Public Health, Welfare and Labor Committee- House
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Senator Missy Irvin
Unverified
0:00
Okay, if everybody can get their seats, we are going to go ahead and get
Speaker 5
0:13
started. Can you hear me okay? Might need to
Senator Missy Irvin
Unverified
0:17
turn that up. There we go. All right, if everybody can get their seats, I've got some announcements that I'd like to make. This committee,
the House and the Senate Public Health Committee, we will meet again on Wednesday, February the 12th.
At 10 a.m. at the Arkansas Heart Hospital, which is located at 1701 South Shackleford Road in Little Rock, Arkansas, you'll need to park on the second floor of the parking deck, which is located next to the hospital. So park on the upper parking deck. We're meeting in the administrative conference room. The reason why we're meeting at the Arkansas Heart Hospital, one of the reasons is, number one, we're going throughout the state, and we're going to be meeting in different areas of the state, and meeting at different hospitals and health care facilities.
And so I picked the Arkansas Heart Hospital for the month of February because the month of February is your heart healthy month and with a focus on heart health. And so that's one of the reasons why we're going there. But they have been gracious to host us and give us a presentation about the Heart Hospital and all the different programs that they have in place. So you're going to need to park on the second floor of the parking deck. We're meeting in the administrative conference room, which is on the third floor. There's going to be signs that are going to guide you.
I need a show of hands of who is going to be able to come Wednesday. If you can raise your hand so Mr. Price can count you. Reason why is we're going to have lunch there. They're providing us with lunch, and so we'd like to give them a number as to how many. That will be a planned activity. If you don't know, the Arkansas Heart Hospital actually has a world-class chef there, and they focus on healthy meals for your heart,
but they've actually, this chef has been featured on national media news. So that's going to be fun. Did you get your count? Did you get your count? Do they need to raise their hands again? Are we good? Yeah. Okay. All right. So just communicate with Mr. Price if you can be there or cannot be there. We are also going to have another meeting again this month on Wednesday, February 19th at 1 o'clock in Committee Room A
with the House and Senate Insurance and Commerce Committee, which we will be discussing rural ambulance funding. um as you're aware a task force on transportation of non-emergency behavioral health patients was formed by act 1041 of 2019 and has been meeting almost um for a year to come up with recommendations representative perry is the chair of that task force and senator hickey you're on that task force so um that's going to be one of the issues we'll be meeting with about on the 19th today we have
UAMS here and we're going to start with them. They are item agenda number H. We're going to start with UAMS to give us an update on the Cancer Institute designation process and then we'll have three rules for consideration and then the health department is going to be giving us an update on vaping and actions being taken in other states by the federal government as well as an update on the coronavirus. And before we begin with our presentation from UAMS, I'd like to have consideration to adopt the January 6th meeting minutes. Is there a motion? Motion. And a
second. Those in favor say aye. Aye. And opposed? Ayes have it. The minutes are adopted. All So we will move to item H. And exhibit H is in your packet. And with that, I'm excited to have Dr. Cam Patterson here with us. And he is going to introduce our new Cancer Institute director. Mr. Patterson, you're recognized.
Speaker 11
4:25
I am. Thank you very much, Senator Irvin, ladies and gentlemen of the committee. It's a pleasure and an honor to be back in front of you. We've had a lot of good things happening at UAMS over the past six months or so, since the last time I was in front of you. And among them has been our ability to jumpstart our march towards National Cancer Institute designation for the Winthropy Rockefeller Cancer Institute,
we could not be where we are now without your support. And so we remain extremely grateful to all the members of the committee, the House and the Senate, for their support of funding to help us achieve that. And we've been in conversation with Larry Walter about the amount of tax revenues that will be generated to support this, and we're going to get a pretty good number. He's estimating at least $7 million generated from tax revenues in this current year.
So this will really kickstart our drive towards National Cancer Institute designation for UAMS, which will make us the first and only NCI-designated cancer center in the state. Now, we can't do any of this without a great leader. And we've had exemplary leadership of the Winthropy Rockefeller Cancer Institute since its inception over 30 years ago. And I'm pleased to introduce to you the newest director of the Winthropy Rockefeller Cancer Institute and one of the newest members of
the UAMS faculty, Dr. Michael Beer. Dr. Beer is an oncologist who has practiced at the National Cancer Institute, Massachusetts General Hospital, and most recently he's been the director of the Cancer Institute at the University of Alabama in Birmingham, and this is important because that is an NCI-designated cancer center as well, so he has the experience to get the job done. Dr. Beer is nationally recognized. He's extremely well-funded. He literally wrote
the book on treatment of ovarian cancer, so he knows what he's doing, and I am pleased today to introduce him to you. Dr. Michael Beer. Thank
Senator Missy Irvin
Unverified
6:52
you, Dr. Patterson. Dr. Beer, we're so happy to have
you here, and we're excited about the fast progress. We're excited to hear from you, but welcome to Arkansas. We appreciate you coming
Speaker 17
7:02
here. Thank you very much, and thank you, Chancellor Patterson, for that lovely invitation. Senator Irving, members of
Speaker 19
7:08
the committee, again, thank you for inviting me here. It's an honor and a pleasure to be here today to tell you a little bit about how we're doing the Cancer Institute and how we will get to designation. I don't want to belabor it, but I think a quick 101, if you will, on NCI designation would be helpful. NCI designation is important because you may or may not realize that essentially any institution can put out a shingle that says we are a cancer center.
It doesn't guarantee the patients who walk in the door are going to get a certain level of care. It doesn't mean that they have clinical trials. It doesn't mean that they have the kinds of research which are important to move the field forward. NCI designation will send the message to patients throughout the state of Arkansas that UAMS will provide that kind of care, outstanding care. They'll have the clinical trials that patients demand. And ultimately, we have a body of researchers that will be contributing to our ability to treat effectively and cure some of these cancers.
So the reason for designation is clear in my mind. I have served on three separate NCI-designated cancer centers. It's exceedingly valuable. There are other fallouts from that process you should be aware of. My ability to recruit first-class researchers and clinicians will be much, much easier if we're NCI-designated. This is what people are looking for in their careers. So that's an added bonus, if you will. And then finally, I'd be remiss if I didn't say I do see a vision here long-term where we can utilize NCI designation
to begin to build and enlarge a biotech pharma park, if you will, within Little Rock or its surrounding, where those companies will bring their expertise, their drugs, and ultimately revenues, utilizing their pipeline of drugs, testing them at the UAMS hospital and the Cancer Institute, and then ultimately hiring young graduates coming out of the system. I saw this work in Cambridge, Massachusetts.
It's doable, and it can really be transformative. How do we get there? I won't say that that process is completely predictive, because anything with the federal government is not predictive. But I will say it's relatively prescribed. In order to become designated, we will have to significantly enlarge our lab-based researchers. We already have an advertisement out in top-level journals. We have 60 CVs sitting in my office.
And we've already hired three individuals who will bring in, we think, between $2 and $3 million of NCI funding. So that's how those resources coming from the state are being leveraged. I can't say enough how critical this is. The NCI will actually look at our portfolio and say, how much money are you getting from the NIH? And we need between $10 and $20 million on that. Second of all, we will need to significantly enlarge our clinical trial effort. Right now we put 100 patients on clinical trials per year.
That needs to be 300. The good news on that is our patients will benefit tremendously from that. They will be getting the drugs that are available in many other cancer centers throughout the country. We will bring them here. So that will be the second effort. The third effort that's important is our clinical care, which is outstanding, is, again, a bit thin. we need to triple the size of medical oncology. And, again, we're already hit the ground running on that.
We have five physicians coming in July. I would like to see that up around 15 or 20. And we will give them protected time so they can do what's known as translational research, which, again, is very, very valuable for the university and the field to move forward. And finally, I'll finish to say the other major component that we will be focusing on is the National Cancer Institute wants to know what is our catchment area and how are we addressing its cancer needs.
Our catchment area is clear. It will be the state of Arkansas. I emphasized the state of Arkansas, not Little Rock. It will extend to all four boundaries. And we will sincerely create a functional cancer network which will provide care and clinical trials throughout the state, and that includes many of the underserved populations, particularly the rural populations, which so much deserve our attention.
That's a quickie about how important designation is and how we're going to get there. And let me just finish up by saying I cannot overemphasize or exaggerate the value of the monies coming from the state. This is mother's milk to a Cancer Institute director because as opposed to NCI funding, which is in the form of grants, we can never quite predict whether we're going to get the grant. But the monies coming from the state are more reliable.
They're there. And so we can implement a vision, I think, quite effectively over the
Speaker 17
12:36
short term. And we will be speeding to NCI designation as quickly as
Senator Missy Irvin
Unverified
12:44
we can. Thank you. Thank you. On the map that you provided, those are, is that areas that, are
those states that do not have NCI cancer institute, designated cancer institutes on this map? Correct. That's right.
Arkansas, Mississippi, and Louisiana. That's right. I mean, I understand we have enough here at home that we need to take care of, but if those other states, Mississippi
and Louisiana, that are neighboring states, could we also be seeing patients from
Speaker 19
13:18
those states as well? Absolutely. And again, I think the long-term vision, once we get NCI designation, is then essentially evolve beyond that to being a cancer center of destination. So rather than have our patients go to MD Anderson or Oklahoma looking for the phase one,
maybe we'll have patients coming from Texas and Oklahoma coming here because we have the clinical trial that they don't.
Speaker 17
13:44
That's quite doable from my viewpoint. And you can see that most of the states are covered with designated
Speaker 19
13:52
cancer centers. Because the NCI has made it clear through a number of, I don't want to say mumblings, but that's what they usually do, that they really want a designated cancer center in
every state in the country. And what's driving that is the need to serve cancer patients in those states. So the timing on this could not be better. It's just our job to get it done and get it done right. and submit what is a relatively large grant. Right. Okay. Are there other questions from
Senator Missy Irvin
Unverified
14:28
members of the committee? Representative Payton? Thank you, Madam Chair.
Speaker 32
14:34
Looking at the bottom of page two where it talks about the expected timeline, it says
Speaker 34
14:40
five years. Is that the it would be five years before you can apply for NCI designation
Speaker 19
14:53
that some? Sure. I think it's an excellent question. Our approach is to do it and do it as fast as we can. The caveat in that is one does not want to submit a grant. These are big grants, 2,500, 3,000 pages, that is deficient and won't fly.
So we need to make sure the quality of it is absolutely outstanding. The other issue is that one needs to recognize that NCI will frequently tell us about things that are somewhat out of our control. If we're applying in a year where we're up against very large established cancer centers, they will actually say, you know, you might want to postpone in six months before you apply. So we'll have a dialogue with them. So to get back to your question, we're aiming for about two, two and a half years for submission
with the understanding that, depending on the circumstances, that could stretch out to three or four years.
Speaker 32
15:51
Yes. Could I have a follow-up? This is totally unrelated to the timeline. It's more or less my curiosity. You may or may not can expound on much of this, but we see a lot of headlines or medical papers where somebody's come up with some great new cutting-edge treatment and cancer's going to be cured. Or, you know, can you tell us anything or give us on these medical trials?
I mean, can you maybe tell us some of the good news that's on
Speaker 19
16:24
the horizon? Sure. So I always couch this to my patients that, like everything in life, is good news and bad news. I think that in many ways cancer is a disease of aging. So I think the sort of axiomatic statement, well, are you going to cure cancer, which my kids used to always ask me about it, the answer is probably no in the sense that we will cure some cancers. Other cancers we will convert to chronic diseases like type 2 diabetes where patients could
live long, happy lives with good quality of life. Having said that, 35 years in the business, this is the most exciting time I have ever seen in medical oncology. I mean, the immuno-oncology drugs are just home runs. Take patients. I'll give you an example. When I was training centuries ago, we had patients with metastatic colorectal cancer to the liver. We would not even treat them. The only drug I had was single agent 5-A-VU, which was terrible, and it wasn't ineffective.
There is now a subset of those patients who have the tumor, came from the colon, it's sitting in the liver, multiple metastatic lesions that we can cure. By giving these immune checkpoint inhibitors and activating the patient's own immune system, It just, the metastatic lesions, the tumors in the liver
Speaker 17
17:45
just disappear. I'll give you another one. We just opened up our CAR-T. I have to say that right, CAR-T. CAR-T. There's a CAR-T. I'm not supposed to speak about that. Yeah. CAR-T commercial applications at UAMS.
