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Limited options for mothers giving birth in Western North Carolina

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Limited options for mothers giving birth in Western North Carolina - North Carolina Health News

Indefinite closure of the WNC Birth Center highlights issues with maternal health in a part of the state that has seen maternity units close in recent years.

By Christian Green

Carolina Public Press

Melissa Fehling’s second child is due Aug. 3. 

She delivered her first child, River, at the WNC Birth Center in Asheville two years ago, and she said she was looking forward to a similar experience there. 

But on June 19, she received an email from the center, announcing an indefinite closure on July 20, just two weeks before her due date. 

Fehling, 34, was at home with her son when she read the email. 

“I just kept rereading it,” Fehling said. “My brain could not understand what the email was saying. It could not comprehend what was going on.”

Nearby in West Asheville, Francesca Santi, another pregnant mother, received news of the center’s closure. 

“I saw the email, and as I started reading through, I just got this pit in my stomach,” Santi said. “I could just feel the news coming and then when I saw it … it sucked. I felt awful.” 

The closure of the birthing center marks the latest in a series of challenges for expectant mothers in Western North Carolina. Reimbursement issues and provider regulations limit choices for pregnant mothers.

Impossible math

The closure was a last resort after all other options were exhausted, said Nancy Koerber, executive director for the birth center.  

“We just couldn’t make it work,” Koerber said. “We’ve really done everything we can. …. We’re 16 women trying to buck an entire system, and it is very, very difficult.” 

Although the WNC Birth Center increased its number of deliveries each year for its five years of existence, the center was never able to make the numbers work for financial sustainability.

The struggle came, in large part, because insurers and Medicaid reimburse birth centers at lower rates than hospitals, even when they deliver the exact same service. Koerber estimated her birth center was reimbursed, on average, less than half of hospital reimbursement. 

“Compared patient to patient, someone who had an uncomplicated birth here versus a hospital, we are reimbursed half of what a hospital would be for the same resources utilized for that patient,” Koerber said. 

Health care facilities like birth centers and hospitals bill for three broad categories when they deliver a baby: a physician fee for prenatal care and the actual work of delivering the baby; a facility fee to cover the infrastructure needed to deliver the baby; and a third fee that pays for care given to the baby after birth. 

Nearly half of patients at the WNC Birth Center paid through Medicaid, consistent with statewide and national averages. 

For physician fees, the WNC Birth Center earned $1,627 from Medicaid per delivery. The funds covered not just the hours worked by midwives at the time of delivery, but also the seven-13 prenatal consultations that occur over the nine months leading up to birth. 

For each delivery, Medicaid paid the center $1,587 in facility fees.

Together, in addition to some smaller fees, Koerber said that the birth center earned $3,712 per birth. 

But on average, Koerber estimated the birth center paid about $6,000 in materials and labor to deliver that baby, meaning that the facility incurred a net loss of over $2,000 for every baby delivered to a mother on Medicaid.

Private insurers generally pay higher rates than Medicaid, but even then, Koerber said, the payments were not enough to sustain the center. 

For comparison, Medicaid generally pays a hospital somewhere between $8,000 and $11,000 for a routine vaginal delivery. 

Koerber said this discrepancy was primarily due to hospitals receiving reimbursement as inpatient services, while health insurers view the birth center currently as an outpatient facility.

Birth centers receive reimbursement at rates similar to hospitals for physician fees, but hospitals receive much higher payments for facility fees, based on the assumption that inpatient services typically cost more to build and maintain than outpatient clinics. 

But birth centers, Koerber said, don’t really fit into the inpatient/outpatient dichotomy. 

“We’re not a fully inpatient facility, but we’re also not just a walk-in clinic,” Koerber said. “With our infrastructure and staffing, we’re somewhere in between.”

Koerber said the “in-betweenness” of birth centers in the current reimbursement model has prompted discussion of a third alternative category. To date, no such category exists, so birth centers are reimbursed at rates that make it difficult to stay afloat. 

“People recognize the problem, but like anything in a system, it just moves so slowly,” Koerber said. “The problem is that, by moving this slowly, they may be actually eradicating a good solution that’s already sitting here right now. That’s the biggest fear.” 

Supervisory requirements influence midwives

When WNC Birth Center closed, it became the fifth North Carolina birth center to do so since 2018, according to Koerber. 

Only two stand-alone independent birth centers remain in the state, one in Chapel Hill and one in Statesville.

While finances are a major barrier to birth center success, it is not the only one, according to Ami Goldstein, president of the North Carolina Affiliate of the American College of Nurse-Midwives. 

Goldstein said the issue of full-practice authority, another barrier for midwives, could be solved more immediately than complicated health insurance reimbursement schedules. 

Midwifery was formalized in North Carolina with the passage of the Midwifery Practice Act in 1983, which established certified nurse-midwives, or CNMs, as a class of advanced practice registered nurses, or APRNs. 

Like all APRNs in North Carolina, certified nurse-midwives are required by law to practice under the supervision of a licensed physician. In the 1990s, several states such as Oregon, Montana and New Mexico, began to pass legislation to grant full-practice authority to APRNs and end supervision requirements. 

Currently, at least 28 states plus the District of Columbia give full-practice authority to APRNs either immediately after completing their education or after some designated period of supervision under a physician.

Within the U.S., North Carolina is one of the most restrictive states when it comes to midwifery. 

Studies find the midwife model can lead to better maternal outcomes, including fewer cesarean section deliveries. 

Goldstein said full-practice authority legislation is important for all APRNs in the state but is particularly impactful for maternal care in North Carolina because states with fewer restrictions are more attractive to the workforce.

“That makes it an access problem,” Goldstein said. “There are people in the western part of the state who can’t open a practice to provide care to people who really need it because they can’t find anybody who will provide the supervision.”

