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The following is a transcript of the podcast episode:

Rachael Robertson: Hey everybody. Welcome to MedPod Today, the podcast series where MedPage Today reporters share deeper insight into the week's biggest healthcare stories. I'm your host, Rachael Robertson.

We're kicking off today's episode with a rundown on what's happening with H5N1, or bird flu, brought to us by Kristina Fiore. Then Joyce Frieden tells us about a case that could change whether emergency departments can offer abortions. After that, Kristina will join us again to talk about the New England Journal of Medicine's surprising change to its embargo policy that will particularly impact medical publications like MedPage Today.

But first, the latest on avian influenza.

H5N1 – avian influenza– is causing unprecedented outbreaks in mammals around the world, including U.S. dairy cattle. While this hasn't been a problem for people just yet, MedPage Today reporters have been asking questions about pandemic preparedness, including vaccination, treatment, and testing. Kristina Fiore is here to tell us more.

Kristina, what do we know about the scope of the H5N1 outbreak so far?

Kristina Fiore: So we know as of right now, Wednesday morning, that 36 dairy herds in 9 states have tested positive for H5N1. It's the same strain that's been found in wild birds in the U.S. since 2021. The first detection in cattle was in the northern panhandle region of Texas in February of this year, and by early March, similar cases were seen in other states, including Kansas and New Mexico.

So experts I spoke with suggest that the outbreak is actually larger than we currently know given two factors. One is that H5N1 was detected in samples from commercial milk. And the other is that viral sequences released by the USDA suggest that the outbreak began in December 2023.

James Lawler, MD, MPH, at the University of Nebraska Medical Center's Global Center for Health Security told me that the U.S. hasn't been testing adequately to be able to get a real picture of how widely the virus has spread in these animals, or even to the farmworkers who tend them, potentially. And the CDC reported that in this outbreak, 44 people had been monitored for symptoms and more are being passively monitored -- so they'll report if they develop symptoms. And a total of 23 people have been tested, and one has tested positive and that's the farm worker in Texas whose only symptom was pink eye.

Robertson: So far, there hasn't been any person-to-person transmission, but should H5N1 evolve to be able to be transmitted between people, is the U.S. ready?

Fiore: So our reporter Jennifer Henderson took a look at vaccine availability. And she found out that there are currently three H5N1 vaccines approved in the U.S. by GSK, Sanofi, and CSL Seqirus. The Administration for Strategic Preparedness and Response, or ASPR, told us that it has a national stockpile program where it works with industry to test updated vaccines. And that program currently has two antigens that are very well matched to the current H5N1 clade that's circulating now. ASPR says that hundreds of thousands of doses could be deployed within weeks of regulatory action, and more than 100 million doses could be deployed over the next months after that.

As for antivirals – you, Rachael, had a great story out this week showing that experts think our current antivirals targeting flu would work against H5N1, because all influenza viruses have extremely similar internal mechanisms for reproduction. The N in H5N1 stands for neuraminidase. That's a flu protein that's targeted by our neuraminidase inhibitors, like Tamiflu. And we also have a polymerase inhibitor called Xofluza that interferes with replication and should work in H5N1 too.

As far as testing goes, the CDC told me that its public health labs all have flu surveillance that will pick up H5N1. It's also working with commercial partners to have commercial PCR tests ready to go to hospitals and clinics should those ever be needed. So in theory, we have the key bases covered should H5N1 jump to humans. But we all know there are a lot of surprises in a pandemic. And this is a virus that has historically had 52% mortality, which is why it's such a public health concern. Lawler told me that while that's probably an inflated number, even like a 5% mortality would be "a society ending pandemic."

Robertson: Well, how likely is it that H5N1 will make that jump into humans?

Fiore: Yeah, so everyone I talked to says they hope it's not likely. But given the unprecedented spread in mammals, they're keeping a very close eye on this.

Lawler said that the more it circulates in mammals, the greater the chance it has of adapting more effectively to other mammals, including humans. Then just this week, the CDC journal Emerging Infectious Diseases published findings from an analysis of tissue samples from cows and cats that caught H5N1 on farms in Texas and Kansas. Now, the cows had mild disease and one of their main symptoms was mastitis and there were high viral loads in their milk. The cats, on the other hand, didn't fare so well. More than half of 24 cats on one farm that were fed milk from sick cows died. So it's pretty severe in that species.

H5N1 has also been detected in a range of mammals in the U.S., including seals, foxes, skunks, raccoons, bobcats, and more. So H5N1 is around and it's in more mammals than ever seen before. The authors of that EID report called for much more surveillance to really get ahead of the spread of H5N1 in mammals.

Robertson: Thanks for that rundown on H5N1, Kristina. We'll be sure to check back in with you as this story develops.

Fiore: Sounds good, thanks.

Robertson: Yet another major case about abortion access is in the courts. Last week, the Supreme Court heard oral arguments on a case that could affect whether emergency departments will be able to provide abortions when the health -- but not the life -- of the mother is at stake. The case is about a federal law known as the Emergency Medical Treatment and Active Labor Act, or EMTALA. MedPage Today Washington editor Joyce Frieden is here to explain.

So Joyce, tell us about EMTALA. What is this case about?

Joyce Frieden: Well, Rachael, EMTALA requires hospitals and emergency departments that accept Medicare funding, which is basically all of them, to provide stabilizing treatment to any patient who arrives with an emergency medical condition, regardless of their ability to pay. However, a new law in Idaho known as the Defense of Life Act outlaws all abortions except in cases of rape, incest, or to save the life of the pregnant person, and anyone who performs an abortion not covered by the exemptions faces up to 5 years in prison. The rape and incest exemptions, by the way, only apply in cases where those crimes have been previously reported to the police.