Speaker 19
18:01
So what is this agent? These are the actual T-cells in the body, which are then engineered to fight the tumor. And so we take them out, we activate them, we then infuse them back. These are drugs, agents that have taken kids with refractory B-cell leukemia, meeting survival of 1.5 months, 1.5 months, terrible, and cured them. So it's a very exciting time. And I'm not, you know, again, I have no agenda here other than to tell the truth.
We have so much to offer our patients. That's not even talking about the small molecule inhibitors, these little, you know, oral pills that we give patients rather than infusion. Lots of those, we understand cancers better now. We can take a patient's tumor and sequence it and look for mutations and say, no, no, no, no, you don't need that horrible cytotoxic drug. you need this pill. And that's targeted to you. So personalized oncology is here to stay. I've seen it in ovarian cancer patients. We just had a whole new class of drugs approved called PARP inhibitors.
These are just revolutionizing the way we look at patients. It's a very hopeful time. We need
Speaker 35
19:17
to bring it here to Arkansas. Thank you. Thank you,
Senator Kim Hammer
Unverified
19:26
Madam Chair. Thank you, Representative Payton. Senator Hammer. Thank you, Madam Chair. I was wondering if you could just kind of educate me as to what your approach is. I noticed on your timeline that you're going to have to recruit, retain leader, leading cancer researchers who collectively bring $10 million in NIH cancer research funding annually,
but you won't make application to NCI until after that. So could you explain to me how you're going to recruit those individuals with that money prior to getting the NCI designation? And is their budget going to be, is there, are their salaries going to be paid for out of their $10 million? Or is UAMS going to have to compensate for those salaries to retain them and get them from other people?
Speaker 19
20:16
Sure. It's a great question. So the general sort of standard approach to this would be, and we've started this, put out advertisements for individuals that would bring in expertise, if you will, that fits the programs that we want to develop in the cancer center. And we need to develop those programs if we're going to get NZI designation. I approach this actually the way we did it at UAB because it was actually relatively successful. We put out a very large omnibus advertisement in New England Journal, Journal
Clinical Oncology, Nature and Science. These are top level journals saying that the Winthropy Rockefeller Cancer Institute with the support of UAMS was starting a major cancer hire in these areas and we listed all the areas that we wanted. Again, I have about 60 CVs which have been accumulated over two weeks. We think that will probably go to 100, and then we have a selection committee to basically take the cream of the crop, if you will, and we'll invite them for interviews, probably two rounds, and then begin to negotiate about them moving their science
here to Little Rock and to UAMS. This process, and this is why I hesitate a little bit about the timeline, this process, to be perfectly frank, takes about one to two years to get good candidates. it's just the way it is. So that's why we hit the ground running. And we certainly hope that we would have between five and ten individuals already on board, I would say by early, no later than early next year. If you look at table two, there's somebody listed called Frank Zahn. My predecessor, Laura Hutchins, had started the negotiations with him. He's
a great example of how it should be done. He was at the University of Iowa. He's a melanoma, I'm sorry, he's a myeloma expert. He has about $3 million in
Speaker 17
22:12
National Cancer Institute grants. And he actually, I interviewed him while I was still at UAB. That was tricky. We hired him, and he's here, and his wife is coming with
Speaker 19
22:23
his family, with his kids in June. But he's bringing all those grants. So he shows up, and our grant portfolio goes up by $2.5, $3 million.
That's the way you want to do it. And more importantly, he's going into myeloma, which is one of our established programs, and we need researchers to bolster that. So that's the process. And I think in the long run, once we become designated, that whole process becomes easier because that's where investigators
Speaker 17
22:53
want to be. In the short run, we don't have that luxury, so we will hire them and we will build towards designation. Senator Hammer, if
Speaker 11
23:02
I may, since you brought up the issue of money,
our feeling is that this is a co-investment. And we are deeply grateful to you and the people of the state of Arkansas for their support. UAMS obviously is contributing to all of the efforts that we are making here, both financially and non-financially, to ensure Dr. Beer's success. And then the community is investing with us as well, And we're seeing generous community members who recognize the importance of this for the state of Arkansas and who are investing along with us to make this all happen.
Senator Missy Irvin
Unverified
23:38
All right. Thank you. Thank you, Madam Chair. I think that's a key component of what's also happening outside of this and the target that you've set. What is that? It's kind of a public-private partnership that we've kind of entered into, so you have a lot of private money that is going to help support this, but
Speaker 11
23:59
you might want to, the goal. Yeah, so absolutely, and we have people here in the audience today and people who have been supportive from the community all along as we went through the legislative process.
And so we're looking at least for a dollar-for-dollar match from the community to bolster and supplement the support that we're getting from the state. We're not going to be able to make this happen without community support. One of
Senator Missy Irvin
Unverified
24:22
the things that was shared with me, just on a personal note, just for the
legislature to kind of get this in your head or wrap your head around this was one of the persons that has been a part of UAMS and has worked and tried to get through this or support this.
They said, we have been working on this for years. How did it take y'all such a short time to get this done? And it just goes to the fact that all these legislators that are sitting around this table, it's y'all. This is y'all's work that really got this thing, going and launching this rocket because we were able to do it in relatively a short period of time to get that support. So it's a huge partnership, but you as legislators, you have to know that y'all were really the rocket fuel that helped launch this rocket in a big, big way
because other places it's taken years
and years and years without that support. So I appreciate that. Are there any other questions? Mr. Tosh,
Representative Dwight Tosh
Unverified
25:26
Representative Tosh. Thank you, Madam Chair. Appreciate you being here today. I'm just curious, as you AMS, are you involved in genetic testing? And if so, I'd like to get your thoughts on that as far as the accuracy of that and possibly predicting any risk dangers through that genetic testing. Yeah, so
Speaker 11
25:46
I would say broadly we have a
very large and robust genetics testing program. We also have a program wrapped around that focused on the ethics of genetic testing. We've got an excellent bioinformatics group that sifts through information derived from genetic assays to figure out how we best utilize this in a most appropriate manner to benefit patients without any potential for collateral damage, which is something that I think has potentially been minimized in many of the
discussions about genetics. And then specifically within the cancer area, Dr. Beer can tell you about what we're
Speaker 17
26:26
doing there. So, again, it's a particularly exciting time in oncology
Speaker 19
26:30
because we know now we have a much better understanding between both inherited abnormalities in certain genes and the risk for developing cancers. And then we know a lot more about the actual mutations that occur in certain tumors to make them grow faster. So standard of care will dictate that patients frequently undergo what's called BRCA1 and 2 testing.
We've now extended that throughout the entire Fanconi pathway. These are genes that predict for the risk of breast and ovary. Colorectal is Lynch syndrome. So these are all standard. We do them routinely. And then we have platforms that we can actually test the tumor on. Most of those right now are commercial platforms, and we send the tumor out turnaround times about two weeks, so it's very fast. I consider what exists here to be absolutely solid standard of care.
Patients are not missing anything, and that's the way
Senator Missy Irvin
Unverified
27:31
it should be. Thank you. Are there any other
Speaker 60
27:35
questions? Senator Hickey? Yes, just page five. Could one of you give me a little bit of
Senator Jimmy Hickey, Jr
Unverified
27:41
information on that? Dr. Beer, you may not be the one to do it. The footnote we have for five out of this fund just shows administrative cost of $77,000 so far.
Yes, sir. Could you expand on that a little bit and tell me what that is? Is that a salary of somebody that
Speaker 60
28:09
we've got hired to manage this fund, or is that investment cost, or
Speaker 13
28:14
do we know? I'm going to let, uh, Dorothy Grace is the, um, uh, director, uh, finance director of the Winthropy Rockefeller Cancer Institute.
Speaker 65
28:22
Um, I'm actually not the finance director. Our CFO is, is the one who compiled this information on the administrator. However, um, from his explanation of this data, those are standard charges from DF&A.
So those are things that we don't have any control over. They're charges that are taken out from funds
Senator Jimmy Hickey, Jr
Unverified
28:39
as they come into UAMS. Well, I see the, are we talking about the same thing now? If you're looking at the, if you're looking at the number three, the processing charges by DF&A, it appears that they charge all 3.1% on the fund, which to be honest with you, that may be something that the legislature needs to look at. But what I'm in reference to is the expense draws down there that are posted under the number five, the footnote for the 77, are you telling me those are DF&A fees also?
Speaker 65
29:06
No, no, no, no. Those are on the page behind, on the following page 6. Sorry about that. I misunderstood your question. Yeah, so that's a detail of expenses. Some salaries. There are some salaries.
Senator Jimmy Hickey, Jr
Unverified
29:23
Okay, so those are on page 6 back here. So those are going to be mostly salaries other than $5,500? That's right. That's right. And you
Speaker 71
29:31
can see, for instance, on the bottom, Ricky. Ricky was one of our recruits.
Speaker 19
29:36
So most of his package came from a different source, but the state money was used to fill out a very small portion
Senator Jimmy Hickey, Jr
Unverified
29:43
of it. Okay. And since you were there and you kind of touched on it, I was going to ask DF&A this behind the scenes, and it may be a question. The $8,500 that they're charging, the 3.1%, it says that that's just a management fee to them. Are you aware is that for investment, or is that just because they're holding the funds over there? Any idea? I do not know,
Speaker 70
30:08
He would have that information. Okay. Well, that'll be fine, or I'll get with him. Thank you, ma'am. We'll get the answer back
Senator Missy Irvin
Unverified
30:15
to you. Thank you, sir. And can you state your name for the record, just so we have it on record? I'm sorry.
Speaker 65
30:21
I apologize. Dorothy Graves, Associate Director for Administration of the Winthrop P. Rockefeller Cancer Institute. Thank
Senator Missy Irvin
Unverified
30:26
you, Ms. Graves. and then any information you want you can get back to Mr. Price and we'll send it to all members of the committee. Thank you. Are there any other questions? All right so part of the legislation
that was passed was required this detailed report and information so we really appreciate it. I think that's we have not had this level of transparency and accountability before in a lot of different areas and so I for one definitely appreciate the detail that you went to in order to provide us all this information especially the finances. I think it's incredibly important and I really particularly like the timeline of where we are so that we can see and understand you have to build
the capacity in order to apply for and that you want to do it right and have everything in place before we go through that process. So it makes it incredibly clear and it's exactly what
I was wanting, so I just appreciate it. Well, we appreciate your saying
Speaker 11
31:22
that, and we certainly welcome any of the committee members to share with us any additional information that you want included in future reports, so we want this to be as informative and transparent as possible. Thank you so much. Thank you
Senator Missy Irvin
Unverified
31:33
for your work, and welcome to Arkansas. We're excited for you to get to work, and I mean, you already have, but more so. Thank you very much. You bet. Thank you so much.
um for the members that have just come in um i just want to make a reminder we're meeting this wednesday at the arkansas heart hospital representative love i don't know if you were in the audience when i said this but this right here is all the information you need about where we're parking where we're meeting and you need to make sure to let mr price know that if you're going to be there or not so that we can give them a correct number for the lunch and again i'll remind you the lunch is going to be incredible because it's a world-class chef that they have
so make sure you let Mr. Price know if you're going to be there so we can give them a number and take this with you because it's got the map of where you park and where we're meeting everybody got it I don't want people texting me where are we supposed to park okay all right moving on we're going to go to um the rules item number d dhs mr white
Senator Missy Irvin
Unverified
32:59
state your name for the record so
Speaker 83
33:03
you're recognized. Yeah, hi, good afternoon. Melissa Stone, Division Director for Developmental Disability Services at the Department of Human Services. And
Speaker 84
33:12
then Tommy Tarpley, Deputy Director of the Division of Developmental Disability
Services, Arkansas Department of Human Services.
Senator Missy Irvin
Unverified
33:20
All right, you may proceed. Thank you. Members, this is item number
Speaker 83
33:27
D and exhibit D. So we're presenting to you guys today the Autism Waiver, which is administered by the Division of Developmental
Speaker 87
33:36
Disability Services And we are assisted with that effort through Partners for Inclusive Communities. They assist us with administering this waiver program.
It's for children with an autism diagnosis between the ages of birth and seven. We've had 150 children on this waiver. What we're presenting today is we're trying to add 30 additional slots so that we can provide the service to more children. The waiver has been highly effective. It has a component of parental involvement where the waiver is focused on treating children with autism in their natural environment,
more often their home or out in the community, such as churches and grocery stores, with their families. So they teach the parents how to interact and step in when there is disruption. And so it's highly effective, and we're just excited to be able
Speaker 83
34:42
to add additional slots. So in addition to the waiver amendment, it has a corresponding Medicaid manual that goes into detail about the service array and the billing codes.
