by tyler | Apr 20, 2023 | CNN, health
A new study on breast cancer deaths raises questions around whether Black women should screen at earlier ages.
An international team of researchers wrote in the study, published Wednesday in the journal JAMA Network Open, that clinical trials may be warranted to investigate whether screening guidelines should recommend Black women start screening at younger ages, around 42 instead of 50.
The US Preventive Services Task Force – a group of independent medical experts whose recommendations help guide doctors’ decisions – recommends biennial screening for women starting at age 50. The Task Force says that a decision to start screening prior to 50 “should be an individual one.” Many medical groups, including the American Cancer Society and Mayo Clinic, already emphasize that women have the option to start screening with a mammogram every year starting at age 40.
Even though Black women have a 4% lower incidence rate of breast cancer than White women, they have a 40% higher breast cancer death rate.
“The take-home message for US clinicians and health policy makers is simple. Clinicians and radiologists should consider race and ethnicity when determining the age at which breast cancer screening should begin,” Dr. Mahdi Fallah, an author of the new study and leader of Risk Adapted Cancer Prevention Group at the German Cancer Research Center in Heidelberg, Germany, said in an email.
“Also, health policy makers can consider a risk-adapted approach to breast cancer screening to address racial disparities in breast cancer mortality, especially the mortality before the recommended age of population screening,” said Fallah, who is also a visiting professor at Lund University in Sweden and an adjunct professor at the University of Bern in Switzerland.
Breast cancer screenings are typically performed using a mammogram, which is an X-ray picture taken of the breast that doctors examine to look for early signs of breast cancer developing.
“Guidelines for screening actually already do recommend basing a woman’s time to initiate screening on the risk of developing cancer, though race and ethnicity have not been traditional factors that go into these decisions,” Dr. Rachel Freedman, a breast oncologist at Dana-Farber Cancer Institute, who was not involved in the new study, said in an email.
The American Cancer Society currently recommends that all women consider mammogram screenings for breast cancer risk starting at the age of 40 – and for women 45 to 54, it’s recommended to get mammograms every year. Those 55 and older can switch to screening every other year if they choose.
But “we are in the process of updating our breast cancer screening guidelines, and we are examining the scientific literature for how screening guidelines could differ for women in different racial and ethnic groups, and by other risk factors, in a way that would reduce disparities based on risk and disparities in outcome,” Robert Smith, senior vice president for cancer screening at the American Cancer Society, who was not involved in the new study, said in an email. “We are examining these issues closely.”
The American Cancer Society’s recommendations appear to align with the findings in the new study, as the research highlights how screening guidelines should not be a “one-size-fits-all policy,” but rather help guide conversations that patients and their doctors have together.
“We, here at the American Cancer Society, strongly recommend that all women consider a screening mammogram from the age of 40 onwards, and that means having a discussion with their doctor,” said Dr. Arif Kamal, the American Cancer Society’s chief patient officer, who was not involved in the new study.
“The authors highlight that age 50 can be a little late,” Kamal said about the study’s findings on when to begin breast cancer screening. “We are in agreement with that, particularly for women who may be at slightly higher risk.”
The researchers – from China, Germany, Sweden, Switzerland and Norway – analyzed data on 415,277 women in the United States who died of breast cancer in 2011 to 2020. That data on invasive breast cancer mortality rates came from the National Center for Health Statistics and was analyzed with the National Cancer Institute’s SEER statistical software.
When the researchers examined the data by race, ethnicity and age, they found that the rate of breast cancer deaths among women in their 40s was 27 deaths per 100,000 person-years for Black women compared with 15 deaths per 100,000 in White women and 11 deaths per 100,000 in American Indian, Alaska Native, Hispanic and Asian or Pacific Islander women.
“When the breast cancer mortality rate for Black women in their 40s is 27 deaths per 100,000 person-years, this means 27 out of every 100,000 Black women aged 40-49 in the US die of breast cancer during one year of follow-up. In other words, 0.027% of Black women aged 40-49 die of breast cancer each year,” Fallah said in the email.
In general, for women in the United States, their average risk of dying from breast cancer in the decade after they turn 50, from age 50 to 59, is 0.329%, according to the study.