Full-practice authority also carries a financial benefit. 

North Carolina ARPN regulations require that all midwives have a physician sign on to serve as their supervisor. In many cases, independent practices have to pay that provider, even though the supervision requirements mandate that they meet with a supervising physician only once every six months. 

“If no physician is willing to sponsor you, you can’t open a midwifery practice,” she said. “If a physician sponsoring you suddenly dies or retires, you can’t touch another patient from that moment on until you find someone else.”

A legislative dispute

A coalition of legislators and advocacy groups already tried to address the full-practice authority issue with legislation in 2015-16 but was unsuccessful. 

The bills were heavily opposed by physicians and pro-doctor lobbying groups, who said full-practice authority for advanced practice registered nurses could result in lower-quality care and diminished safety. 

Goldstein disputes their arguments. “There’s just no strong evidence to support that idea,” she said. 

None of the states that have granted full-practice authority over the past two decades have reimposed restrictions, and several studies show that APRNs who are acting independently and within the scope of their training deliver care as well as physicians. 

An updated version of the SAVE Act has been introduced in both the N.C. House and Senate with broad and bipartisan support. More than 70 representatives signed on as sponsors to the bill in the House, and 25 senators are listed as sponsors. 

Though the bills would likely pass if brought to a vote, given the many sponsors, they currently sit in committees, where they died in previous sessions. 

Sen. Jim Burgin, (R-Harnett, a primary co-sponsor on the Senate bill, said he hoped the measures make it to the floor for a vote this time around, but that will ultimately depend on broader political negotiations in the General Assembly. 

“We have bills that are over there,” Burgin said of the process.

“They have bills that are over on our side, and there is this trading that goes back and forth. Plus, we have the added aspect of having budget negotiations going on and the horse-trading that goes on in the budget. So, this bill will be something that gets included in all of that negotiation.”

Physicians who do not oppose full-practice authority for certified nurse-midwives may oppose the act because they oppose full-practice authority for other providers such as nurse practitioners and other APRNs, Koerber said. 

Koerber is open to legislation more narrowly tailored to just granting full-practice authority to CNMs if that would be more likely to pass, but other organizations such as the North Carolina Affiliate of the American College of Nurse-Midwives disagree, saying that APRNs are stronger together in their fight for full-practice authority. 

As the legislative battle continues, the concerns are immediate for expectant mothers in Western North Carolina. 

“We just lost what I feel is a very important option for prenatal and maternal care in our area,” said Savannah Talley, who gave birth at the WNC Birth Center just months before it closed. 

“I am so heartbroken for the women in this area, for the women who are in the middle of their pregnancy now and for women in the future who now have one less option.” 

Though the center is now closed, Koerber did say that she has hope it won’t be permanent. She is currently in talks with potential partners, whom she declined to name, who hope to be able to bring the center back. 

“After we announced we were closing, there was a huge outpouring of grief in the community,” Koerber said. “People have seen the resources we provide, and our results have been recognized. We can’t live on false hope …, but I feel like the community deserves for us to explore every single option and leave no stone unturned.”

semi white crystal methamphetamine on a black background, both shattered pieces and full crystals

Communities struggle with meth outside spotlight of opioid crisis

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Communities struggle with meth outside spotlight of opioid crisis - North Carolina Health News

Increase in methamphetamine use in Western North Carolina affects 'misery index,' even if death rate is lower than opioids.

by Christian Green for Carolina Public Press, July 13, 2021

While the opioid crisis gripped many rural areas of the state, the proliferation of methamphetamine challenged communities in Western North Carolina.

“The biggest thing out here in Graham County is meth,” Graham County Health Director Beth Booth said. 

“Unlike opioids, with meth, there’s nowhere to point the blame and no one picking up the staff to fight it,” Booth said.

“There might not be as many deaths directly associated with it, but meth is readily available, it’s really cheap, it ruins lives, and there really is no good treatment.”

Insufficient data

The impact of meth on a specific community is difficult to assess from data, in part because one key data point used to illustrate the severity of a substance is overdose deaths. 

While the high rate of opioid deaths indicated the seriousness of the opioid epidemic, the outcomes of meth use were more difficult to decipher because it is less likely to result in a direct overdose death. 

In 2018, the state medical examiner told Carolina Public Press 160 people had died during the previous year as a result of methamphetamine-related overdoses. That was less than 10% of the 1,974 opioid-related deaths reported by the state medical examiner in the same year. 

But the death rate is only one factor in understanding the effect of meth use on communities. 

“I would certainly not want to give the impression that, just because deaths are lower, methamphetamine is somehow less devastating to communities and individuals,” said William T. Stetzer, acting U.S. attorney for the Western District of North Carolina. 

“Methamphetamine might not have the same number of overdose deaths, but I think the misery index it brings is still very high as far as communities, tribes and families who are suffering.”

Stetzer, who oversees the prosecution of criminal cases against drug trafficking organizations, described a “significant” increase in the amount of methamphetamine arriving in North Carolina from cartels in Mexico via a supply line that runs through Atlanta to Charlotte, before continuing to Tennessee and then north. 

In 2012, U.S. Customs and Border Protection listed that it seized about 18,000 pounds of methamphetamine crossing into the country. By 2018, that number had increased to 85,000 pounds, and in 2020 that number skyrocketed to 177,000 pounds of methamphetamine and crystal meth. 

Local producers of meth within communities still exist, Stetzer said, but the influx of high-purity crystal meth had caused prices to decrease by more than half. 

“More drugs come in, larger quantities are distributed to local dealers who, in turn, sell even more crystal meth into our communities,” Stetzer said. 

Part of polysubstance use

Across the state, 75% of drug-related deaths were caused by multiple drugs taken by a single user, or polysubstance use, according to a recent report by NC Health News.