And so that is presented to you guys today as well. It has
Speaker 87
34:59
been sent to CMS for approval. We have a call with CMS on the 13th that just got scheduled to answer any questions they have. But we don't anticipate any problems with that approval. And we'll be able to offer those additional slots if you guys approve it on March the 1st. So I'm
Speaker 83
35:21
happy to answer any additional questions. and I appreciate you allowing us to be here.
Senator Missy Irvin
Unverified
35:27
Members, behind Exhibit D is the legislation that
was passed, and on page 12 under Section 15, Special Language, is where this authority is coming from. Are there any questions? Senator Hammer.
Thank you, Madam Chair. Would you go over the
Senator Kim Hammer
Unverified
35:44
number of slots again? How many currently are receiving it? How many will need it with the addition of these 30? Would you just summarize that again, please? Happy to.
Speaker 87
35:57
So, Senator Hammer, we've been providing 150 slots, and this is an additional 30, so we'll be able to serve 180 children. And do you know what the
Senator Kim Hammer
Unverified
36:08
total need is as far as the total number as of today, or do you have any measuring stick to?
Speaker 83
36:18
I do. So I know what's on the wait list. So, as of an update I just received, we have 41 children waiting on this waiver, and
Speaker 87
36:26
we will remove 30 with these slots.
So, we'll have a wait list of 11.
Senator Missy Irvin
Unverified
36:37
Thank you, Madam Chair. Are there any other
Speaker 31
36:42
questions? Representative Payton? Thank you, Madam Chair. So, reviewing the legislation, it says it would eliminate the list.
Speaker 32
36:49
Yes. And it allocated up to a million dollars. Can you discuss how much it's going to cost on the 30 slots and why
Speaker 87
36:56
we're not eliminating the list? I can. So that when it passed, we had 30 children on the list.
We wrote the waiver for the 30 children and started the process. And since that time, we've had more children come on board. So that is the reasoning behind it. We have to start our rules so far in advance that when we started, that was eliminating the list. I would like to say, though, that you get onto the waiver, and it's an intensive waiver that you have to get off of by the age of seven. So we do have turnover where children are coming off and new children are coming on.
So I don't want you to think that because we didn't add them additional slots does not mean that they won't necessarily get served. For example, we ended up, the waiver allows for 150, but we ended up serving 173 kids last year. It's a point-in-time number, so I can't serve more than 150 at any given moment, but when they roll off, like I said, we ended up serving 173 last year. So I have faith that we'll be able to get those 11 children in very quickly.
Speaker 32
38:05
Just to follow up, so do you have data on how long they've been waiting on the list, especially like the 11 that will be left on the list? Yes. Have they had a significant wait time,
Speaker 34
38:14
or is it short? I asked that same thing this morning. So they
Speaker 87
38:17
have been signed up since August of 2019. They were put on the wait list this past August. Okay, thank you. Thank you, Madam Chair. Yes, Representative Brown. Thank you, Madam Chair.
Speaker 107
38:33
She answered my question, but now I've got another one.
What is the average, I wanted to know about how long these kids would have to wait, these 11. So you've answered that. About what age do most children go on to this wait list? Do you know? I will get that for you. I don't want to
Speaker 83
38:49
make a guess. I have an idea in my mind, but I don't want to make a guess. I'll get it for you, though. Well,
Speaker 107
38:56
so a child is diagnosed with autism at about what age? Around three or four. Oh, okay. Okay.
Senator Missy Irvin
Unverified
39:05
Thank you. Thank you. Are there any other questions?
Senator Kim Hammer
Unverified
39:12
Senator Hammer. Thank you, Madam Chair. Under comment number six, it talks about, in your response, it says monitoring services will be performed by the consultant on at least a monthly basis. Are you, do you have a, what is the appeal process that if somebody feels that their child qualifies for this waiver but they are turned down, what's the appeal process for them and are those appeals included, the numbers that you're giving out today as far as the waiting list?
Speaker 83
39:47
Senator Hamer, similar to how we operate the Community and Employment Support Waiver, so once you fill out the application
Speaker 87
40:00
and you've proven that you meet the diagnosis criteria, when a slot opens up, you are provided this service. If families appeal, it's because they're not in agreement with what we've approved in terms of the treatment plan. Maybe they're asking for more hours or less hours than what the clinicians agree with.
And so that piece of it is appealable just like any other Medicaid service, and they would follow the Medicaid appeal process, which is you appeal if you're a provider, you appeal to the Department of Health, and if you're a beneficiary, You appeal internally to our hearing and appeals, and then the next round is circuit court. So it follows the same appeal process as any denial of a
Senator Kim Hammer
Unverified
40:49
Medicaid service. So once it is determined by the physician and the appropriate diagnosing individuals
that the child has severe enough autism that they can be placed on the waiver, they automatically are placed on the waiver of which we've got 41 30 are going to be taken care of 11 are going to be left but then any of the appeals that deal with that is after they've already been added to the waiver and they are questioning whether they're getting enough services is that correct yes do you know how many appeals are on do you know how many appeals are right now because the parents don't feel that their children are getting enough services no but
Senator Missy Irvin
Unverified
41:31
I can get that for you. Okay, that'd be great. Thank you. Are there any other questions? All right, seeing none, without objection, this rule will be reviewed. Thank you. Thank you. Item E, Department of Health.
Speaker 118
42:01
Good afternoon. Thank you, Madam Chair, Mr. Co-Chair, members of the committee. I'm Laura Shue. I'm general counsel for the Department of Health. I have with me today Dr. Glenn Baker, the director of the Public Health Lab, and Christy Sellers, who is the center director for health advancement. They are here to help answer any questions. All right. Thank you. Go ahead.
We're here today to present to you the rule pursuant to Act 58 of 2019 regarding testing of newborn infants. The proposed, excuse me, the proposed amendments to the rules pertaining to testing for newborn infants adds the tests for screening including spinal muscular atrophy and there's also three additional tests including the Pompey disease, MPS1 spectrum of disease, and childhood onset Cerebral X-ALD. This is pursuant to Act 58 of 2019 and also pursuant to our
General Authority under Title 20-15-302. At the present time, there are approximately 29 tests that are performed at the Public Health Lab soon after an infant is born. The current fee is $121 and the proposed amendment will add an additional $10 charge for the SMA test, which will also include the three additional tests. The proposed amendments to the rules pertaining to testing for newborn infants were approved by the Board of Health on October 29th of 2019. We filed the rules with the Secretary of State and the Bureau of Legislative Research on December 30th of 2019
and we also placed the required information on our website. The 30-day comment period will continue until February 12th this Wednesday. As of this date we have not received any public comments and we have the attached financial impact that was provided by DHS when it presented its rule and its hospital Medicaid rules that were presented to this committee, the ALC rules committee, and approved by ALC earlier this year. And I have Dr. Baker to answer specific questions, and he may have a short presentation. You're recognized, Dr. Baker.
Speaker 123
44:17
Push your button. As a background, as far as
Speaker 124
44:23
newborn screening is concerned, There are about 37,000 to 40,000 new births per year in Arkansas, and we perform 29 assays on those 40,000 new births, except perhaps 1% of prematures and are not eligible for testing. Those samples come to the public health laboratory, and we perform the assays and report them back to the ordering clinic or ordering hospital and to the follow-up program.
The four new tests, three of
Speaker 123
44:57
those tests have FDA approval as far as assays are concerned. That is, the testing is, the tests are available in the marketplace. We can purchase the reagents, the protocols, the instruments, and implement the tests. And we're in the process of doing that. SMA is different. It's a molecular assay requiring DNA extraction from the blood spot and identification of a missing gene in a particular chromosome.
That test has not been approved by the FDA, although the recommendations from the national screening bodies are that states perform the SMA, and we have legislation to instruct us to proceed. There is an opportunity for laboratories to develop their own assay and receive laboratory approved FDA. And we're in the process of completing that. We have equipment in place. Individuals have been trained. We are working with several states that have the test online
and have gone through the same process that we're going through. We've collected samples from those states that are positive. And so we're in a position to analyze negative samples as well some known positives to make certain that our assay is valid and correct. And we're prepared to implement this particular assay, the SMA assay, soon. The validation will be finished this week. As indicated in the protocol there, this does require a blood sample.
Speaker 124
46:30
However, the existing blood spots are sufficient to provide adequate samples for these four new assays.
Senator Missy Irvin
Unverified
46:42
But we are prepared to move forward. Great. Are there any
Representative Deborah Ferguson
Unverified
46:50
questions? Representative Ferguson. Thank you, Madam Chair. It seems like every session I've been here, we've passed legislation to require an additional newborn testing. It's my understanding that there is a national recommendation.
I guess it comes from the CDC. why would we not just do all the tests that are recommended nationally and not keep passing this
Speaker 123
47:13
through statute? There is a national body called the Recurrent Uniform Screening Panel that serves under the Secretary of Health. They make recommendations. They do not mandate that all the tests be performed, but they do make the recommendations. Those recommendations are coming as they evaluate inheritable or congenital diseases, and in fact, they've just added SMA to the recommended list.
So we try to stay current with whatever their recommendations are.
Representative Deborah Ferguson
Unverified
47:42
I mean, it's my understanding we're three or four tests short now of the recommendation. Is
Speaker 124
47:48
that right? We will be current when these four are implemented, yes.
Representative Deborah Ferguson
Unverified
47:53
We'll be completely within the recommendation when these are added? No. No, we won't be. No. How
Speaker 124
48:03
many will we be short? I think we will be current with these assays unless new ones are added by this recommending committee.
There's also an advisory committee for the
Speaker 123
48:15
Newborn Screening Laboratory for the Health Department that takes these recommendations into consideration, and they make their recommendations to us to proceed with certain tests. And this committee is made up of geneticists and pediatricians that understand the diseases with the appropriateness of testing. I guess the
Representative Deborah Ferguson
Unverified
48:32
reason I'm asking, I had thought about running legislation just to require the health department to stay current with the recommendations. Would that be a problem, I mean, fiscally or?
Speaker 124
48:44
That would not be a problem as far as the laboratory is concerned. We still require the Board of Health to review the request. Okay, thank you. So,
Senator Missy Irvin
Unverified
48:57
just to recap, with the additional, with these four additional tests, though, we are current, unless they add something new. That's correct. Gotcha. Okay. Representative Payton. Thank
Speaker 134
49:10
genetic record is created, and who keeps the database? There is no genetic record.
Speaker 124
49:15
We take the sample, extract the DNA from that sample, and analyze only for the presence or absence of this one particular gene. And there's no DNA spectrum obtained. It's just one particular gene.
Speaker 136
49:29
Thank you. Thank you, Madam Chair. Thank you. Are there
Senator Missy Irvin
Unverified
49:33
any other questions? All right. Seeing none, this rule will be reviewed. Thank you, Dr. Baker, for coming and presenting to us. We appreciate your expertise.
Thank you. Thank you for coming. All
right. Item F. Ms. Hsu.
Speaker 118
49:59
Thank you, Madam Chair. Laura Hsu, General Counsel for the Department of Health. We also have a rule to present under item F. This is following up with our occupational licensure requirements. We promulgated 27 rules last year. Approximately, I believe, 13 of them are in accordance with our occupational licensure requirements that were passed in the last session.
