgment.” The AAFP also refuted the notion that two-year old data were clinically actionable or meaningful to physicians and urged CMS to find a way to provide feedback to physicians within one year or less. “The law mandates that the performance period and payment period be as close together as possible, and a two-year gap simply ignores this legislative mandate,” said Wergin.

Quality Measures

The AAFP stood its ground on previous recommendations regarding the use of quality measures. “The AAFP supports reasonable and achievable quality improvement programs that promote continuous quality improvement and measure patient experiences. The AAFP opposes an approach that requires physicians to report on a complex set of measures that do not impact or influence the quality of care provided to patients,” said Wergin. He insisted that all measures used in MIPS and APMs “be clinically relevant, harmonized among all public and private payers, and minimally burdensome to report.” Wergin called on CMS to use the core measure sets developed by the Core Quality Measures Collaborative, a multistakeholder group of which the AAFP is an active member. In addition, he expressed concern about “parity in reporting” across all specialty and subspecialty physician groups in regard to quality measure sets related to MIPS. “If CMS requires a lower number of quality measures for particular specialty groups in MIPS, that lower number of measures for reporting should be available to all MIPS-eligible clinicians,” said Wergin. “Reducing what seem to be reasonable/achievable requirements for some specialties will result in a continued disproportionate burden on those specialties (such as family medicine) that have been engaged in quality measurement and development,” he added.

Medical Homes

The AAFP has been a leader in the medical home movement dating back to mid-2000 when the Joint Principles of the Patient-Centered Medical Home(3 page PDF) were developed by the Academy and three other physician organizations and officially adopted by the groups in 2007. With that background in mind, it’s no surprise that Wergin insisted that physicians not be forced to “pay a third-party accrediting body to receive recognition as an advanced primary care practice,” such as a PCMH. The AAFP suggested that CMS “use a deeming authority to grant any entity which meets the necessary criteria as a PCMH accreditor to be an approved program,” and encouraged the inclusion of state-based, payer sponsored and regional PCMH recognition programs. Furthermore, the Academy adamantly opposes CMS’ proposed financial standard for the medical home model and called its inclusion in the proposed rule an “arbitrary imposition of financial risk placed upon clinicians in the models,” said Wergin. “This is a significant misinterpretation of the law, which was designed to protect and foster medical homes,” he added. Wergin called the medical home model “the crux of a value-based health care system” and a concept that has been proven to reduce spending and utilization.

Additional Issues

The AAFP commented on numerous other provisions in the proposed rule. For instance, Wergin

•  objected to CMS’ application of the total per capita cost of care and Medicare spending per beneficiary measures to primary care physicians who are not part of an advanced APM,

•  deemed the current proposal for “advancing care information” too complex and in fact said it had “missed the mark in a major way,”

•  called CMS’ definition of a “medical home model expanded” too narrow and a deterrent to physicians looking to participate in the APM program, and

•  expressed concern about CMS’ proposal to implement a “MIPS APM” category.

Regarding the final bullet point, Wergin said, “Unfortunately, throughout this section of the proposed rule, there are so many different rules and exceptions that no practicing physician could reasonably understand and report accurately to get a fair payment.”  

May 12th’s Severe Combined Immunodeficiency Screening and May 20th’s Developmental Screening Webinars from the Department of Public Health are now available on the GAFP website.