Polysubstance use compounds the challenge of determining meth’s impact in Western North Carolina. 

Though meth is the dominant substance in Graham County, Booth said, it’s not uncommon for people to use multiple substances. Most commonly, they mix meth, a stimulant, with another substance that serves as a depressant, such as opiates. 

“Right now, a lot of our participants are mixing meth with heroin or fentanyl,” said Tanasia Boyd, the harm reduction coordinator with Buncombe County Department of Health and Human Services. 

In North Carolina, the majority of recent overdose deaths have been among individuals using multiple substances, and nationally the majority of overdose deaths involving stimulants like methamphetamine also involve an opiate. 

Over the past two decades, Rebecca Smith, social work division director with the Buncombe County DHHS, has seen different drugs come into and fade out of popularity. Today, though, she said it seems as if illicit substances are more available than ever before. Boyd agreed. 

In her experience, Boyd said, not a lot of people of color were using meth. “Now I’m starting to see more and more people,” she said. “It’s everybody. Everybody using everything.” 

Treatment challenges

Even for those who are using only meth, receiving care or resources can be more difficult than for those using opiates, Boyd said.

In one situation that Boyd encountered, a woman was using meth and wanted to seek treatment, but she had not yet been using it long enough to qualify for any detox protocols.

“She ended up having to wait a couple of weeks before finally getting in and getting treatment,” she said.

“She’s doing great now, which is good. But if she had had opiates in her system, it would have been automatic. She would have gotten in that day.” 

Even when those using meth are able to seek treatment, they face a difficult road because, unlike many other substances including opiates, no approved medication to treat a meth overdose or to alleviate withdrawal symptoms exists currently. 

“That’s the biggest difference when treating addiction for meth and for opiates — there are no treatment options for methamphetamine.” said Michael Nader, a professor of physiology and pharmacology at Wake Forest University School of Medicine who specializes in stimulants. 

Nader’s colleague Thomas Martin, professor of anesthesiology at Wake Forest who studies pain and opioid abuse, said that when it comes to treating opiate addiction, three approved medications offer options. 

Naloxone, also known by its brand name Narcan, is a fast-acting medication that blocks the effects of opioids. It is often used in emergencies to save someone experiencing an opioid overdose. 

The other two medications, methadone and buprenorphine, are long-term treatments used to counter addiction to opioids. They are able to prevent or lessen withdrawal symptoms while also decreasing the body’s response to opioids so that an individual is less likely to abuse them in the future. 

These drugs are used in combination with other treatments such as therapy and counseling in a process known as “medication-assisted treatment” to aid those who are addicted to opiates. 

“It’s honestly generally a lot easier to wean someone off of opioids than it is to get them off meth,” said Booth of Graham County. 

“There is no substance-use treatment for meth, so they just have to quit on their own, and that’s really hard. So, it’s kind of counterintuitive, but opioid addiction honestly seems probably like it would be the easier one to tackle.”

Joel Chisholm, an addiction psychiatrist and the behavioral health medical director of the Cherokee Indian Health Authority in Swain County, said he saw a similar dynamic in his clinics. 

“We see a lot more people who use opiates engage with treatment because we can provide them medication,” Chisholm said. “The carrots are just a lot bigger for them to engage with treatment versus someone using meth; we still provide them therapy and recovery classes, but it’s a lot tougher. 

Ongoing research seeks to create medication that can serve a similar purpose for people who use stimulants, such as cocaine or methamphetamine, Nader said.

Creating treatment drugs in the current climate may be more difficult than in the past, Nader said. Methadone, which was approved for use in treating opioid addiction in the 1960s, would likely not be approved today because it has some potential for abuse, he said. 

“The way the FDA has approached potential treatments for stimulant abuse,” Martin said, “… they want something that makes people abstinent but also has pretty much zero abuse liability and of itself.  Methadone certainly doesn’t meet that criteria for opioid treatment, so it’s true. There’s a chance it wouldn’t have been approved today.”

Nader said he hopes the U.S. Food and Drug Administration will set out specific guidelines for what it would like to see in a methamphetamine treatment, possibly a drug like methadone, which still has some similar effects, but to a much lesser degree so that it would have less chance to be abused. 

In the meantime, while no medication exists for treatment of meth and opioid use continues to receive higher prioritization in many clinics when beds are scarce, it can be difficult for meth users to find help. 

“If we have someone coming … off meth (who) wants to get in for treatment and beds are limited, there’s a chance they are actually not going to take them in,” said Samantha Brawley, a peer-support specialist with the Asheville-based Sunrise Community for Recovery and Wellness and a medication-assisted treatment user.

“When that happens, we suggest that they sleep, eat and rest. But sometimes they don’t have a place to sleep, eat or rest, so it becomes a battle. It’s always a battle to try to get somebody in the right place at the right time.”

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Parts of Western NC see vaccine demand drop to a ‘trickle’

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Parts of Western NC see vaccine demand drop to a ‘trickle’ - North Carolina Health News

Several Western NC counties seeing recent surge in COVID-19 cases even as willing pool of vaccine recipients dries up.

by Christian Green, Carolina Public Press May 7, 2021

In late April, Gov. Roy Cooper set the end goal for North Carolina’s COVID-19 vaccination rollout at two-thirds of adults. When that number is reached, Cooper said, then he would end the statewide indoor mask mandate, effectively ending pandemic restrictions. 

But it may prove difficult to reach that number soon, as there has been a slowdown in vaccinations in some parts of Western North Carolina, driven by a lack of demand. 

“In Rutherford last week, we had a clinic and, in a place where we were previously doing 1,100 (doses) a day, we did 190, and we were open all day,” said Karen Powell, health director of Foothills Health District, which covers Rutherford and McDowell counties. 

“Right now, we’re like at this … it’s not a screeching halt, but it’s a trickle,” she said. 