We have exhibits F1, 2, 5, and 6 to show the acts in which we are complying, 820, 1011, 990, and 315. We are adding the military licensure requirements and defining the returning military veteran as per 820 of 2019. We're also adding in good standing to the reciprocity portion of this rule and the criminal history background disqualifications as per Act 990. We held a public hearing on this rule on January 15th of 2020, and the public
comment period expired on that date. We received no public comments. We did receive one question from the Bureau of Legislative Research, and we are correcting a typo with the his or her that was missing. Perfusionists are folks that operate heart-lung bypass equipment during open-heart surgeries. They do require board certification. It's a common method for several states to assure that licenses are current in the knowledge and practice skills. Apparently there are, or excuse me, currently there are 18 states that follow the American Board of Cardiovascular Perfusion
with the ABCP to apply this certification. The agency also did not find any financial impact with regard to these amendments to the rules, and we appreciate you all giving us an opportunity to present these rules to you today for review. All right. Are there any questions? Representative
Senator Missy Irvin
Unverified
51:51
Brown. Thank you, Madam Chair. And this may
Speaker 107
51:56
just be a typo because on page where you just said it, but it says there's
no financial impact, but on the top of the financial impact statement, item one is checked, yes. and then over on the next page there's no dollars shown. That's correct Representative Brown that was a
Speaker 118
52:20
typo and I apologize for not getting that corrected we were our attention was drawn to that earlier with our rules, attorneys, staff that did reach out to us and that box was checked incorrectly. Was that the one
Speaker 73
52:34
you were speaking of? There was another typo of his
Senator Missy Irvin
Unverified
52:42
or her and we're getting that corrected too but we appreciate you pointing that out. Thank you Are there any other questions? All right. Seeing none, this rule will stand reviewed. Thank you. Thank you for your work on that. That was a lot to deal with because of all the different pieces of
legislation that was passed this past session. We appreciate it. Okay. Moving on, item G. We have an update from the Department of Health. Dr. Nate Smith is here.
Update on vaping-related illnesses and actions taken at the state and federal level and an update on the coronavirus. And if you'll just introduce yourselves for the record, then please proceed. And if we need to hit our lights, we can do that so we can see the presentation. And
Speaker 140
53:36
we also have a handout. Thank you. Thank you, Senator Irvin. Thank you, Representative Leidyman.
Speaker 141
53:41
It's a great honor and privilege to be able to give you updates on these two evolving issues.
I'm Dr. Nate Smith, Secretary of Health for the Arkansas Department of Health. I have with me Dr. Bala, who is our acting chief medical officer at the
Speaker 142
54:01
Arkansas Department of Health and also our
Speaker 141
54:09
state chronic disease director. I'd like to start with our update on vaping-related lung injury. Since
Speaker 143
54:15
I last spoke to you, this has been relabeled
e-cigarette or vaping product use associated lung injury, or EVALI. This is just a way of review. I've given you additional information that we'll go through quickly just for your reference. But this is basically just talking about how vaping or e-cigarettes work. And this is what we now regard as a traditional e-cigarette. It's got an area for liquid. It's got a heating element. And then the vapor is breathed in.
This, though, is what these devices look like now. They don't really look anything like a cigarette at all, and I'm sure there will be subsequent generations of devices that are recognizable by users, but maybe not by teachers and others in the community. As a reminder, the liquids that are used in these devices are unregulated, and they have a lot of different chemicals in them.
Perhaps not as many as tobacco itself, but certainly lots of different compounds, and especially with the flavorings, the safety of these for inhalation is not well studied. Some of them are known to be damaging or injurious, though. And this is what we've reviewed before. Over the last 10 or so years, we've had a good, steady decline in youth smoking, but
over the last couple of years, we've had a dramatic increase in nicotine addiction through these vaping devices, and this has been true also in Arkansas. These are lifetime use of e-cigarettes among youth in Arkansas, and you can see on the far right, amongst our 12th graders in 2018, almost half of them had used an e-cigarette or vaping device at some point. And then in terms of regular use or current use, in 2018,
almost a third of high school seniors were currently using e-cigarettes or vaping devices. So this is
Speaker 141
56:43
really unprecedented uptick in use of a nicotine delivery device of any
Speaker 143
56:50
kind. Switching to EVALI or e-cigarette or vaping-associated lung injury, all states have had cases. These are severe injuries that have resulted in hospitalizations and sometimes in deaths.
And Arkansas, of course, is one of those. The good news is that the peak of those cases was back in September, and since then we've seen a gradual decline. Since the beginning of this calendar year, we've had, I believe, 21 reported cases. So the number of cases went from a peak of about 200 reported per week down to something like two is where we are currently.
Overall, looking at this epidemic, we've had over 2,500 cases hospitalized. All states have been involved and also two U.S. territories. Two-thirds were male. The age range was pretty broad, but generally these are younger individuals. Of the 60 deaths that have been confirmed, the age was older than for the overall cohort. So those who are older were at higher risk of death.
And of the approximately 2,000 for whom we have substance use information, over
Speaker 149
58:17
80 percent of them had been using a THC product. They may have also been using nicotine devices as well, but
Speaker 146
58:30
there was a strong association with THC-containing devices. In Arkansas,
Speaker 149
58:36
we've had 23 cases that were either confirmed or
Speaker 143
58:41
probable, and we've not
had any new cases reported since before the beginning of
Speaker 149
58:49
the year. Our median age was also on the young side at 21
Speaker 143
58:55
years, ranging from 17 to 54. Like the national experience, about two-thirds of ours were in men. All of these patients were hospitalized. We've not had any deaths fortunately in Arkansas, and the clinical presentation was similar for the rest of the country, shortness of breath, progressive respiratory failure.
In some cases there have been some GI symptoms and some cases some
Speaker 149
59:26
low-grade fever as well. In terms of ongoing activities, together
Speaker 143
59:31
with the CDC and FDA we're continuing to investigate, information on known cases. To date, no single substance or product has been implicated as the cause of all these illnesses. However, in 51 bronchoalveolar lavage samples that were tested,
48 of them had vitamin E acetate. And that is basically used as a cutting agent for some of these e-liquids that were prepared, you know, on the street or, you know, not a proper manufacturer and oftentimes used with the THC e-liquids. Vitamin E is a fat-soluble compound, so it
has to be dissolved in oil. And you can imagine heating oil to high temperatures and then breathing it in, you know, can cause lung injury. Now, there are some of these cases where they haven't found vitamin E acetate, and there are other compounds that may also cause this. Coconut oil has also been found in some of these clinical specimens, so it's not all vitamin E acetate, but that seems to be a very important cause.
So, although the number of cases has dropped down, investigations are ongoing. In terms of key messages for students and parents, these are, you know, ones we need to make sure to get out. First of all, don't use vaping or e-cigarette products, or especially don't use those that contain THC or ones that are obtained from the street or from someone you don't know. modify or add substances. Many of these devices allow you to put in your own liquids or they can
be modified in some way. And these products that contain oil-based or vitamin E acetate in particular are particularly dangerous. Overall message, no youth or pregnant woman should use any vaping product, regardless of substance or regardless of manufacturer. And then monitor yourself for symptoms. Properly seek, promptly seek medical attention. These individuals can get really sick really fast. What I'd like to conclude this presentation with are some policy
gaps. I've been asked by decision makers like yourselves, you know, what do we need to do? what are next steps? Well, the federal, the FDA took action against some of these products, particularly the Juul products to remove most of the flavoring, leaving only the menthol and tobacco flavoring. But those restrictions actually were pretty narrow, and they left some pretty
significant exemptions. At the time, those were not the products that most youth were using, but since then, there's been a big uptake in youth use of some of these products, particularly the
Speaker 149
1:02:51
disposable e-cigarettes. And I'll show you a picture of some of these in a
Speaker 143
1:02:59
moment. Puff Bar and Mojo are examples. These were exempted from that restriction. And so a lot of the kids have moved to these products now that are disposable. The restriction only applied to
pre-filled cartridges like Juul, but the nicotine e-liquids that are used to refill refillable products were not included, so there are lots of different flavors still out there for someone who's going to refill a device. And there are some sleek, refillable e-cigarettes like Sorin and Smoke that are becoming more and more popular with youth.
They're like a Juul, except you can add and fill your own nicotine e-liquids or whatever kind of e-liquid that you want to put in there. In some ways, with this risk of EVALI, these may actually be more dangerous than the Juul products that were restricted. And then of course menthol, although was not the most popular youth flavoring, a lot of youth still do use that and so that's available through the Juul product. And just to look at what some of these products
look like. The top line here, these are these disposable vaping or e-cigarette products, and you can see that many of them are sort of colorful labeling, lots of flavors for youth to choose from. These are some examples of some of the e-liquids that are available in lots of flavorings that are attractive to youth. And then these are the refillable devices that were not restricted.
This is smock or smoke. I'm not sure how to pronounce that. And this is the Sorin, I believe, is what it is. Incidentally, the empty Juul cartridges have also been very popular. They sell the empty cartridges, and then the youth can use whatever flavor they want to fill it and continue using Juul, if that's what they want to continue. The two slides I have at the end of this are just to give you the case definitions of Ivali
just for technical details, but I won't go through those. So maybe I can pause here and ask if there are any questions before we go to the second presentation on the
Senator Missy Irvin
Unverified
1:05:45
2019 novel coronavirus. Yes, I have a quick question. So is there any discussion about not allowing refillable cartridges? Are there any states that have looked at trying to eliminate that as a product that somebody can sell in their state, a refillable cartridge?
Speaker 141
1:06:09
I believe that is the case. I think some states have restricted certain flavors across the board. Dr. Bala, can you give some further details on that? Sure. Thank
Speaker 157
1:06:25
you for the opportunity. Yeah, at least four states are looking into that. And as Dr. Smith mentioned, the investigation opened up new information about the system. There is an open system and there is a closed system of e-cigarettes.
And most of these cases have been associated with open system e-cigarettes where the additives can be added. AT LEAST FOUR STATES, NEW JERSEY, ILLINOIS, IOWA, AND I CAN'T REMEMBER THE FOUR STATES, ARE LOOKING INTO COMPLETELY BLOCKING THESE OPEN SYSTEMS WHERE PEOPLE CAN ADD AND CONSEQUENTLY ADD SOME OF THESE HARMFUL PRODUCTS AND CAUSE THESE ILLNESSES. Well,
Speaker 159
1:07:08
you should especially ask about restrictions on flavorings.
Speaker 157
1:07:14
Flavorings, I think federally, they are trying to, as Dr. Smith mentioned, most of the flavors except for menthol. And the common flavors which are going to be impacted are the mango, fruit juice, birthday cake, and others which are going to be the ones which are going to make an impact in decreasing the e-cigarette use. Do you have any information on
Speaker 159
1:07:37
whether there are states that have banned flavors of cross products? Yeah, I think that's
Senator Missy Irvin
Unverified
1:07:43
my, yeah, that's one of the questions I have.
So the FDA at the federal level banned flavors, but that was only for what you're referring to as a closed system e-cigarette.
Speaker 141
1:07:56
Is that correct? The cartridge-based. The cartridge-based e-cigarette. Basically the Juul or Juul-like devices. And that was based on information they had
Senator Missy Irvin
Unverified
1:08:07
But now that's going to push youth to use an open cartridge system to put their own flavors in. Or disposable ones. Or disposable ones.
Speaker 142
1:08:17
The disposable ones have been very popular. Right.
Senator Missy Irvin
Unverified
1:08:20
And with that, they have the potential to mix THC or an illegal substance with
Speaker 141
1:08:25
it. What we can do is we can provide an up-to-date analysis of what other states are
Speaker 143
1:08:31
doing and, to the best of our knowledge, what they're contemplating doing. You know, this is a rapidly moving target. I know there are some states that have, for example, Massachusetts initially banned all flavorings across the board, and some other states did, but we can give a more detailed analysis on that.
Senator Missy Irvin
Unverified
1:08:51
Yeah, I would appreciate that. Just because if you go to, I mean,
what's going to prevent a kid from having an open e-cigarette vape product that's an open cartridge and going and putting cooking flavor in it, cinnamon or, you know, you can, I mean, that
you use for baking. I mean. They can use whatever they
Speaker 141
1:09:16
want. Now, of course, these products that are out there are unregulated.
Speaker 143
1:09:21
So, you know, they may not be safe just because
you're buying them from the manufacturer, but you're right. Someone could put anything they want. And that's, I think, really why we ended up with these cases of Vivali, people putting in vitamin E acetate just to cut the THC or whatever, not realizing how harmful that would be to someone's
Speaker 167
1:09:45
lungs. Well, and from the YouTube videos that I've watched, there really is no warning on there.