“However, this risk level is reached at different ages for women from different racial/ethnic groups,” Fallah said. “Black women tend to reach this risk level of 0.329% earlier, at age 42. White women tend to reach it at age 51, American Indian or Alaska Native and Hispanic women at age 57 years, and Asian or Pacific Islander women later, at age 61.”
So, the researchers determined that when recommending breast cancer screening at age 50 for women, Black women should start at age 42.
Yet “the authors didn’t have any information on whether the women included in this study actually had mammographic screening and at what age. For example, it is possible that many women in this study actually had screening during ages 40-49,” Freedman, of the Dana-Farber Cancer Institute, said in her email.
“This study confirms that the age of breast cancer-mortality is younger for Black women, but it doesn’t confirm why and if screening is even the main reason. We have no information about the types of cancers women developed and what treatment they had either, both of which impact mortality from breast cancer,” she said.
The harm of starting mammograms at a younger age is that it raises the risk of a false positive screening result – leading to unnecessary subsequent tests and emotional stress.
But the researchers wrote in their study that “the added risk of false positives from earlier screenings may be balanced by the benefits” linked with earlier breast cancer detection.
They also wrote that health policy makers should pursue equity, not just equality, when it comes to breast cancer screening as a tool to help reduce breast cancer death rates.
Equality in the context of breast cancer screening “means that everyone is screened from the same age regardless of risk level. On the other hand, equity or risk-adapted screening means that everyone is provided screening according to their individual risk level,” the researchers wrote. “We believe that a fair and risk-adapted screening program may also be associated with optimized resource allocation.”
The new study is “timely and relevant,” given the overall higher mortality rate for breast cancer in Black women and that Black women are more likely to be diagnosed at a younger age compared with other ethnic groups, Dr. Kathie-Ann Joseph, surgical oncologist at NYU Langone’s Perlmutter Cancer Center and professor of surgery and population health at the NYU Grossman School of Medicine, said in an email.
“While some may argue that earlier screening may lead to increased recalls and unnecessary biopsies, women get recalled for additional imaging about 10% of the time and biopsies are needed in 1-2% of cases, which is quite low,” said Joseph, who was not involved in the new study.
“This has to be compared to the lives saved from earlier screening mammography,” she said. “I would also like to point out that while we certainly want to prevent deaths, earlier screening can have other benefits by allowing women of all racial and ethnic groups to have less extensive surgery and less chemotherapy which impacts quality of life.”
Breast cancer is the most common cancer among women in the United States, except for skin cancers. This year, it is estimated that about 43,700 women will die from the disease, according to the American Cancer Society, and Black women have the highest death rate from breast cancer.
Even though Black women are 40% more likely than White women to die from the disease, Kamal of the American Cancer Society said that the disparity in deaths is not a result of Black women not following the current mammogram guidelines.
Rather, implicit bias in medicine plays a role.
“In the United States, across the country, there are not differences in mammogram screening rates among Black women and White women. In fact, across the entire country, the number is about 75%. We see about 3 in 4 women – Black, White, Hispanic, and Asian – are on time with their mammograms,” Kamal said.
Yet there are multiple timepoints after a patient is diagnosed with breast cancer where they may not receive the same quality of care or access to care as their peers.
“For example, Black women are less likely to be offered enrollment in a clinical trial. That is not because of a stated difference in interest. In fact, the enrollment rate in clinical trials is equal among Black women and White women, if they’re asked,” Kamal said.
“What we have to understand is where the implicit and systemic biases held by patients and their caregivers and their families may exist – those that are held within health systems and even policies and practices that impede everyone having fair and just access to high quality health care,” he said.
Additionally, Black women have nearly a three-fold increased risk of triple-negative breast cancers. Those particular type of cancers tend to be more common in women younger than 40, grow faster than other types of invasive breast cancer and have fewer treatment options.
Black women also tend to have denser breast tissue than White women. Having dense tissue in the breast can make it more difficult for radiologists to identify breast cancer on a mammogram, and women with dense breast tissue have a higher risk of breast cancer.
But such biological differences among women represent just a small part of a much larger discussion around racial disparities in breast cancer, Kamal said.
“There are systemic issues, access to care issues that really go beyond biology,” he said. “The reality is cancer affects everybody and it does not discriminate. Where the discrimination sometimes occurs is after the diagnosis, and that’s really what we need to focus on.”
by tyler | Apr 20, 2023 | CNN, health
The rate of suspected suicides and suicide attempts by poisoning among youths rose sharply during the pandemic, a new study says. Among children 10 to 12 years old, the rate increased more than 70% form 2019 to 2021.