Health directors across the region voiced the same story. 

“We’ve hit a wall, basically,” said Kathy McGaha, director of the Macon County Public Health Administration. 

The least vaccinated counties in the west are Rutherford, Cherokee and Graham counties, with an estimated 34%, 36% and 37% of adults vaccinated, respectively. 

“At this point, we’ve pretty much vaccinated everybody who wanted to be,” said Beth Booth, health director of the Graham County Health Department. “Even those who were on the fence.”

Booth was pleasantly surprised that her county reached those numbers.

“When we passed (having vaccinated) a quarter of our population, that was a higher uptake than I thought we would have,” Booth said.

“If you’ve spent any time out here, you would quickly figure out that it’s a very suspicious, closed group out here. … So, I got to say I’m pretty proud of how many folks have taken it.”

Though some individual western counties are lagging, the total percentage of vaccinated adults in the 18 westernmost counties is around 47%, according to an analysis conducted by Carolina Public Press, not far behind the 50% of adults vaccinated statewide.

While vaccine hesitancy in Western North Carolina is not dissimilar from the state and the country, some of the reasons for hesitance or resistance differ by region.

Local differences for hesitancy 

As has been previously reported, no single factor drives vaccine hesitancy, and no single group is uniquely hesitant. 

Booth said Graham County is uniquely distrustful of influence from outside the county. She thinks that mindset contributes the most to low rates of vaccination in the county. 

“They’re very private, and so if they have a belief system, if outside government is trying to step in or if the government is trying to overreach, they aren’t having it,” Booth said.

“It’s really hard to change their mind because … it’s not necessarily the science or any medical reason. It’s a belief system.”

This aligns with previous survey studies that have reported that conservatives appear to be more hesitant to receive a COVID-19 vaccination than liberals, but that does not tell the full story. 

For instance, Avery County voted for former President Donald Trump at a similarly high percentage as Graham County in the 2020 election; however, Avery County has vaccinated roughly 45% of adults, compared with Graham’s 37%. 

In general, a county’s 2020 election results had a weak correlation with the level of vaccination, based on CPP’s analysis. 

Instead, education levels, measured in this case by how many people over the age of 25 held a bachelor’s degree or higher, were the strongest predictor of vaccination levels. The percentage of residents living below the poverty line was the second-strongest predictor. 

This disparity can be seen in the margin of vaccinations in the neighboring counties of Swain and Jackson. Swain has vaccinated roughly 37% of its adults while Jackson has vaccinated around 42%. 

The two share similar demographics, poverty levels and cultures, but Jackson is home to Western Carolina University and has nearly double the number of residents with bachelor’s degrees as Swain. 

It is possible that higher levels of education are not directly responsible for increased vaccine uptake, but that educational achievement is correlated with other socioeconomic factors like income, living conditions and access to health care, which may also affect vaccine enthusiasm.

When looking at county trend-line data, one in particular stands out: Macon County. 

Macon County voted heavily Republican in 2020, it has a below-average number of bachelor’s degrees and an above-average number of people living in poverty. By all metrics, it should be lagging in vaccinations. 

But Macon apparently has vaccinated over 51% of its adults, putting it just ahead of the statewide average. 

McGaha, director of Macon’s Public Health Administration, said she wasn’t entirely sure why the county’s vaccination rate was so high. If she had to guess, she said, it was because of her department’s approach to contact tracing and communication throughout the pandemic. 

“Anyone who tested positive for COVID-19 was called by our staff every day to check in on them,” she said.

“We did very intensive contact tracing with them, and we spent a lot of time on education. … The community developed relationships and trust for this agency over the past year. I think that probably is part of what we see now.” 

In other counties, people have said personal relationships with individuals and agencies matter. 

Powell said she would have expected McDowell County to have a lower rate than Rutherford, but McDowell is almost 10% more vaccinated. Powell said she thinks the strong relationship between McDowell residents and their local Emergency Management Services Department is key. 

“Their residents trust them. So, if emergency management says, ‘Hey, you need to do this,’ they say, ‘OK, because you never, ever led me astray.’” 

Rutherford County, on the other hand, had less trust in institutions on average, which makes it tougher to overcome people’s doubts about vaccination, Powell said. 

‘This pandemic is not over’

The slowdown in vaccinations means that it may take months to reach the 66% goal set by Gov. Cooper, and even that number would likely not produce a level of “herd immunity” that would completely squash the disease. 

While cases and deaths are way down from their January peaks, the state is still reporting over 1,000 new COVID-19 cases per day and local health departments remain worried about outbreaks.

“We have right now, we have a cluster in McDowell,” Powell said. “An outbreak with 11 positives in a business, and none of them are vaccinated, and they probably won’t be. They probably will not do it.”  

Booth also said that after nearly two weeks of zero new cases, Graham County had recently begun to see cases rise again. Graham has found seven new positive cases in the past week.

To try to quash the possibility of more outbreaks, health departments are shifting tactics to try to reach and convince more people to get vaccinated. Powell said her department is using mobile clinics to reach into neighborhoods with low vaccination rates. 

She hopes that even if people don’t immediately choose to get vaccinated, it will be an opportunity to educate them and make a contact that might eventually change their minds. 

Booth said she thinks that hearing from neighbors will prove to be even more important than education from health officials. 

“I think the only way at this point to really see an increase in vaccinations in Graham County is just time,” Booth said.

“They’re not going to believe the science behind it. They want to see that their neighbors are OK. And I don’t mean two weeks or a month. … They want to see that over a long period of time that it really is OK.”

Powell has less patience. 

“This pandemic is not over,” she said. “The outbreak we have right now in McDowell is a clear indication of that. And it scares me. You know, with the low vaccine rate that we have in the county, these outbreaks will just continue to happen.”

shows people behind a fence with razor wire on the top, they're in the yard of Central Prison in Raleigh. Many prisoners have refused vaccine.