Senator Missy Irvin
Unverified
1:09:51
There's nothing that says this product could do that. I mean, there's nothing. I mean,
they basically are teaching you how to chemically break down whatever it is into a liquid form and then filling their cartridges with it. Okay. Senator Garner. Thank you, Madam
Senator Trent Garner
Unverified
1:10:15
Chair. I have two questions. First one is, when this initially came out, I know there was a recommendation from the Department of Health and others not to use any vaping-related products. It seemed like the CDC supported that theory. But last month, the CDC revised the recommendations and said the initial recommendation that everybody should quit
vaping products has now been revised and only those who are adolescents, pregnant, or who are non-tobacco users. Do you support that CDC decision that has changed at the federal level here in
Speaker 143
1:10:47
the state of Arkansas? The reason for the change in the CDC guidance
Speaker 141
1:10:52
was more information on the cause of these e-cigarette or vaping-associated lung injuries. And the CDC is not recommending
Speaker 143
1:10:58
that anyone use these products, but initially they said the only way, since we don't know which of these products
are causing these life-threatening lung injuries, you don't use any of them. Now that we've narrowed it down and it seems to be these products that had vitamin E acetate or similar substances in them, If you avoid those, you'll avoid that risk of acute lung injury. And we've seen people respond to that. We've seen the number of acute lung injuries decrease. Now, there are other types of lung injury that are being reported that are more chronic. They take a longer period of time, and it's not clear exactly what are causing those.
So, CDC, neither CDC nor the Arkansas Department of Health is telling anyone that these products are safe. But they have changed the guidance from don't use any of these to prevent acute lung injury to these are the substances that appear to be most strongly
Speaker 142
1:11:58
associated with acute lung injury. And that's my point, if I can follow
Senator Trent Garner
Unverified
1:12:03
up on it. So when this initially came out, there was
a call for additional regulation and taxation on this product. And it seemed in my time that that would drive people to the illegal or online vaping products
that would eventually lead to this disease because of the vitamin E alkylate that was added, which was obviously findable at that time. And it seems like now that we're calling for additional regulation and taxes on the regulated normal manufacturing products whenever it seems like the overwhelming evidence shows is these on-the-street, black-market, THC-related products. So I think there's a clear line of distinction between those two, and I get worried when we go down this path that we go after normal, regulated vaping products and put them in the same thing,
and I think the initial scare showed that. So I guess my point is, when you're calling for additional regulation on the things you can get, whether it's Juul or any of the products you can get from a gas station that are credible companies or credible manufacturing, do you see a distinction between those and the vaping products that you
Speaker 141
1:13:14
buy off the street? None of these products that are out there, regardless of manufacturer, are really being regulated at this point.
So although the vitamin E acetate was found in so-called street products, there was nothing to have stopped any other manufacturer from using that substance or a similar substance. And that's what I get very concerned about. Excuse me, Doctor. Didn't
Senator Trent Garner
Unverified
1:13:36
we have roughly 10 to 15 years of e-vaping cigarettes being used from that capacity without this major health crisis? And it wasn't until this insinuation of THC-related and street-related things that caused this. And then now that the market has adjusted, as information has gotten out that this is a relation,
you have admitted that the case has dropped significantly as people have stopped using that for
Speaker 141
1:14:03
vaping-related uses. There are new products being released onto the market all the time with different flavorings, different chemical compounds.
Speaker 143
1:14:11
I don't know when the next lung injury type of situation is going to occur, because these products really are, what is the substances in these e-flavorings and the types of devices are not regulated.
I would like to think that these were safe or that someone was watching over that, but new products are being released, and, you know, we don't know if they're going to be safe. We don't know if they're going to have long-term effects or short-term effects,
Speaker 141
1:14:42
you know, and because of the popularity among youth, basically, these companies
Speaker 179
1:14:47
are experimenting on our young people. Thank you. And just to, there
Senator Missy Irvin
Unverified
1:14:52
are no regulated vaping products. There are none. They haven't, because they have not done, gone through FDA approval.
Speaker 182
1:14:58
None of these have gone through the FDA
Speaker 141
1:15:02
approval process to establish safety and efficacy. What's the cost associated with the FDA approval process? I'm
Senator Missy Irvin
Unverified
1:15:06
going to move on to Representative Ferguson, but you can, I mean, I think they're making
plenty of money. They can pay for an FDA process. Representative
Representative Deborah Ferguson
Unverified
1:15:26
Ferguson. Oh, there we go. Thank you, Madam Chair.
Yeah, and my concern is, it sounds like maybe Senator
Gardner has bought into the tobacco lobbyist argument, and that's my concern about leading with the deaths. Certainly I'm concerned about the deaths, but because the deaths have included other things besides nicotine, the tobacco lobbyists have spent a lot of money and done a very good job of distracting us from the real issue, which is that we are creating a whole new generation
that's addicted to nicotine. And trust me, all that distraction about the THC and the deaths, and they're not all just nicotine, and they're not regular vaping products, that's big money tobacco talking when you hear that. My concern is, just like we addressed smoking, you know, earlier in the 60s, we're creating a whole generation addicted to nicotine, and that needs to be what we're focused on, is how do we prevent a whole new generation that's addicted to nicotine.
Do we have any, my superintendent tells me we don't, do we have a curriculum that you will provide to schools so that they can talk to middle schoolers about vaping and that it is nicotine addiction, which I think anybody who's ever smoked will tell you nicotine is one of the most addictive substances out there. My husband smoked when we first got married. I thought it took him six years to quit. So what are we physically and actually doing as a health department and as education systems to address these kids not vaping?
Speaker 149
1:17:08
Thank you. That's an excellent question and excellent observations as well.
Speaker 143
1:17:14
And that is also my concern with 2018 data, a third of Arkansas youth being current e-cigarette users. These are kids who are, many of them will be lifetime nicotine addicts. And we know from our experience with smoking, one out of three people who smoke will eventually die from a smoking-related illness, and my grandfather was one of them. In terms of education for youth, we really have pivoted to where we're focusing our education at the community levels and, you know, targeted towards youth, towards these devices.
We've also included this in our nicotine cessation messages through Be Well Arkansas to include counseling on how to get off of these vaping and e-cigarette devices. I really didn't think when I started in this job that we were going to need to have a program to help teenagers to quit nicotine products. but that seems to be where we are right now.
Speaker 188
1:18:25
Balad, do you want to talk more about the messaging for youth?
Speaker 157
1:18:32
Yeah, thank you, Dr. Smith. So we have a vibrant coalition. It's called Project Prevent Youth Coalition. The health department works with the Children's Hospital through their wide network, and it's a grassroots organization, and they work with the Department of Education and have enrolled more than half of the counties with their school districts and have a champion within and have created teams within the schools
to talk about the harmful effects of not just traditional combustible tobacco but also the e-cigarettes and the newer vaping devices. So these are student-led coalitions from different school districts and they come together every year, and we work closely with the Children's Hospitals and the Department of Education in these grassroots efforts.
Speaker 109
1:19:30
Thank you. Representative Brown? Thank you, Madam Chair. Dr. Smith, in a previous presentation that was done on the vaping and e-cigarettes, There was a distinction made between products that have a vapor and those that are aerosol. Are any of those aerosol products anything that we're discussing today?
Speaker 154
1:20:02
What I have here are the vaping devices,
Speaker 143
1:20:07
the heated element products that produce an aerosol without a vapor, those are coming on the market. But they don't seem to be in the vanguard of what youth are using right now. Follow-up. It
Speaker 109
1:20:24
seemed that there was some distinction that one was worse than the other,
an aerosol versus a vapor. Do you have a comment on
Speaker 145
1:20:39
that? I may not be understanding your
Speaker 109
1:20:41
question exactly. I didn't understand the comment about the vapor and the aerosol. I tried to find out about it, and I can't find
Speaker 141
1:20:51
anything that clarifies it for me. There are some newer devices that have been popular, I believe, in Europe,
Speaker 143
1:20:57
but have been less popular here so far, where they just heat the tobacco-containing element
It doesn't create a vapor like these products do, but it basically delivers the nicotine into the lungs. But I'm not sure that you could say that one of those is safe and the other is not. Again, none of these have gone through an FDA approval process for safety and efficacy. Bala, did you
Speaker 141
1:21:30
want to talk about those newer products?
Speaker 157
1:21:33
So, as Dr. Smith mentioned, most of the products are liquid-based, so in other words, if the liquid is heated through the filaments, electronic filaments, they create into water vapor, and they have aerosolized particles of other compounds which are in there. However, in Europe and also here in illegal markets, there are dry products which could be heated and also inhaled, but predominantly what we're seeing here is the liquid-based product, which is heated and becomes
water vapor, and which contains aerosolized particles. So that's the dry vapor versus the water vapor, which is from the heated liquid, are the two products. But here in the U.S., it's primarily the liquid-based water vapor and aerosolized particles. Thank you.
Representative Jack Ladyman
Unverified
1:22:30
Representative Leidyman. Thank you Madam Chair. Dr. Smith, back on slide number four, you
don't have to look back at that, but we're at list of chemicals that has a list of chemicals, benzene and so forth. Are these elements found in the vaping product and is it the manufactured product or the added in liquids?
Speaker 141
1:22:54
These are all compounds that have been found in various liquids. Remember, there are many, many different types of products, many, many different compounds used for flavorings. And so these aren't necessarily all found in a single product,
Speaker 143
1:23:12
but the nature of an unregulated industry is that you will find unexpected things that you probably didn't want to find.
And that's the nature of this. Follow
Representative Jack Ladyman
Unverified
1:23:27
up, Matt. Yeah. So these are some pretty nasty products. You know, you've got benzene, toluene, xylene. These are controlled in industry, the emissions, the amount that you can be exposed to. So, I mean, my concern here is long-term effect because if you're, you know, as an example, if you're exposed to benzene or xylene or toluene or diethylene, glycol,
any of those over an extended period of time, there can be long-term effects, diseases and so forth. Not only that, secondary vapors, someone not even using the product. So if these are found in these products and there's no control on that at all, do you see long-term effects of that if
Speaker 141
1:24:17
that's the case? This is the concern, and there are some early reports of longer-term
Speaker 143
1:24:23
injuries. Remember, this is difficult to study because of the wide variety of products.
You can find an injury, but then trying to trace it back to a specific product is very, very difficult with these. It was difficult with tobacco, but that was relatively easy compared to these because there's so many different types of products with so many different types of compounds. It's really difficult to know, did someone use the same product throughout their entire vaping life? It will be difficult to sort out, but some of these we have very good information from industry and other sources
that we know they're bad actors, and we know they shouldn't be in a product that is used for human consumption of any type, especially not something that you would breathe into your lungs. And that is why I think it is really critically important that the FDA does move forward at some point to require these devices to demonstrate their safety as well as their efficacy for whatever they're being marketed for, which is mostly they've said that these are safe alternatives to cigarettes.
Speaker 141
1:25:33
And I'd like to see that safety data, you know, before I would feel
Speaker 178
1:25:39
comfortable with these. Thank you. You asked
Senator Missy Irvin
Unverified
1:25:48
my question. Just exactly, I mean, that's exactly what I was, so just to recap what he asked, Those that you have listed, those are found within a manufactured jewel or e-cigarette as well as those that are open cartridges that people are filling.
Is that correct? So those substances that we're looking at, just to follow up on Representative Ladyman's questions. These
Senator Missy Irvin
Unverified
1:26:17
products? So whether they're closed cartridges from the manufacturer themselves or something that somebody has filled themselves. What may be helpful
Speaker 182
1:26:25
is if we get to you specific published
Speaker 141
1:26:28
studies on specific devices so that you'll
Speaker 143
1:26:32
have a broader sense for that. And some of this work has been done looking at the compounds used for flavorings,
which, again, although they may have been tested for safety in foods, they're not necessarily safe for
Speaker 141
1:26:47
inhalation. And Dr. Bala, perhaps you can get some published studies to this group for their review. That'd be good.
Speaker 157
1:26:56
Yeah, I'll be glad to do. And as Dr. Smith mentioned, this is not regulated. So the results shown here are based on independent researcher buying products out of the market and taking it to the laboratory and testing.
You had asked about long-term consequences. The diethylene glycol is one which historically we know that causes what is called the bronchiolitis obelotrons or popcorn lung disease. And there's very published literature about the harmful effects. Again, arsenic is a cancer agent which has been known. Formaldehyde is used as an embalming agent, which is not supposed for vapor. So, again, long-term studies on some of these compounds are known,
but because of the diversity of the products in the market, and since they are not all going through the FDA regulation currently, we don't know what's
Senator Missy Irvin
Unverified
1:27:54
in there. Right. Got it. Okay. Thank you. Representative Payton. Thank
Speaker 32
1:28:00
you, Madam Chair. I don't know if I can consolidate this in less than five minutes or not, but I'm just old enough to remember when vaping equipment was called a bong and it was drug paraphernalia. And so when I tried to figure out where government should be involved
and where it shouldn't be, I mean, I think these that are loadable with whatever you want to pull out of the kitchen cabinet, you know, and we know people are eating Tide Pods and things, I mean, you know, i think that's drug paraphernalia and but i think government's responsibility here is to create some accountability to the manufacturers i don't see how we can regulate as long as we allow the manufacturer and sale of the reloadable bongs i mean i think that's drug paraphernalia if they
can put anything they want in it but when you get down to the ones that are not reloadable where we can hold the manufacturers accountable. If we have the manufacturers label and put those things on there, I don't think government should try to outlaw everybody's bad decision in using it. So what is the practicality of trying to stop the manufacturer and sale of the reloadable ones and regulate the manufacturer and sale of the ones that we could hold the manufacturer accountable?