This new analysis, published Thursday in the US Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report, looked at what the National Poison Data System categorized as “suspected suicides” by self-poisoning for 2021 among people ages 10 to 19; the records included both suicide attempts and deaths by suicide.
The data showed attempted suicides and suicides by poisoning increased 30% in 2021 compared with 2019, before the Covid-19 pandemic.
Younger children, ages 10 to 12 years, saw the biggest increase at 73%. For 13- to 15-year-olds, there was a 48.8% increase in suspected suicides and attempts by poisoning from 2019 to 2021. Girls seemed to be the most impacted; there was a 36.8% increase in suspected suicides and attempts by poisoning among girls.
The records showed that many of the children used medicines that would be commonly found around the house, including acetaminophen and ibuprofen.
The data could only capture the number of families or institutions that reached out to the poison control line; it cannot account for those who attempted suicide by means other than poison. It also can’t capture exactly how many children or families sought help from somewhere other than poison control, so the increase in suspected suicides could be higher.
The American Academy of Pediatrics has said the pandemic exacerbated mental health struggles that existed even prior to Covid-19. In 2021, the AAP called child and adolescent mental health a “national emergency.” Emergency room clinicians across the country have said they’ve seen a record numbers of children turning up with mental health crises, including attempts at suicide.
In 2020, suicide was the second leading cause of death among children ages 10 to 14 years old and it was the third leading cause among 15 to 24 years, according to the CDC.
While the height of the pandemic is over, kids are still emotionally vulnerable, experts warn. Previous attempts at suicide have been found to be the “strongest predictor of subsequent death by suicide,” the study said.
“An urgent need exists to strengthen programs focused on identifying and supporting persons at risk for suicide, especially young persons,” the study said.
Research has shown that there is a significant shortage of trained professionals and treatment facilities that can address the number of children who need better mental health care. In August the Biden administration announced a plan intending to make it a lot easier for millions of kids to get access to mental and physical health services at school.
At home, experts said families should continue to check in with children to see how they are doing emotionally. Caregivers need to make sure they restrict children’s access to “lethal means,” like keeping medicines – even over-the-counter items – away from children, and keeping guns locked up.
Dr. Aron Janssen, the vice chair of clinical affairs at the Pritzker Department of Psychiatry and Behavioral Health at Lurie Children’s in Chicago, said he is not surprised to see such an increase in suspected suicides “but it doesn’t make it any less sad.”
Janssen, who did not work on this report, called the increase in suspected suicides “alarming.”
The rates of suicide attempts among kids had been increasing even prior to the pandemic, he said, “but this shows Covid really supercharged this as a phenomenon.
“We see a lot of kids who lost access to social supports increasingly isolated and really struggling to manage through day to day.”
Janssen said that he and his colleagues believe these suspected suicides coincide with increased rates of depression, anxiety and a sense of real dread about the future. One of the biggest concerns are that ” previous suicide attempts is the biggest predictor of later suicide completion,” Janssen said. “We really want to follow these kids over time to better understand how to support them to make sure that we’re doing everything within our power to help steer them away from future attempts.”
Janssen said it’s important to keep in mind that the vast majority of kids survived even the worst of the pandemic and did quite well. There are treatments that work, and kids who can get connected to the appropriate care – including talk therapy and in some cases medication – can and do get better.
“We do see that we do see improvement we do see efficacy of our care,” Janssen said. “We just have to figure out how we can connect kids to care.”
by tyler | Apr 18, 2023 | CNN, health
At some middle and high schools in the United States, 1 in 4 teens report they’ve abused prescription stimulants for attention deficit hyperactivity disorder during the year prior, a new study found.
“This is the first national study to look at the nonmedical use of prescription stimulants by students in middle and high school, and we found a tremendous, wide range of misuse,” said lead author Sean Esteban McCabe, director of the Center for the Study of Drugs, Alcohol, Smoking and Health at the University of Michigan in Ann Arbor.
“In some schools there was little to no misuse of stimulants, while in other schools more than 25% of students had used stimulants in nonmedical ways,” said McCabe, who is also a professor of nursing at the University of Michigan School of Nursing. “This study is a major wake-up call.”