The federal government is arguing that in some cases, medical care that a state may characterize as an abortion is necessary emergency stabilizing care that hospitals are required to provide under EMTALA. Examples of conditions that may necessitate an emergency abortion include ectopic pregnancy, severe preeclampsia, or a pregnancy complication threatening septic infection or hemorrhage. But the state of Idaho is arguing that the law would not prevent emergency doctors from providing necessary emergency care. Idaho says that the federal government "has failed to present any credible evidence of any pregnancy-related medical emergencies in Idaho requiring, under EMTALA, emergency medical treatment that will result in loss of the preborn child's life but that the [Idaho] statute prohibits." They note that an operation to treat an ectopic pregnancy, for example, is not prohibited by the law in question.

Robertson: So how are the Supreme Court justices reacting? Do they seem to be leaning one way or another during the oral arguments?

Frieden: Well, you might not be surprised to hear that the court seemed to be divided along ideological lines. For instance, Justice Elena Kagan seems to be favoring the federal government's position:

Justice Elena Kagan: "All of these cases are rare, but within these rare cases, there's a significant number where the woman's life is not imperiled, but she's going to lose her reproductive organs. She's going to lose the ability to have children in the future unless an abortion takes place. Now, that's the category of cases in which EMTALA says, 'My gosh, of course, the abortion is necessary to assure that no material deterioration [of her health] occurs.' And yet Idaho says, 'Sorry, no abortion here,' and the result is that these patients are now helicoptered out of state."

Frieden: The lawyer for Idaho agreed that such situations raised tough medical questions, but he also said that the state feels there are two parties to consider here, the pregnant person and the unborn child. Kagan didn't seem sympathetic to that argument. On the other hand, Justice Brett Kavanaugh asked Idaho's lawyer whether there was any condition where EMTALA requires that an abortion be performed, but the Idaho law does not. The lawyer said there was, and it had to do with mental health emergencies. He noted that even though the Biden administration claims that abortion is not on the table under such circumstances, and also says no professional organizations have suggested such a thing, the American Psychiatric Association in a 2023 position paper says that abortions are "imperative" for mental health conditions.

Robertson: So for now, the Idaho law remains in effect. What have the results of that been so far?

Frieden: The law is definitely affecting care in Idaho, according to Jim Souza, MD. He's chief physician executive of St. Luke's Health System, which is in the Boise area. He said last week that during 2023, when Idaho's law was not in effect for emergency medical conditions, only one pregnant patient presenting to an emergency room was transferred out of state for care. And he said, "In the few months since Idaho's law has been in effect, six patients with medical emergencies have already been transferred out of state for [pregnancy] termination. And if we annualize that, we can anticipate up to 20 patients needing out-of-state care this year alone."

Robertson: Thank you for this update on the case, Joyce.

Frieden: Thanks, Rachael.

Robertson: Scientific and medical journals typically provide reporters embargoed access to their papers. That includes journalists from mainstream publications, like The New York Times or NPR, as well as the medical press. But the New England Journal of Medicine (NEJM) is rescinding that access for certain publications – including MedPage Today. Kristina Fiore is back to tell us more.

So Kristina, what is going on with this change?

Fiore: Yeah, so last month, one of our reporters tried to access an embargoed paper, and she noticed that the NEJM media site no longer had PDFs. So she emailed the press team, and they told her that they were no longer giving advanced access to reporters who work primarily for publications focused on physicians. That would be publications like ours, like Medscape, Healio, MJH Life Sciences, Haymarket publications, and so on. So of course, we looked further into this, and New England Journal told us that access will unwind as reporters apply to renew their media credentials. Some MedPage Today reporters have applied to renew their credentials and have been denied because our publication "primarily serves clinicians and health care professionals."

Robertson: That's a pretty big change. What caused it and why only physician focused publications and not everybody?

Fiore: We don't know. NEJM introduced its embargoed access policy decades ago. And when we asked NEJM, their communications director only said that medical publishing "has changed considerably, as have our own publications." She said that parent company NEJM Group has grown to include "several journals to which physicians and clinical professionals can subscribe." And that's happened as the number of media outlets focused on medical professionals has increased, she said.

So I reached out to Ivan Oransky, MD, who has written about embargoes extensively for decades and he told me that NEJM is "apparently trying to grow their market share. They're prioritizing that over the free and transparent and sometimes critical flow of clinical information," he said. Oransky called it a really bad policy and he said it's a way backward with embargoes.

Robertson: What are the next steps here?

Fiore: Well, we're all hoping that NEJM changes its mind and that no other journals take this approach. The embargo system was developed so that reporters could have enough time to report on studies accurately and gather outside perspectives on new research without the fear of being scooped, which could then lead to inaccurate, sloppy, or rushed reporting. And that's not good, especially in this environment of pervasive misinformation.

Robertson: Thanks so much, Kristina.

Fiore: Thanks, Rachael.

Robertson: And that is it for today. If you liked what you heard, please leave us a review wherever you listen to podcasts, and hit subscribe if you haven't already (, ).

Also a quick plug. We recently released our first MedPod Today Deep Dive into the problems with for-profit nursing programs. That series is the last two episodes in our feed. Check it out to hear about why some for-profit nursing schools have suddenly shuttered and the other problems that students in these programs have faced. Anyway, we'll see you again soon.

This episode was hosted and produced by me, Rachael Robertson. Sound engineering by Greg Laub. Our guests were MedPage Today reporters Kristina Fiore and Joyce Frieden. Links to their stories are in the show notes.

MedPod Today is a production of MedPage Today. For more information about our show, check out medpagetoday.com/podcasts.

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