Speaker 141
1:29:23
I think that's a very good question, and I think your observation is right on. About 30% of youth that are using these vaping devices are also vaping THC-containing compounds. In some of the drug busts that have been made, they've also found, you know, large quantities
of empty cartridges. So I think this is also being used and probably in the future will be used more frequently as a delivery device for things other than nicotine. In terms of what to do to restrict that, there had been limited action at this point from the federal government, but each state, I think, is responsible for protecting their own people.
So I think that's really a decision for this group and your peers in the state legislature to contemplate, you know, what actions would be appropriate to try and protect the people of
Speaker 142
1:30:36
Arkansas and especially our youth. well thank you i'm not sure i i
Speaker 32
1:30:43
mean maybe we need the state police to define how come we're not calling these reloadable ones drug paraphernalia but uh no i i understand your
Senator Missy Irvin
Unverified
1:30:55
point i i don't i don't disagree with you i mean i think and that's why i asked the question about open car open systems and closed systems because you're you're correct in that if they're manufactured, we can hold them accountable. I mean, I think it's a policy decision. Do we decide, you know, are we going to not allow the sale of, and that would be illegal, to allow the sale of a refillable type system, refillable cartridge that we cannot regulate? I mean,
one of the testimonies that we had was from one of the judges that came that said that they're seeing a huge rise in drug arrests from teenagers and kids using these as those devices for illegal drugs. So the judicial side is also raising alarms about exactly what you're saying. So I mean it's just it's a policy decision of how we label it, how we deal with it. And I think those are good
questions that you asked. Representative Johnson.
Representative Lee Johnson
Unverified
1:32:06
Yeah, I'm reluctant to wade in at this late point in the conversation, but just as a point of clarification, when you say unregulated for the open systems, if I as a person want to start in my house making something, a liquid, and marketing it in my garage as something that can be used in a refillable open system. Is there anything
to control what I put in that in the process of me making this product? Is there anything to, any law to protect against me just going out and making whatever I
Speaker 178
1:32:48
want in marketing it? There's certainly a federal law now against the sale of that to someone
Representative Lee Johnson
Unverified
1:32:54
less than 21. Right. But if I want to market something as e-liquid, and I want to put in X amount of vitamin E acetate and X amount of, you know, arsenic and X amount of these other chemicals at any proportion I want to, there's nothing to control that. Is that correct in the current statutes?
Speaker 141
1:33:15
I think if your product were found to be harming people, then hopefully that would be detected by state and local health officials, and there would be some action taken against you locally. But in terms of a proactive restriction, I'm not aware of any. Dr.
Speaker 157
1:33:39
Bala? No. I concur with Dr. Smith. I'm not aware of any local jurisdictions besides a physician's reporting some particular area having increased frequency
Speaker 211
1:33:48
of some kind of illness and then to
the health department and to the local health authorities. So
Representative Lee Johnson
Unverified
1:33:55
we're fortunate that we found that this vitamin acetate this time is the product that's being randomly inserted into these chemicals that are being touted as e-liquid consumables, but who's to say the next time it's some other product because we have no real idea of knowing what any of these things are, or what's in any of them with regard to these open system products? That is correct.
Senator Missy Irvin
Unverified
1:34:24
I think to follow up on that, that's becoming a big problem,
I believe, in the state of California. Is that not correct? Where they are manufacturing and selling these type products, and then they're also being sold in large quantities and then traveled across state lines to
Speaker 141
1:34:44
other states. It's difficult to have really good real-time data on that. I think this is a problem probably across the country. And as you know, with Internet sales, you know, a manufacturer in one state can have a market that's, you know, really throughout the country.
Senator Missy Irvin
Unverified
1:35:04
Right. Okay. All right. Senator Garner, you have one last
Senator Trent Garner
Unverified
1:35:09
question? Thank you. Just a quick comment. I think Representative Johnson hit it on the head. I think that was an excellent point. The ability of people right now to make vaping fluids in their garage or do it in a completely unregulated fashion is where the epidemic came out of, and that is my concern. If we overregulate or tax semi-day-to-day operation where there's Juul or somebody else, what will happen indefinitely is you will push people to the cheaper,
on-the-street market vaping product, and that is what the concern is. while I think we should add some regulations to it and make sure that we do it in the right fashion to put some public safety help on there, I think not having, if we overtax it or overregulate, you're going to drive people to those more illegal, to the more on-the-street black market, to the more dangerous products, and that's what concerns me. Thank you for allowing me to make that comment, Madam Chair. I was about to say, is there a question there,
Senator Missy Irvin
Unverified
1:36:00
or is that just a comment? Do you agree? Representative McCollum.
Speaker 216
1:36:06
I was just going to ask, could we get this sent digitally, please? Yes.
Representative Jack Ladyman
Unverified
1:36:15
Thank you. Can I make one comment? Yes, Representative Lightingman. Just a comment on what Representative Johnson said there. I think this seems similar to me to synthetic marijuana, if you all remember 10, 12 years ago, that hit the market. And nobody knew that there was a problem. And to your point, Representative Johnson, anybody can go mix up anything in their garage and put it out there. And until we know it's hazardous or dangerous, I mean, you know, you don't know what to do.
You can't control it. And the synthetic marijuana, we started seeing that in gas stations in our city. And we actually passed an ordinance not to be able to sell that in the city because nothing had been done statewide and federally. And I think that's where we're at on this. We know now there's a problem. You know, we just don't know all the ingredients and all the inputs that are coming into this. And I think Madam Chair is right, as we have to develop some kind of policy, hopefully one that will be accepted by all parties, including the industry.
But they're probably going to have to be controlled. But we don't know that until we see there's a problem. So that's just
Senator Missy Irvin
Unverified
1:37:27
a comment. Thank you. Thank you for your presentation on this. We're going to move to the next one, which I requested kind of at the end of last week, which is an update on the coronavirus. I think it's really important for us to get this information out. I know that I've got lots of questions, and we do have a handout on this.
thank you madam yes go ahead thank you madam chair representative rye can
Speaker 222
1:38:07
you turn your mic off yes ma'am i was just
Senator Missy Irvin
Unverified
1:38:15
going to ask a question oh oh i'm sorry oh i'm sorry did you raise your hand yes ma'am oh i'm so sorry we didn't see you i apologize well go
Speaker 225
1:38:23
ahead with your quick question okay i apologize i appreciate that madam chairman 20 or 30 years ago
Representative Johnny Rye
Unverified
1:38:31
we knew cigarettes were bad for us and we kept advertising on television it kept on going until Richard Nixon cut that off back in 1972 now what I would like to know if you do a comparison between the cigarette let's just say a Marlboro Red and what we're talking here of just a standard material that people are smoking. How much worse is the cigarette with the tar, or is it less?
Speaker 149
1:39:05
Can you give us answer on that? That's a very good question. It's also a
Speaker 143
1:39:15
very difficult question to answer at this point. The reason is it took us really quite a while before we had the data accumulated about the harms of cigarette smoking. And we're very early in the process with these products. These products have a lot wider diversity. They are lacking some of the harmful compounds in cigarettes, but they also have some things that cigarettes don't have. And so we
really don't know. I would like to think that they are safer. And in fact, a year or so ago, I might have said, yeah, they probably are safer until some of these products started killing people. And so I'm very reluctant to say that at this point. And maybe I would say that given the choice of cigarettes or vaping devices, my choice would be none of the above. And for my kids and the people I know and love, I would prefer them to avoid all these
products. And I don't necessarily think that it's a one or the other. You know, when I was growing up, we didn't have e-cigarettes or vaping devices. And so if you told us we couldn't have it, we weren't going to go to illegal devices to do that. We give people choices, but sometimes the choices that we give them are harmful and
Speaker 141
1:40:43
are dangerous, and that's part of our job is to give people proper information, guidance, and protect them from
Senator Missy Irvin
Unverified
1:40:52
harms. Thank you. Thank you. Yeah, I think
Representative Leidyman, I mean, I think there's great discussion, great comments. I think the The long-term cost, we don't know, the long-term cost and hospitalization of nicotine addiction and all the different chemicals and all that. There's so many questions that need to be answered, but we do need to have some sort of policy moving forward that hopefully we can come together on. Thank you. All right. With that, we're going to move on to your next presentation, and I really appreciate you pulling this
Speaker 149
1:41:24
together. Thank you. We'll shift gears here to an update on the 2019 novel coronavirus.
And with me, I have Dr. Jennifer Dillehay, who is our medical director for immunizations and outbreak response. And she has been part of a team that's been leading our response to this. Most of what I'm going to present to you, though, has to do with activities elsewhere outside of Arkansas, because we do not, at this point, have a known case within our state. We have had one person who met the criteria for testing at the CDC, and that individual tested negative.
So, so far, we do not have this 2019 novel coronavirus in our state to our knowledge. I'd like to keep it that way. And if we do have a case, I'd like to keep that contained. I'm going to go ahead and I've given you a lot more information than probably we can cover in a short period of time. But I wanted you to have it. So we'll go through some of these slides quickly. First of all, I want to point out that not all coronaviruses are the same. There are a large family of viruses called coronaviruses. And some of them are available in testing in a routine lab, and they cause the common cold.
So if your child comes back with a lab test report that says coronavirus, you don't need to freak out. Okay, those are known coronaviruses that cause cold-like symptoms. There are three, though, that are more dangerous. The first was the SARS, or Severe Acute Respiratory Syndrome coronavirus, that emerged in 2002. And that was contained and went away. The second was the Middle East Respiratory Syndrome coronavirus, which continues to have small outbreaks.
and it is related to exposure to camels, but can be passed from person to person and has involved a number of health care workers. Those have been in outbursts, but have not become global and pandemic. And then the third is this 2019 novel coronavirus, which first appeared in December of last year and has been spreading rapidly. The reason why they're called coronaviruses
is not because of the beer, but because some virologists thought that the spikes on the surface that you can see there, this is an electron micrograph that's colored in of the MERS coronavirus, those little spikes look to someone like a crown or the corona of the sun. So this is what the novel coronavirus, the 2019
Speaker 143
1:44:13
novel coronavirus, looks like under electron
microscope. This is a very confusing slide. All this is up here to do is to show you that this is a new virus that is closely related to some coronaviruses in bats. And you can see most of the coronaviruses that have been isolated have been in bats. They seem to be a natural host for these viruses. There is some similarity to the SARS coronavirus and a more distant similarity to the MERS coronavirus, but this is a brand new virus, but probably most likely came from a bat
coronavirus. This is the symptom chart for our first case in the U.S. that was found in Washington State, and most of these cases have fever. They also have cough, and it's usually a
Speaker 149
1:45:02
dry cough, and then most of them progress to shortness of breath. They may also have some fatigue. Sometimes they have
Speaker 143
1:45:11
some GI symptoms as well. But the early symptoms are pretty nonspecific, and then these people can become very, very ill.