NC prisons running out of people willing to accept COVID vaccine

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NC prisons running out of people willing to accept COVID vaccine - North Carolina Health News

Health experts worry NC prisons will fall short of COVID-19 vaccination levels needed for herd immunity.

By Jordan Wilkie

Carolina Public Press

A year after the more than 460-case outbreak at Neuse Correctional Institution in Goldsboro became one of the biggest hot spots for COVID-19 at the time, the N.C. Department of Public Safety (DPS) is reporting only 18 active cases of the disease across all 55 state prisons, in addition to 139 staff members who are currently off the job for testing positive or being exposed to an active case. 

Since the pandemic began, more than 10,000 confirmed cases have occurred among people incarcerated in North Carolina state prisons and another 3,828 cases among staff. Since January, about half of the more than 42,000 people who live or work in the state’s prisons have received at least one dose of the vaccine.

Now, DPS is reducing vaccines and slowing the rate at which it is vaccinating its staff and people in prison. The reason, prison spokesperson Brad Deen said, is that after vaccinating almost 22,400 people, fewer incarcerated people or prison staff are left who want to be vaccinated. 

“The key point is that the goal for Prisons has been and will continue to be getting ‘shots in arms’ as promptly as possible,” Deen wrote in an email to Carolina Public Press.  

Over two weeks, starting April 5, DPS accepted only 1,500 first doses of the Moderna vaccine the state Department of Health and Human Services offered, half of what DPS received every week since late March. Prisons continue to distribute 3,000 second doses of the vaccine each week. 

The slowdown in vaccinations could hurt people in the prison system by delaying a return to more normal operations, which both prison staff and incarcerated people have said they want, or by putting staff and incarcerated people at risk of illness if they return too quickly. 

In March, Deen wrote to CPP, “Any actions that bring us to adequate levels of herd immunity would facilitate a quicker return to regular operations.” When asked what level of vaccination DPS would deem “adequate,” Deen wrote, “That’s a better question for public health and epidemiology experts to answer.”

If the goal is to limit potential outbreaks, using vaccines to reach herd immunity, or “community immunity,” the point at which enough people in a group are immune to a disease that its spread is limited, could help. 

But a 50% vaccination rate in the prisons is likely too low for that, according to Dr. Chris Beyrer, public health and human rights professor at Johns Hopkins University. 

“That’s troubling because that probably isn’t high enough,” Beyrer said. 

“Vaccines have multiple roles. One is to protect the individual. The second is to really have a role in reducing transmission and that probably isn’t high enough to really achieve the kind of public health protections we want to see where we really reduce transmission overall.”

With a high level of immunity, either through prior infection or vaccination, even if a virus is introduced to a prison, it would not spread like wildfire as it has for most of the last year. 

Prisons have restarted certain privileges like family visitation and work release on a limited basis.

“The most important thing is going to be able to be able to communicate with their family members,”  said Sandra Hardee, executive director of the advocacy group NC-CURE. “Not having visitation privileges, and having them be so limited during this pandemic, has been really hard on these men and women.”

But restrictions will not fully ease, and the risk of outbreaks will continue, until more people are vaccinated, according to both DPS policy and the opinions of experts like Beyrer. 

Vaccine rollout

North Carolina began vaccinating health care workers in December, including medical staff at the state’s prisons. Shortly thereafter, DPS began getting its own vaccines and distributing them to prison staff.  

To date, 6,500 prison staff members are partially vaccinated, which is just under 50% of the workforce. DPS is not tracking data on which staff members are getting vaccinated, according to Deen, so it is not clear what the vaccination rates are for the medical staff or corrections officers who actually work face-to-face with incarcerated people, as opposed to administrators and other staff who may have a more removed role. 

In February, DPS began vaccinating incarcerated people ages 65 and older, which makes up just over 1,100 of the 28,600 incarcerated people in the state. Not until late March did DPS began vaccinating the entire prison population, a delay DHHS implemented in accordance with guideline updates from the national Centers for Disease Control and Prevention. The rollout came months later than the state’s initial plans or recommendations from public health experts and the National Academies, another federal organization.

To date, DPS has administered at least one dose to 15,872 incarcerated people, and those needing second doses are scheduled to be completed within a month.

Now, DPS is running out of other volunteers to take the shot due to hesitancy among both incarcerated people and prison staff, which follows similar trends in other prison systems.

People’s trust in their vaccine provider is essential, according to Julie Ward, a registered nurse and doctoral candidate in health and public policy at Johns Hopkins University. Without it, people are less likely to take the vaccine. 

“There are a variety of reasons that people, in general, tell us they are hesitant to vaccinate,” Ward said. “Sometimes it’s because they think the vaccine is inconvenient, unpleasant or hard to get. Sometimes it’s because they don’t have all the information about vaccine safety, or they don’t trust the people who are conveying that information.”

Not vaccinating is a risky decision, Ward said, and one that affects others, because people who vaccinate also make the people around them safer. 

DPS issued an incentive program for incarcerated people to get vaccinated, informally encouraged its staff to get vaccinated and released educational materials to both groups. 

To determine who wants a shot, “Wardens and other administrators report estimates based on anecdotal discussions and other informal information-gathering practices,” Deen wrote, noting that the number of willing participants changes constantly.

Across the country, more people are deciding to take the vaccine over time, according to a Census Bureau report, as people wait to see if it is safe for others.

Getting to community immunity 

In the North Carolina state prisons, COVID-19 has killed 53 incarcerated people and 12 prison staff members since March 2020. Roughly one out of five incarcerated people and one out of four prison staff have tested positive for the disease, according to data from DPS. 