Nonmedical uses of stimulants can include taking more than a normal dose to get high, or taking the medication with alcohol or other drugs to boost a high, prior studies have found.
Students also overuse medications or “use a pill that someone gave them due to a sense of stress around academics — they are trying to stay up late and study or finish papers,” said pediatrician Dr. Deepa Camenga, associate director of pediatric programs at the Yale Program in Addiction Medicine in New Haven, Connecticut.
“We know this is happening in colleges. A major takeaway of the new study is that misuse and sharing of stimulant prescription medications is happening in middle and high schools, not just college,” said Camenga, who was not involved with the study.
Published Tuesday in the journal JAMA Network Open, the study analyzed data collected between 2005 and 2020 by Monitoring the Future, a federal survey that has measured drug and alcohol use among secondary school students nationwide each year since 1975.
In the data set used for this study, questionnaires were given to more than 230,000 teens in eighth, 10th and 12th grades in a nationally representative sample of 3,284 secondary schools.
Schools with the highest rates of teens using prescribed ADHD medications were about 36% more likely to have students misusing prescription stimulants during the past year, the study found. Schools with few to no students currently using such treatments had much less of an issue, but it didn’t disappear, McCabe said.
“We know that the two biggest sources are leftover medications, perhaps from family members such as siblings, and asking peers, who may attend other schools,” he said.
Schools in the suburbs in all regions of the United States except the Northeast had higher rates of teen misuse of ADHD medications, as did schools where typically one or more parent had a college degree, according to the study.
Schools with more White students and those who had medium levels of student binge drinking were also more likely to see teen abuse of stimulants.
On an individual level, students who said they had used marijuana in the past 30 days were four times as likely to abuse ADHD medications than teens who did not use weed, according to the analysis.
In addition, adolescents who said they used ADHD medications currently or in the past were about 2.5% more likely to have misused the stimulants when compared with peers who had never used stimulants, the study found.
“But these findings were not being driven solely by teens with ADHD misusing their medications,” McCabe said. “We still found a significant association, even when we excluded students who were never prescribed ADHD therapy.”
Data collection for the study was through 2020. Since then, new statistics show prescriptions for stimulants surged 10% during 2021 across most age groups. At the same time, there has been a nationwide shortage of Adderall, one of the most popular ADHD drugs, leaving many patients unable to fill or refill their prescriptions.
The stakes are high: Taking stimulant medications improperly over time can result in stimulant use disorder, which can lead to anxiety, depression, psychosis and seizures, experts say.
If overused or combined with alcohol or other drugs, there can be sudden health consequences. Side effects can include “paranoia, dangerously high body temperatures, and an irregular heartbeat, especially if stimulants are taken in large doses or in ways other than swallowing a pill,” according to the Substance Abuse and Mental Health Services Administration.
Research has also shown people who misuse ADHD medications are highly likely to have multiple substance use disorders.
Abuse of stimulant drugs has grown over the past two decades, experts say, as more adolescents are diagnosed and prescribed those medications — studies have shown 1 in every 9 high school seniors report taking stimulant therapy for ADHD, McCabe said.
For children with ADHD who use their medications appropriately, stimulants can be effective treatment. They are “protective for the health of a child,” Camenga said. “Those adolescents diagnosed and treated correctly and monitored do very well — they have a lower risk of new mental health problems or new substance use disorders.”
The solution to the problem of stimulant misuse among middle and high school teens isn’t to limit use of the medications for the children who really need them, McCabe stressed.
“Instead, we need to look very long and hard at school strategies that are more or less effective in curbing stimulant medication misuse,” he said. “Parents can make sure the schools their kids attend have safe storage for medication and strict dispensing policies. And ask about prevalence of misuse — that data is available for every school.”
Families can also help by talking to their children about how to handle peers who approach them wanting a pill or two to party or pull an all-night study session, he added.
“You’d be surprised how many kids do not know what to say,” McCabe said. “Parents can role-play with their kids to give them options on what to say so they are ready when it happens.”
Parents and guardians should always store controlled medications in a lockbox, and should not be afraid to count pills and stay on top of early refills, he added.