This is showing the first infections that were identified in Wuhan, China, and this graph here on the left is showing the age distribution and what is very surprising to me is that we have very, very few children who have become ill with this virus. Now, whether that will continue to be the case or not, no one really knows, and whether it's that children are less likely to be infected or if they're infected just less likely to become symptomatic, we don't know, but that's been noted that we have very few
Speaker 149
1:45:53
children with this. And then we, these red areas are those who have required in ICU care, intensive intensive
Speaker 143
1:46:03
care unit care. And these are, this is the timeline for the first 41 cases that were identified in Wuhan, China. And most of these, the red parts, had contact with this seafood, the Hunan seafood market in Wuhan, China. But so that may be where it came from is exposure to
an animal that was carrying this coronavirus. But we know that it's now person to person. It really is not. These new cases are not from animal exposure. Wuhan is a large city in China. It's got 11 million people. Before travel restrictions, there was intense travel in and out of the area. In fact, the mayor has said that before the travel restrictions were put into place, approximately 5 million people had left the city. So this is a major transportation hub. This is a
photograph of the city of Wuhan. You can see it's a major city. And this is the so-called seafood market. There's a lot more than seafood being sold there. And there are a lot of live animals that were brought into this market and then slaughtered on site. And so there's lots of opportunities for people to become exposed to animals and for a virus to jump from one species to another. This is looking at the risk of spread outside of Wuhan. Again, making the point that this is a
center for transportation. People came and went from this city at very high rates. And this is a map looking at airports that are at highest risk because of the air flight transport. And you can see some of those are in the U.S. And these are the areas in the U.S. that were considered in this mathematical model to be at highest risk for importation. And all the flights
from China are now being funneled into 11 airports, and those coming from China at this point are being evaluated at those points of entry. This is a map now about a week old showing where the cases are. You can see most of them, 95% of the cases have been in mainland China, but there have been cases throughout the world, including a total of 12 in the U.S. so far. This is a timeline. It's just there really for your reference. The point here is that this has evolved very, very rapidly.
The first known case became ill the first of December. And by early January, the genetic sequence of this virus was already known and published online. And then tests were made available. The speed of technology has been unprecedented in the response to this outbreak. And as of January 30th, the World Health Organization declared this a public health emergency of international concern.
Speaker 149
1:49:15
Now this is a slide that is less than a week old, but it is completely obsolete. A week ago we had about 20,000 cases worldwide. We're now, as of this morning, over 40,000 cases worldwide. A week ago we had over 500 deaths. Now we have over 900
Speaker 143
1:49:39
deaths. This outbreak, this epidemic, has been doubling in size about every week.
So this is something of
Speaker 149
1:49:47
real concern. Again, so far we only have 12 cases known in the U.S. The number of cases, though, is growing, and, you know, we're
Speaker 143
1:49:59
watching this very, very carefully. In terms of key characteristics, we say that the incubation period is from 2 to 14 days. That means the period of time between someone is infected and when they begin to show symptoms.
Most of the cases become ill within 3 to 6 days after infection. We're using that 14 days so that we catch everyone. So when we put someone in quarantine or observation for 14 days, that's because we want to make sure that we catch even the latest cases. The R-naught there is the number of new infections for every one person who's infected. So if I became ill and I'm not sick and I'm healthy, I don't have coronavirus, how many people would I spread the virus to?
For this infection, estimates have ranged between one and a half to three and a half people. And so you can see that this is accelerating. The only way to get rid of an epidemic is to get that R-naught down to less than one. And we're not there. These control measures have been put in place in China and certainly here in the U.S. to try and decrease that R-naught down to less than one so that we can contain this epidemic.
Estimates are, though, that control measures need to block over 60% of transmission to
Speaker 149
1:51:35
be effective. This just gives you some of the WHO, World Health
Speaker 143
1:51:41
Organization, strategic objectives. I won't go over this, but this ranges from getting control of transmission of new infections to developing treatments and vaccines, to minimizing the economic impact, which has already been huge. This is a timeline of control efforts. The U.S. has taken very aggressive
measures to try and keep this virus out of the U.S. or if it enters the U.S. to keep it from spreading. I don't remember measures like this ever having been taken in our history in terms of travel restrictions and aggressive follow-up of those coming from mainland China, particularly from the Hubei province, including the city of Wuhan. This is a health alert card that's being given to all travelers returning from China, telling them what to do, what to look for.
and it is available in a Chinese version, but I figured probably the English would be preferable for this group. This is a definition of a person under investigation or a patient under investigation, someone who has fever, cough, shortness of breath, who's coming from Wuhan or Hubei province, someone who has those symptoms and has a known contact with someone with this
novel coronavirus infection, or someone with these symptoms sick enough to be hospitalized who is coming from any place in mainland China. Potential treatments. Top line is there are no antiviral treatments for coronavirus infection that have been proven to be effective, but there are a number of things that are being tried aggressively, especially as the number of cases grow. About 20 to 30 percent of people infected, as far as we know at this point, will become
severely ill and will require intensive care or intensive health care measures. So the need for effective treatments is definitely there, and so already clinical trials are ongoing. In terms of vaccine development, the National Institute of Health is moving forward very aggressively in partnership with a biotech company called Moderna, and they are hoping
to have something available to put into human testing as early as April, but it could take as long as a year or more before there is something that's shown to be safe and effective. So right now, our main line of defense is to try and keep people from spreading the virus to other people. And that's what I have. We can answer questions specifically about the Arkansas response. Bottom line is we don't have any infections here in the state yet, but we are monitoring very closely.
Representative Jack Ladyman
Unverified
1:54:47
Representative Lightyman. Thank you, Madam Chair. um dr smith um you and i were in austin a couple weeks weekends ago at a meeting and they had a suspected case in san antonio which was like 50 miles away and i don't i'm glad to know you don't have the virus i don't think i do either and that turned out negative but my point is you know that was a little scary uh and you talk about the number of cases this virus has already passed the number of exposed people with SARS, right? It's already
Speaker 149
1:55:23
worse than SARS. Yes. SARS, depending on how you count them, killed about 800 people. This is already over 900. Now, this is not as deadly. The SARS coronavirus, the case fatality, the risk of dying, if you got the infection, was about 10%, which is pretty high. This one is only about 2 to 3%, but
Speaker 143
1:55:48
this has spread so much further and faster that the total number of people who have
died has already exceeded what SARS did over the course of
Representative Jack Ladyman
Unverified
1:56:00
18 months. So I guess my question is, pandemic, when do we recognize this as a pandemic event? I mean, when it's doubling every month or so, and it's in all these countries, what is the definition, and what would happen if it was identified as a pandemic globally? To have pretty much everyone comfortable
Speaker 141
1:56:30
calling this a pandemic would mean that we were seeing ongoing
Speaker 143
1:56:34
cycles of transmission in multiple geographic areas. Right now, we are seeing ongoing cycles of transmission really in mainland China. We have cases and we've had a few episodes of transmission. Two of our 12 cases in the U.S. have been people who didn't travel to China but were infected by someone who did travel from China. But we don't have ongoing transmission here in the U.S. at
this time. If that occurs in multiple parts of the world, though, then we would be calling this a pandemic. Right now, we are, we have been able to contain it at this point and keep it from transmitting from person to person to person in the United States. Now, there are some parts of the world where it will be more difficult to do that because they don't have the kind of health care infrastructure that we have. For example, in the continent of Africa, there's a lot of travel between China and Africa, and their health departments don't have anything near the
infrastructure that we do here in the U.S. and here in Arkansas. So I am concerned that we will see ongoing transmission in other parts of the world as well. Representative Ladyman, I don't think
Speaker 141
1:57:53
I scare easily but this has got has me very very concerned.
Representative Deborah Ferguson
Unverified
1:58:02
Thank you. Representative Ferguson. Thank you Madam Chair. Are we making any effort to supply hospitals with personal protective equipment like the N95 mask in Arkansas?
Speaker 149
1:58:16
planning. You know when we put wrote up the plans We were, you know, sort of our doomsday scenario there was an influenza that was as deadly as the 1918 so-called Spanish influenza. This coronavirus seems to be spreading sort of like influenza does. It doesn't seem to have as high a case fatality rate as the 1918 influenza.
influenza, but to this point, the case fatality has been about 2 to 3 percent, as opposed to seasonal flu, which is about 0.1 percent. But our pandemic planning has been around something exactly like this, even though we didn't know it was going to be a coronavirus that we were preparing for. So we have plans in
Speaker 143
1:59:07
place with all of our hospitals. There's a strategic national stockpile. Now, I'm not going to say that any level of planning is necessarily going to cover
all the bases, but we have done quite a
Speaker 152
1:59:21
bit of preparation for a threat like this. Yeah, I mean,
Representative Deborah Ferguson
Unverified
1:59:26
it's my understanding it's a traditional mask. It's not protective, that it takes more than that. You don't
Speaker 141
1:59:35
know if those are available in hospitals. What is recommended for healthcare workers
Speaker 149
1:59:40
caring for someone with the novel coronavirus is to use standard precautions, contact isolation,
Speaker 143
1:59:47
respiratory isolation, as well as an eye mask.
And what is recommended for healthcare workers is an N95 mask. But for those who actually are having symptoms, we just put a simple face mask on them to catch the droplets. It's thought that this novel coronavirus is transmitted like influenza or like the common cold. It's mostly droplets, mostly within about six feet. If we can
Speaker 149
2:00:15
capture those droplets, that reduces the infectivity. But to protect our health care workers, we really want
Speaker 143
2:00:23
to give the maximal level of protection, which is why we recommend the N95 masks. May
Representative Deborah Ferguson
Unverified
2:00:30
I ask a follow-up? I know part of the problem is being that the test has taken like eight hours to get back. I understand there's a rapid test now that hospitals can do
Speaker 149
2:00:41
in about 15 minutes. Is that available in the U.S.? There's only one test for this coronavirus, one type of test, which is a PCR. Basically, it looks for the genetic sequences. That was developed very, very rapidly. considering the genetic sequence of this virus was put
Speaker 143
2:00:58
out on the Internet on January 10th.
Up to this point, all that testing in the U.S. is
Speaker 149
2:01:04
being done through the CDC. We submitted a sample, and it was received on Thursday, I believe. We got the result back on a Sunday afternoon. But those test kits have gone out to all state labs, including ours. We're going through the process of validating that test to make sure that we can do it properly. It's thought that that process will take one to two weeks. After we have that up and running in Arkansas and in the other states,
the CDC will continue to confirm
Speaker 143
2:01:34
positive results, but we will have an enhanced ability to get those results rapidly. I thought
Representative Deborah Ferguson
Unverified
2:01:39
in Hong Kong they were now doing a test in the hospital that took about 15 minutes.
Speaker 143
2:01:47
They're all using, I believe, the same PCR test. Of course, they're doing things at a much higher volume in China. I know there's a lab in China that's doing something like 5,000 of these tests a day. But it's basically similar technology.
Speaker 239
2:02:02
Okay, thank you. Representative Boyd. Thank you, Madam Chair. Representative Ferguson mostly had my question, but I want to make a couple points with that to add to it. So in addition to what Representative Fergus already asked and you answered, I'm concerned because a lot of our manufacturing and the medical equipment is done in China, but we have apparently some excess, is what I understood, or a plan for that. And then with the flu epidemic going on, or flu outbreak going on in the state of Arkansas,
was that going to add an extra strain? So
Speaker 143
2:02:44
add. Yeah, this is really poor timing for an outbreak. I can't think of a good timing, but especially during a bad flu season, this is not good timing. Our best strategy, which is, you know, why our federal partners are really leaning into this hard, is to keep it out of the United States, keep us from having ongoing cycles of transmission. And that's where our efforts and priorities are right now.
If we do see ongoing cycles of transmission here, then we're going to need to concern ourselves with making sure health care workers have all the proper personal protective equipment that they need. Again, anything we can do, though, to slow this down will be to our advantage. If everyone who is going to get sick got sick at one time, it would overwhelm any health care system. If we can slow it down, though, we can handle that better.
So that's where our priority right now is. But there is a strategic national stockpile, and, you know, we'll start to access that as we need it. Hopefully we don't, but as easily as this appears to spread, you know, right now a lot of people are talking about more slowing it down than guaranteeing that we're going to be able to
Speaker 241
2:04:06
forever keep it out of the United States. Senator Garner?
Senator Trent Garner
Unverified
2:04:13
Thank you, Madam Chair. First, thank you, Dr. Smith. I think that was very helpful. First, a comment. The China numbers that I'm seeing coming out, I know I've heard from some federal delegation and others that it's very suspect that we can actually trust those numbers to be accurate because it comes from the state party. And as we know, the state party heavily regulates and controls the media. So the number of cases, probably in reality, would say would be excessively more than what we have on there. Is that
Speaker 228
2:04:43
a correct statement? You are probably correct, not necessarily because of a particular party,
Speaker 149
2:04:48
but although I'm not disputing that in any way, I'm just saying that
Speaker 143
2:04:53
the reality is that there's a certain testing capacity, and they can only test so many a day. And once you exceed that capacity, you know, there could be lots of infections out there that you don't know about. And I think what they are probably doing is only testing the most severe cases. And so there are probably a lot of people who are less severe or are in areas that are outside of Big City
or don't have as good access to testing that are being infected but never recorded. So, yes, the models, the mathematical models show much, much higher case counts than we're actually seeing reported and confirmed. And very quickly, can you give us the three talking points on what our constituents
Senator Trent Garner
Unverified
2:05:36
know for this disease? If you have this symptoms, if you're in contact with these kind of people coming from China or people, can you give that so we can tell them succinctly what they could do and show the report to a hospital if they had these
Speaker 143
2:05:51
symptoms? The most important message at this point is that we do not have this virus in Arkansas.