Each survivor now has some built-up immunity to the virus, though people who are vaccinated are even better protected, according to Beyrer at Johns Hopkins, especially from the virus variants, which can cause a second round of COVID-19 illness and are seeing increased spread throughout the United States. 

But it’s not clear what level exactly needs to be met to achieve community immunity, and that level changes based on the risk of transmission that a group of people has, according to Dr. Jason Andrews, an associate professor of medicine at Stanford University. 

“The first thing is that the transmission rates … are much higher in prison than in the community, everywhere in the country and really in every prison system in the world,” Andrews said. 

Transmission rates also vary depending on the type of prison and how openly it’s operating. 

For example, the level of COVID-19 immunity through vaccination and illness needed to protect prisons against the rapid spread of COVID-19 is higher for a dormitory-style prison allowing visitation than it would be for a single-cell prison, where the only people to come and go are prison staff. 

“I don’t know that we have a good idea of what that would be for different prisons in North Carolina, but it’s probably higher than one might imagine,” Andrews said. 

In a December interview with The New York Times, Dr. Anthony Fauci, the chief medical adviser to both Presidents Donald Trump and Joe Biden, said he estimates achieving community immunity will take close to 90% immunity across the population, significantly higher than what many public health experts had previously estimated.  

At the current pace of vaccination of 800 first doses per week, it would take another seven months for NC prisons to reach 90% vaccination rates, assuming enough people would volunteer to take the vaccine and the population remained the same. Thousands of people are booked into and released from prison each month.

Unless more prison staff and incarcerated people volunteer to be vaccinated, North Carolina will fall well short of that benchmark. DPS is not currently considering an incentives program or making vaccines mandatory for inmates or staff, according to Deen.

Quality of life and normal operations

Most of North Carolina’s prisons have gone on lockdown in the last year to try to control the spread of COVID-19, with some prisons limiting movement for months at a time. 

That means fewer opportunities for people to get out of their cells or out of dormitories they share with dozens of other people, to get outside, exercise or call a loved one. 

“I think they’re going to be much happier to not have their movement so restricted,” Hardee said of incarcerated people in North Carolina. “So many lockdowns to one unit, very limited space, very limited time in any recreation or exercise. That has been the state of affairs during this pandemic.”

Hardee gets numerous letters from people in prisons and calls from their family members. The fear that people had of getting sick and dying has eased somewhat since the beginning of the pandemic, she said, in large part because so many people have already survived. 

But the fear, lack of visitation and long weeks of lockdown have worn on people. 

Andrews has seen similar stress on people in California’s prisons, where he has observed a worsening of incarcerated people’s mental health over the last year. 

Resuming programming in prisons is important, he said, which puts the people who run prisons in a tricky place. 

The solution is improving vaccine uptake, he said, so that people can be safe from the virus and restart visitations and other activities that are essential to well-being while incarcerated. 

Even though Beyrer thinks 50% vaccination is not enough, he also said many activities like family visitation could likely resume safely, given continued safety measures like mask wearing, 3-foot social distancing and proper hygiene. Other medical experts also say visitors should be vaccinated or test negative for COVID-19 within 48 hours of arriving at the prison.

But risk is a constantly changing variable, both doctors point out. What may be safe in one place may not be safe in another, and it depends on a complex interplay between the percentage of people in a group who are immune to COVID-19 and the risk people in that group have of spreading COVID-19 to each other. 

As prisons bring in new staff and newly incarcerated people, DPS should strongly encourage them to get vaccinated, Beyrer said, even if the department cannot mandate it. The more people there are without immunity, the more they put themselves, and everyone around them, at risk.

the photo is taken from the back seat of a car. You can see a man in profile leaning over to talk to his mom, also in profile

Long-term care facility restrictions lifted

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Long-term care facility restrictions lifted - North Carolina Health News

North Carolina families reunited after more than a year of socially distanced visits.

by Kate Martin, Carolina Public Press

Phil Wells and his siblings visited his 93-year-old mother every weekend.

Described as a “social butterfly” by her son, Rosalee Wells was a homemaker who raised five children. She lives in a Wake County nursing home and had a vibrant social life before the pandemic.

“We took her out for lunch. We took her shopping. We took her to dinner. We took her to Sunday school and church,” Wells said. “Her friends and neighbors took her out for outings. And that was part of her life.”

Then the COVID-19 pandemic hit.

“Well, suddenly, my sister took her back to the facility one day, and they said, ‘You can’t go back into her room with her.’ And when my mother walked back in the door that day, thus began the COVID lockdown.”

Family members had been able to visit with Rosalee outdoors on a screened-in porch or talk with her on the phone.

But Rosalee, who has dementia, didn’t understand why her family couldn’t hug her or why they were wearing masks.

“The main thing I want to do is to hug my mother’s neck again. That’s what I want,” Wells said early last week. On Friday, he got his wish.

Earlier this month the state rescinded a health order that restricted visits to residents in long-term care facilities like nursing homes after new federal guidance indicated in-person visits in nursing homes and other care settings could resume.

“Facilities should allow responsible indoor visitation at all times and for all residents,” the Centers for Medicare & Medicaid Services said a little more than a week ago, regardless of vaccination status of the visitor or resident.

In North Carolina, some nursing home residents started getting vaccinated in December. More than 80% of residents have had their first dose of one of the COVID-19 vaccines, said Jennifer MacFarquhar, an epidemiologist with the N.C. Department of Health and Human Services.

Coronavirus cases and outbreaks have also dropped in the past couple of months.

“One of the other positives that we’ve seen is the length of time that an outbreak is ongoing in facilities, that length of time has also been decreasing,” MacFarquhar said. Early in the pandemic, some outbreaks lasted longer than six weeks.

Though visits are now allowed, MacFarquhar said she recommends people continue to wear masks, wash their hands and stay physically distant.