“Finally, if parents suspect any type of misuse, they should contact their child’s prescriber right away,” McCabe said. “That child should be screened and assessed immediately.”
by tyler | Apr 17, 2023 | CNN, health
As more communities reel from deadly mass shootings – including Dadeville, Alabama, where four people were killed and 28 injured at a Sweet 16 birthday party over the weekend – there’s evidence that the trauma of gun violence in the United States is taking a collective toll on the nation’s mental health.
Research published this year suggests that the negative effects that mass shootings can have on mental health may extend beyond the survivors and community directly affected to a much broader population.
In the days after a school shooting in Uvalde, Texas, in May, a mental health crisis line received a spike in messages that referenced guns and other related firearm-related terms, according to a study funded by the US Centers for Disease Control and Prevention. Although the study did not track the specific location of the messages coming in, Crisis Text Line – a nonprofit organization offering free confidential crisis intervention – serves people nationwide.
Mass shootings have escalated to a record pace in the US, with at least 162 already reported in 2023. It has been a week since the deadly mass shooting at a bank in Louisville, Kentucky, and there have been more than a dozen since, according to the Gun Violence Archive.
The devastating frequency means more and more people are directly affected, and the general public is regularly exposed to the indirect impacts.
“We know that exposure through the media – which can happen across many different outlets, with the swipe of a finger or a ding on your phone – to some type of traumatic event can result in someone experiencing an acute stress reaction and can trigger underlying post-traumatic stress they may have from something else,” said Leah Brogan, a psychologist who works at both the Center for Violence Prevention and the Center for Injury Research and Prevention at the Children’s Hospital of Philadelphia.
“So certainly, that constant exposure can be escalating and activating people even when they don’t experience something directly.”
A recent survey from the Kaiser Family Foundation found that gun violence more broadly has affected most families in the US in one way or another. Nearly 1 in 5 adults has had a family member killed by a gun, including in homicide and suicide, and about 1 in 6 has witnessed an injury from a gun.
Brogan works as a trauma therapist for youth who land in the emergency department after a violence-related injury. Often, she says, beneath the incident that brought them to the hospital is a history of trauma that has instilled negative emotions related to loss of control, loss of predictability and helplessness.
“Many are returning to communities where gun violence is, unfortunately, a reality. And that reality can be quite triggering,” she said. “And so a lot of work is done to validate that reality for them and also try to identify where they may have some degree of control within their own life.”
As mass shootings and gun-related deaths reach record levels in the US, an underlying trauma may be building up in the broader population that could be creating those same feelings of helplessness at the national level.
After the Uvalde school shooting, the study found, grief become a central point for a significantly larger share of the firearm-related conversations that were coming into the Crisis Text Line.
“People are reaching out so that they can establish a sense of stability and calm in their own lives,” said Dr. Shairi Turner, an internist and pediatrician who is also the chief health officer for Crisis Text Line.
Whether they are members of the community affected or just aware of a tragedy that happened across the country, immediate connection helps people find connection and address whatever emotions they may have, she said.
Public health interventions that target feelings of grief specifically may help reduce acute mental health crises that arise immediate after mass shootings, according to authors of the study.
Crisis Text Line primarily serves children and young adults, and the vast majority of messages that the mental health help line receives are from people who are younger than 25.
The CDC and others have called attention to the nation’s youth mental health crisis, and experts say that this group is particularly at risk to the negative impacts of a mass shooting.
“Under the age of 20 or 22, our brains are still developing, and we’re still formulating our understanding of the world,” Turner said. “Children and young adults start to create narratives around their own safety, the safety of their schools and homes and communities based on what they are witnessing. Tragedies can tend to make them think that the world is an unsafe place.”
But the adolescent brain is also very malleable, and kids are remarkably resilient, Brogan said.
“What I always stress is that bad things can happen to us, but they don’t need to define us,” she said. “It goes back to understanding that there are things out of our control, and we’re really spinning our wheels when we try to control them. What we do have control over is the way we respond to it.”
Seeking help by reaching out to a crisis hotline is one way to do that.
“It can take days to weeks to months to process tragedy,” Turner said. “Reach out for support, listen to each other’s feelings, and set boundaries around how much you’re taking in of current crises.”
by tyler | Apr 17, 2023 | CNN, health
Ninety-seven confirmed or probable cases of blastomycosis have been identified in Michigan’s Delta and Menominee counties, according to the local health department, and they are believed to be associated with a paper mill in the town of Escanaba.