So we're not looking for people here with symptoms unless they've traveled to China. If they've traveled to China, we need to know about them because we need to monitor them for the 14-day incubation period. And if we're monitoring them, they need to work with us. And they need to stay in and stay away from other people until they're cleared from that 14-day period. So those are the big, big talking points is we don't have it here right now, but we want to keep it out, and if you've traveled to an area or been exposed to someone
Speaker 149
2:06:30
with an infection, you need to work with us and do what we tell
Speaker 32
2:06:41
you to do. Thank you. Representative Payton. Thank you, Madam Chair. I think you've basically answered my questions, but the symptoms that you described are very common with other illnesses, and so basically, unless they're related to exposure, travel somewhere where it exists, you really don't know that
it would be corona or not. So once it breaches those barriers and is in the continental U.S., we could be very much like what Senator Garner was describing, where you really can't test every person that has these symptoms to know if it's coronavirus or something else. What
Speaker 143
2:07:23
you're saying is exactly true. At this point, our risk assessment is very much based on travel history and whether someone has been in contact with a known case.
If we do get cycles of transmission here in the U.S., if it becomes widespread, we're going to have to fundamentally change our strategy. And if we can delay that
Speaker 149
2:07:43
until we have testing capability to where we can test people, You know, so we're testing them for both flu and for novel coronavirus. You know, we need time
Speaker 143
2:07:53
to get to that point, and we're not there yet. So anything that we can do to keep the virus out at this point will help us because it really is a race against time to get that capacity.
If it gets to the point where it's spreading like influenza is spreading, we're going to need to have that capacity to test people when they come into the clinic or come into the hospital. We're not there yet, but that's what we're working towards. So just
Speaker 32
2:08:23
to follow up, just trying to listen to what you're saying and read between the lines, you don't expect to see a vaccine available within the time frame that we need it in order to stop or prevent the spread?
Speaker 149
2:08:38
Unfortunately, with new pathogens like this one, The period of time
Speaker 143
2:08:43
to develop a vaccine has shortened tremendously from years down to maybe a year, year and a half. But in no case have we ever been able to develop a vaccine for a novel pathogen in time to help with that first wave. Now, coronaviruses in general tend to be seasonal. And if this one is, we may get a break when warmer weather comes.
And that may give us time, you know, before it hits us, you know, the following fall or winter. But we don't know. This is a new virus. We don't know what it's going to
Speaker 244
2:09:31
do. Okay. Thank you. Thank you, Madam Chair. Thank you. Representative Penzo. Yeah, this is kind of a two-part question. Are you basing mortality rates on the current death numbers and total cases? Is that accurate?
Speaker 141
2:09:42
That is correct, and there are a lot of caveats to that. First of all, it's a lot easier to tell whether someone's dead
Speaker 143
2:09:49
than whether they're infected, so there could be a lot of other people out there with mild infections, and so the mortality rate actually might be a lot lower. On the other hand, there's a lot of people with recent infections who may go on to die, and so the mortality rate may actually be higher
Speaker 141
2:10:06
than what's anticipated. But right now, the best numbers that we have put it at about 2% to 3%. Okay, because
Speaker 244
2:10:12
that's kind of why I was asking, because the recovery rate based on the death rate
was like a 30% plus mortality rate. And since it's kind of in the exponential growth phase, you know, as long as R0 is at 2.6, I mean, it seems like the 2 to 3 percent is probably
Speaker 247
2:10:32
understated at this point. It could be
Speaker 143
2:10:38
overstated as well. If it turns out that there are a lot of mild infections that are not being tested and reported. Okay. Thank you.
Representative Deborah Ferguson
Unverified
2:10:48
Thank you. Representative Ferguson. May I ask a question on a related
Senator Missy Irvin
Unverified
2:10:56
subject? Yeah, before you do that, I'm going
to ask a quick question, which is, so when it says that the first reported patient became ill December 1st, so is it safe to say then that they were probably exposed sometime in November because of the incubation period
is 14 to 15 days, so mid-November of 2019?
Speaker 149
2:11:19
19? The usual incubation period appears to be more like three to six
Speaker 141
2:11:25
days, but could be as long as 14 days. So probably late November would be
Senator Missy Irvin
Unverified
2:11:31
the exposure. Okay. And then they, but they didn't shut down
the seafood market until sometime in January. And I mean, I guess my question is, I mean, are you
going back and tracking how many people were traveling in China back in November
of 2019? And I mean,
Speaker 143
2:11:55
we are not because for two reasons. First of all, those people would be outside of that 14 day incubation period. So they'd no longer be a risk of if they haven't gotten sick, by now they're not going to get sick. And the second reason is the number of cases back in December was very, very small. Out of a city of 11 million people, really 41 is all that were
recognized. Now since then, you know, that has continued to double about every week, the number of reported cases. And so we're more concerned with people who have been exposed in recent weeks because the risk of exposure is so much higher in the past month than it was in that first four to
Senator Missy Irvin
Unverified
2:12:48
six weeks. Okay, I understand that. So, I mean, clearly it's person-to-person transmission.
That is correct. And are we anticipating that people from the World Health Organization or the CDC
Speaker 149
2:13:07
are going to go in to China? China has already invited officials
Speaker 143
2:13:12
from the World Health Organization. The CDC has also offered help. Unless something has changed recently, I think they were still waiting to actually enter the country. But there's been a lot of exchange of ideas and information.
Representative Deborah Ferguson
Unverified
2:13:27
Okay. All right. Representative Ferguson. On sort of a related subject, not the coronavirus, but regular flu, I have several friends that have gotten the flu, and they said they got a flu shot, and they said, I'm not going to take a flu shot anymore. Can you address what I should say to people like that, that got the flu, but they also got a
Speaker 149
2:13:50
flu shot? Well, what we know about the flu shot is that it's not 100%, but it does decrease the risk and tends to decrease the severity for those who get it.
Speaker 143
2:14:00
This is not a perfect analogy, but it's like a seatbelt. A seatbelt won't keep you from having a traffic accident, but it makes more likely that you'll survive it if you do. And it wouldn't make any sense to get in a wreck and say, I'm never wearing a seatbelt again. And it's kind of the same way with the flu vaccine. And Dr. Delhay, do you want to
Speaker 138
2:14:25
talk about that a little bit? Sure. People
Speaker 252
2:14:28
have a hard time understanding the flu versus other
respiratory viruses. So sometimes people will get a flu vaccine and get exposed to the flu within the two weeks after the vaccine and they haven't developed the immunity from the vaccine yet. So that can happen. But a lot of times people will get a other respiratory virus that the flu vaccine doesn't protect against and think it's the flu even though it's not diagnosed as a flu and feel like the vaccine didn't protect them.
Well, it didn't because they didn't get the flu. But it is true that on a good year, a flu vaccine will prevent people, about half of the people, from actually getting the flu. The real benefit is that it helps keep people out of the hospital and it helps them survive the flu if they get it. Yeah, no, and
Representative Deborah Ferguson
Unverified
2:15:23
I'm a real proponent of vaccines and flu vaccine in particular. I just, I like the seatbelt analogy. like that. Thank you. I've
Speaker 167
2:15:33
got Representative Payton and then Representative Boyd.
Speaker 34
2:15:37
Thank you, Madam Chair. I'll try to be quick. I have two questions, though. Number one,
Speaker 32
2:15:43
part of your data and you, it piqued your interest that it didn't show a lot of youth being infected. Do we know whether or not the youth that are not showing symptoms and not showing up as infected could be carriers?
Speaker 34
2:15:58
And then also, how long does the virus survive like on surfaces and things like that? Those are
Speaker 143
2:16:06
both excellent questions. With regard to your first
question about children, we don't know. We don't know if they are asymptomatic carriers who could be spreading the virus. There are certainly many viruses where that's the case. We've been dealing with hepatitis A outbreaks in the United States, and we know that's a virus where the children tend not to get sick, but they spread it to other people. Not in this, you know, this outbreak we're dealing with right now tends to be amongst adults, but historically. So it may turn out that that is the case. It may turn out that children, although they
may not get sick as often as adults, they may actually be helping to spread the virus. We don't know that at this point, but there's a lot of unknowns. If you can consider that But six weeks ago, I don't even think I even knew that Wuhan City existed, even though it's a city of 11 million people. Now, as far as your second question, how long does it last on surfaces? We don't know that answer, absolutely. We know from other coronaviruses that contamination of surfaces doesn't seem to be a major part
of transmission. It's a virus that's called an envelope virus. It's got like a membrane around it. It's kind of like a soap bubble. So, you know, once it dries out, it kind of pops. That's a really crude analogy. But most envelope viruses don't persist on surfaces for a really long period of time. Again, that's an unknown. But at least with other coronaviruses, that doesn't seem to be the major driver. It seems to be mostly droplets spreading directly from one person to another.
Speaker 238
2:17:53
Thank you. Thank you, Madam Chair. Thank you. Representative Boyd. Thank you, Madam Chair. This is really just, if you don't mind, a
Speaker 239
2:18:03
very quick comment to the committee. Yeah. Because normally, so we're one of only a handful of states that has price gouging laws for emergencies. I never thought about this in the terms of emergency, but as I sit here and listen to this And I think about personnel, protective equipment, and medication, and what could happen. It could be a devastating thing if the market was not allowed to respond to that. So I don't know. I just wanted to bring that up for anybody else that was interested.
Senator Missy Irvin
Unverified
2:18:26
No, good point. Any other questions? All right. I really do appreciate it. I know there's a lot of information out there on this. And if you've ever attended an infectious disease conference, it will scare the living daylights out of you. And so to hear that you're concerned concerns me. So I do appreciate y'all keeping us informed on this. Thank you very much. Thank you, Madam Chair.
Thank you. And members, just a last reminder, please take your Arkansas Heart Hospital information with you and
make sure you let Mr. Price know if you're going to be there on Wednesday. I assure you it's going to be a great meeting. And with that, we are adjourned.
Agenda
Call to Order
Comments by the Chairs
Consideration to Adopt the January 6, 2020 Meeting Minutes (EXHIBIT C)
Department of Human Services (DHS), Division of Developmental Disabilities Services, Review of a Rule to Amend the Autism Waiver to expand capacity by 30 slots to provide early intervention treatment for children diagnosed with autism spectrum disorder and to amend the Autism Waiver Provider Manual to be consistent with the waiver. This rule enacts the provisions of Act 874 of 2019. (EXHIBIT D)
4. Discussion and Action by the Committees
Arkansas Department of Health (ADH), Public Health Lab, Review of a Rule pertaining to testing of Newborn Infants, Review of a Rule adds tests for newborn screening including for Spinal Muscular Atrophy (SMA) pursuant to Act 58 of 2019. It also adds three additional tests for Pompe Disease, MPS 1 spectrum of disease, and childhood onset (cerebral) X-ALD. The four tests can be performed in the local health laboratory utilizing existing blood samples
Arkansas Department of Health (ADH), Health Facility Services, Review of a Rule pertaining to the licensing standards for perfusionists. This rule change implements the changes in Act 315 of 2019 eliminating the word regulations, adds definition of returning military veteran and added military licensing requirements in Act 820 of 2019, adds reciprocity language in good standing from Act 1011 of 2019, adds criminal history background disqualifications from Act 990 of 2019 and adds severability clause to all ADH rules for continuity. (EXHIBIT F)
2. Discussion and Action by the Committees
Update on Vaping Related Illnesses and Actions being taken at the State and Federal Level and Update on the Coronavirus
H. Update on University of Arkansas for Medical Sciences(UAMS) Cancer Institute Designation (EXHIBIT H)
3. Discussion by the Committees
I. Other Business
J. Adjournment
Documents
Speakers
Senator Missy Irvin
Unverified
Speaker 5
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Senator Kim Hammer
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Representative Dwight Tosh
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Senator Jimmy Hickey, Jr
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Representative Deborah Ferguson
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Senator Trent Garner
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Representative Jack Ladyman
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Representative Lee Johnson
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Representative Johnny Rye
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