“There is a caveat in there that if, particularly if both parties are vaccinated, if they choose to have that close physical contact, they can do so,” MacFarquhar said, as long as both parties wear well-fitting face masks.

A person is fully vaccinated two weeks after receiving the second dose of either the Pfizer or Moderna vaccine or two weeks after receiving the single-dose Johnson & Johnson vaccine, MacFarquhar said.

A man in a rain jacket and a mask helps his mother into the passenger seat of a car
Phil Wells helps his mother, Rosalee Wells, get into his car to attend a dentist appointment and get breakfast biscuits. Rosalee is a resident at Cadence Senior Living in Wake Forest, which closed to indoor visitation more than a year ago. “It’s been a long time since I’ve been able to help you down the curb, huh?” Phil asked his mom. Alicia Carter / Carolina Public Press.

A different way of living

For Phil Wells, plans that would otherwise be mundane have new meaning.

“This Friday, I’m taking her to the dentist. It will be the first time,” he paused for several moments before continuing, “in over a year that I’ve gotten to do that. That I’ve been able to take her out and be with her.”

Throughout the past year, they celebrated milestones at a distance, such as a car parade on Mother’s Day, which coincided with Rosalee Wells’ 93rd birthday.

He hopes her 94th birthday this May can be celebrated differently.

In the past year, they’ve had phone conversations and attempted using video technology, but a window visit did not go well.

“Early on, we went and sat outside her window. She could not understand why we wouldn’t come in. She’d say, ‘Why aren’t you coming in to see me?’” he said. “For people with dementia, there’s this whole added element of confusion and uncertainty and difficulty.”

After the first couple of times trying a window visit, they stopped, he said.

“That was worse than not seeing her at all,” Wells said. “You’d see all of these pictures in the newspaper of these cutesy window visits. Well, they weren’t so cute to us, because they confused my mother even more.”

The past year has been “catastrophic” for people in long-term care, who have mostly been socially isolated, said Lauren Zingraff, executive director for the nonprofit Friends of Residents in Long-Term Care.

“In many cases, they have essentially been in their rooms by themselves. The only contact they’ve had has been with staff members who have been wearing PPE and masks to bring them meal trays three times a day,” Zingraff said, referring to personal protective equipment.

A few months into the pandemic, Zingraff said, people started noticing changes in their loved ones, such as increases in depression or anxiety. Some residents stopped eating and drinking.

“They would verbally share, ‘Why am I even alive?’” Zingraff said.

While the new guidance is giving hope to family members weary of the separation, there are some limitations.

Facilities should limit visitation if the county’s positivity rate is higher than 10% and fewer than 70% of residents are fully vaccinated, if any residents have a confirmed COVID-19 infection, or if the resident is in quarantine, according to federal guidance from the Centers of Medicare and Medicaid Services and the Centers for Disease Control and Prevention.

Before trying to visit a loved one, people need to call the facility first, said Adam Sholar, president and CEO of the N.C Health Care Facilities Association, which represents nearly 400 skilled nursing centers.

As community spread of the virus escalated and then peaked two or three months ago, Sholar said, “those restrictions were important to try to minimize the impact that community spread had on that nursing facility.”

Though cases are on the decline, nursing homes and other facilities are still fighting the coronavirus.

“We are still in the midst of this pandemic,” Sholar said. “This is still an extremely deadly virus. There is still not an insignificant amount of COVID circulating in the community. The direction is still to adhere to the core principles of infection control, which include masks and social distancing… This is not a return to pre-COVID visitation.”

While it wasn’t exactly like their pre-pandemic visits, Wells’ visit with his mother exceeded his expectations.

Despite concerns about awkward or hesitant moments, “it was wonderful,” Wells said. “Absolutely wonderful. We had a great time. It’s hard to imagine that a trip to the dentist could be so much fun.

“I was on the phone with my sister telling her about it. What was most striking was the sense of normalcy. I dropped her off at the facility a year ago and picked her up today, and we started right where we left off.”

A woman in a paper surgical mask worn against COVID leans out the window of the drivers seat of her car so a woman in a mask can give an injection in her right arm.

New guidance on life after COVID vaccination

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New guidance on life after COVID vaccination - North Carolina Health News

New Centers for Disease Control and Prevention guidelines offer looser rules for people who've received both doses of either Pfizer or Moderna or a single dose of Johnson & Johnson vaccines.

By Christian Green

Carolina Public Press

As nearly 2 million North Carolinians have received at least one dose of a vaccine against the deadly coronavirus, individuals are beginning to ask questions about what practices they need to continue in a post-vaccinated world.

On Monday, the national Centers for Disease Control and Prevention released the first set of guidelines for fully vaccinated individuals, which provide recommendations for how people can safely interact without social distancing or masking and possibly begin to return to a version of pre-pandemic normalcy.

The initial changes are relatively small, but they are significant for families and friends who want to see each other safely. They also set the stage for the CDC to gradually recommend a stepwise loosening of restrictions as more people become vaccinated and data continues to show the vaccine’s effectiveness at protecting individuals and preventing the spread of disease.

What does it mean to be ‘fully vaccinated’?

According to the CDC guidelines, a person is fully vaccinated beginning two weeks after receiving the second dose of a two-dose vaccine (Pfizer-BioNTech or Moderna) or two weeks after receiving a single-dose vaccine (Johnson & Johnson).

The vaccines require two weeks to allow the immune system to produce enough antibodies to establish a robust immunity to SARS-CoV-2. It is possible to contract COVID-19 in the period between vaccination and antibody production, so it is important to continue to follow all safety measures in the meantime to ensure a high level of immunity, the guidelines said.

What can happen once one is fully vaccinated?

Answers to some common questions about post-vaccination behavior.

“Can I eat dinner with other fully vaccinated people?“

Yes, according to the latest guidance. There is “likely a low risk” for fully vaccinated individuals to meet each other indoors without wearing masks or social distancing, the guidance stated.