One death has been associated with the outbreak: A contractor who worked at the Escanaba Billerud Paper Mill until recently passing away due to blastomycosis.
“We were saddened to hear this news. Our heartfelt sympathies and prayers go out to the family, friends and co-workers who have lost their loved one,” county health officer Michael Snyder said in a news release.
“Everyone at Billerud is deeply saddened by this news,” Brian Peterson, Escanaba Billerud Paper Mill’s vice president of operations, said. “Anyone who works at our facility is part of our team, and we are keeping this individual, their family, coworkers and friends in our thoughts and close to our hearts.”
Blastomycosis is caused by a fungus, Blastomyces, that lives in the environment, especially in moist soil and decomposing matter like wood or leaves, according to the US Centers for Disease Control and Prevention. It is predominantly found in the Midwest and the South, particularly around the Ohio and Mississippi rivers and the Great Lakes.
There are only one or two cases per 100,000 people each year in states where blastomycosis is a reportable condition, according to the CDC. One analysis found 1,216 deaths related to the illness from 1990 to 2010.
People can breathe in these microscopic fungal spores, and although most of them won’t get sick, some will develop symptoms like a fever or cough between three weeks and three months later, the CDC says. Other symptoms may include chest pain, trouble breathing, night sweats, fatigue, weight loss, and muscle or joint pain, according to Public Health Delta & Menominee Counties. In rare cases, the infection can spread outside the lungs to places like the skin, bones, brain and spinal cord.
Blastomycosis does not spread from person to person. It’s treated with antifungal medication that must be taken for a period ranging from six months to a year, depending on the severity of the illness and the person’s overall health.
Twenty-one of the cases linked to the mill have been confirmed by culture or microscope, and the other 76 are probable, meaning the person had symptoms of blastomycosis and a positive antigen or antibody test, the health department said. Twelve people have been hospitalized. All of the cases are either employees, contractors or visitors of the mill, officials said.
“Although the source of the infection has not been established, we continue to take this matter very seriously and are following recommendations from health and government officials and implementing numerous, proactive steps to protect the health and safety of our employees, contractors and visitors,” Peterson said in a statement from the health department.
On Thursday, the company announced the “temporary idling” of the Escanaba mill for additional cleaning.
by tyler | Apr 13, 2023 | CNN, health
Almost 90% of mpox-related deaths in the United States were among Black men, and nearly all had weakened immune systems, according to a new report from the US Centers for Disease Control and Prevention.
From May 2022 to March 2023, 30,235 people in the US were diagnosed with mpox, previously known as monkeypox. Thirty-eight deaths were linked to mpox; 36 of them were men, and 33 were Black men. The average age of those who died was 34.
Mpox spreads through close contact, and it can infect anyone. during the 2022 outbreak, infections were mostly among gay or bisexual men or other men who have sex with men.
Most people hospitalized for severe cases of mpox were Black men with uncontrolled HIV that may have caused a weakened immune system, according to the report, which was published Thursday.
Although most of the people who died got one or more prompt treatments and intensive care, nearly a quarter had delays of three to seven weeks from diagnosis to treatment, and two got no treatment for mpox.
“These findings highlight the importance of integrating prevention, testing, and treatment for multiple sexually associated infections,” the report says. “Equitable access to prevention, treatment, and engagement and retention in care for both mpox and HIV should be prioritized, particularly among Black men and other persons at risk for sexually associated infections.”
A separate CDC report published Thursday urged equity-based strategies, such as tailored messages and expanded vaccine services, to increase vaccination among racial and ethnic minorities.
Early in last year’s outbreak, vaccination rates were lower among Black and Hispanic men than among White men, but by August, rates among Black and Hispanic men exceeded those among White men. However, the vaccination-to-case ratio was lower among Black and Hispanic men, and vaccination rates were not proportionate to the “elevated incidence rates” among Black men, the report said, leaving vaccination needs unmet.
Between May and December 2022, 723,112 people in the US received the first of two doses of the mpox vaccine, and 89.7% of the doses were given to men.
“Continued implementation of equity-based vaccination strategies is needed to further increase vaccination rates and reduce the incidence of mpox among all racial and ethnic groups,” the report says.
More than 30,000 people have been diagnosed with mpox in the United States as of Wednesday, and 42 people have died, according to the CDC.