If everyone is vaccinated, it is safe to hug family members and eat a private dinner with friends indoors, according to the guidelines.

“Can I socialize with people who are not fully vaccinated?“

It depends. Here’s where things get a little tricky.

According to CDC guidelines and current understanding of immunity from vaccinations, vaccines not only protect people from getting seriously sick, but there is also growing evidence that they also keep people from developing asymptomatic COVID-19 and that vaccinated people are less likely to spread SARS-CoV-2 even if it is in their systems.

Because of this, the CDC says that the decision to meet unvaccinated individuals indoors, without social distancing or masks, depends on the unvaccinated people’s susceptibility to severe infection from SARS-CoV-2.

In other words, if the unvaccinated people are not at high risk for severe COVID-19 symptoms, they can be around a fully vaccinated household, according to the guidelines.

For example, two fully vaccinated grandparents are fine to visit with unvaccinated grandchildren, provided that no grandchildren have any serious underlying health conditions such as immunocompromised systems or heart conditions, according to the CDC.

However, if any single individual in a household is unvaccinated and is at high risk of developing severe COVID-19, then the CDC recommends that the entire household still follow masking and social distancing guidelines, even when visiting with fully vaccinated people. Because scientists are unsure if vaccinated individuals might pass even a small amount of SARS-CoV-2 to an at-risk individual, these gatherings are not currently recommended.

If a fully vaccinated person wants to visit an unvaccinated friend who is 70 years old, that meeting should still take place outdoors and with necessary precautions for now, the guidance said.

As the research about how much vaccination affects a person’s ability to transmit even small amounts of Sars-CoV-2 continues to develop, the recommendations may change. Because there is no definitive answer at this point, the CDC recommends an abundance of caution for now.

“Can I get together with a large number of unvaccinated people?”

At this point, no.

Because community spread of COVID-19 is still high, the CDC still recommends that, in any situation where two or more households are not vaccinated, the meeting should still take place outside and with necessary precautions.

As of March 4, six counties in North Carolina were listed as “red status,” or areas of critical spread, down from 27 red counties in the prior reporting period. Thirty-four counties were still listed as “orange status,” denoting substantial community spread. The number of percent positive tests across the state is still around 5%, meaning precautions such as outdoor gathering and mask wearing are still important.

If three households meet and only one is vaccinated, there is still the possibility for one unvaccinated household to infect the other, so proper precautions should still apply, the guidance said.

The CDC also advises against medium and large gatherings of crowds, regardless of vaccination status.

“Do I still need to quarantine after contacting someone with COVID?“

No, though one should still monitor for symptoms. Fully vaccinated individuals are very unlikely to contract COVID-19, so new CDC guidelines do not recommend quarantine after contacting a person who is diagnosed with COVID-19.

Though quarantine is no longer required, a person has been in contact with someone who is COVID positive should still monitor for symptoms of COVID-19, such as fever, shortness of breath, persistent coughing, or any of these other symptoms.

A person who has been exposed and experiences any symptoms related to COVID-19 should immediately isolate and get tested.

For a test, contact a doctor or a local health department. Testing locations are also on the N.C. Department of Health and Human Services website, and testing is still free in many locations.

Looking for a vaccine? Check out our county by county guide.

There is an exception to the quarantine exemption for members of congregate housing, like homeless shelters, where transmission is much easier. In those situations, even vaccinated people are urged to quarantine after exposure to prevent possible spread. Individuals in congregate living, except for those in long-term care facilities, are not scheduled to be eligible for the vaccine until March 24 under current DHHS guidelines.

“Do I still need to wear a mask in public?“

Yes.

“People who have been vaccinated still need to wear masks when they are in public settings and around those who are not vaccinated,” DHHS advised in an email Monday.

That’s because, at this point, only around 10% of the U.S. population has been fully vaccinated for COVID-19, and roughly 10% of North Carolinians have been fully vaccinated.

Even though fully vaccinated people appear unlikely to contribute to disease spread, it is unrealistic for someone in public to be able to know who has been vaccinated and who has not.

“Even if they (fully vaccinated people) are at much lower risk, it’s not reasonable to expect a grocery store to try to verify who’s vaccinated or to have two classes of people with different rules.” Zeynep Tufecki, associate professor at the University of North Carolina wrote in The Atlantic.

“For now, it’s courteous and prudent for everyone to obey the same guidelines in many public places.”

Unless guidance changes, even fully vaccinated people should continue masking in public.

Looking to the future

The set of guidelines was a “first step,” and more updates can be expected as more people are vaccinated and COVID-19 cases and deaths fall across the country, CDC Director Dr. Rochelle Walensky said in a White House press briefing Monday.

Future updated guidelines are contingent on three key areas, she said: getting more people vaccinated; seeing a continued decrease in new COVID-19 cases and deaths; and further studies to determine exactly how effectively vaccines reduce disease transmission in the rare cases of “breakthrough disease,” wherein a vaccinated individual contracts COVID-19.

Breakthrough cases are very rare, and even when they do occur, Walensky said, the severity of the disease is much milder. Additional research, such as a preprint study from Israel, has found vaccinated individuals carried lower levels of virus, suggesting that breakthrough cases are less infectious and lead to milder disease.

“While we are seeing COVID trends moving in the right direction, cases and hospitalization numbers remain elevated, and we still have work to do,” a DHHS spokesperson wrote. “We need to keep protecting each other while we get everyone a spot to get their shot.”

In the CDC’s “Science Brief,” a document containing its rationale for recommendations, describes the future timeline: “As vaccination coverage increases, a balanced, stepwise approach to phasing out certain prevention measures in fully vaccinated people, ideally those that are the most disruptive to individuals and society, can be taken.”

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