April 15, 2022 Edition

Reminder: 2022 CHEAC Annual Meeting Workshop Abstract Proposals Due Monday

The CHEAC Annual Meeting provides networking and learning opportunities to local health department leadership and staff throughout California. This year’s conference will occur October 5-7 in Sonoma County with the theme of “Public Health Equity & Readiness Opportunity (HERO) – Achieving an Equitable and Resilient Workforce and Recovery.” The conference will once again include keynote sessions with guest speakers, as well as a myriad of workshops intended to stimulate best practice sharing and/or discussion around issues impacting public health.

CHEAC invites local health departments and key partners to submit workshop abstracts should you wish to host a workshop session.  Roughly 15 workshops will be hosted between 10:00 am and 4:00 pm on Wednesday, October 5 and Thursday, October 6.

Those interested in submitting an abstract can find more information on our website here. All abstract proposals are due to CHEAC via email by COB Monday, April 25, 2022.

Legislature Returns from Spring Recess on Monday

The California State Senate and Assembly are set to return to Sacramento from their 10-day Spring Recess on Monday, April 18. Lawmakers face a busy schedule ahead, including an April 29 deadline for policy committees to hear and report to fiscal committees bills with a fiscal impact introduced in their house of origin. A similar policy committee deadline for non-fiscal bills is set for May 6.

Just beyond the two upcoming deadlines, lawmakers will receive the Governor’s May Revise Budget in mid-May, representing modifications to budget investments proposed by the Governor based on the latest available tax revenues and economic conditions. Following the release of the May Revise, Budget Subcommittees will again meet to consider new and modified budget investments.

On Wednesday, after returning from a family vacation in South and Central America, Governor Gavin Newsom signed into law SB 349 (Umberg)requiring every treatment provider in California to adopt and provide a client bill of rights, ensuring that residents seeking substance use disorder treatment are provided basic rights and protections in a treatment setting that is safe and ethical. The measure also prohibits treatment providers from engaging in false and misleading advertising. Additional information is available here.

While Sacramento was quiet this week, a notable announcement was made by Senator Richard Pan regarding SB 871, which would prohibit public and private schools and childcare and daycare centers from unconditionally admitting a pupil unless they have been fully immunized against COVID-19. The measure would have also removed an exception for full immunization against hepatitis B as a condition of admission to public and private schools and removed personal belief exemptions for additional immunizations deemed appropriate by the California Department of Public Health (CDPH).

In a statement announcing that he would hold the measure, Senator Pan noted:

Unfortunately, COVID vaccination rates, particularly among children, are currently insufficient, and the state needs to focus its effort on increasing access to COVID vaccinations for children through physicians and other health providers who care for children and on education efforts to give families accurate information about the COVID vaccine. Until children’s access to COVID vaccination is greatly improved, I believe that a state-wide policy to require COVID vaccinations in schools is not the immediate priority, although it is an appropriate safety policy for many school districts in communities with good vaccine access.”

Senator Pan reiterated the importance of enacting policies to protect California children from COVID and indicated he and his colleagues in the Vaccine Work Group will continue their work during the legislative session.

SB 871 now becomes the second measure relative to COVID-19 vaccines from the Vaccine Work Group to be shelved during the legislative process. Just two weeks ago, Assembly Member Buffy Wicks announced her decision to put on pause AB 1993which would have required employers to require employees and independent contractors to be fully vaccinated against COVID-19.

Other measures from the Vaccine Work Group, including SB 866 by Senator Scott Wiener to authorize a minor 12 years of age and older to consent to a vaccine approved by the FDA and recommended by CDC ACIP, remain in the legislative process.

For a full update, the latest edition of the CHEAC Weekly Bill Chart is available here.

CDPH Delays COVID-19 Vaccine Requirement for Schools

Late Thursday, the California Department of Public Health (CDPH) issued a statement announcing a delay in the timeline for adding the COVID-19 vaccine to the list of vaccinations required to attend school in California. The move comes as the U.S. Food and Drug Administration (FDA) has not yet fully approved COVID-19 vaccines for individuals of all ages within the 7-12 grade span.

Recall, California announced last October that full approval by the FDA was a precondition to initiating the rulemaking process to add the COVID-19 vaccine to other vaccinations required for in-person school attendance, such as measles, mumps, and rubella, pursuant to the California Health and Safety Code. As such, and to ensure sufficient time for successful implementation of new vaccine requirements, California will not be initiating the regulatory process for a COVID-19 vaccine requirement for the 2022-23 school year. Any COVID-19 vaccine requirements would not take effect until after full FDA approval and no sooner than July 1, 2023.

CDPH’s announcement came just hours after a statement from Senator Richard Pan indicating he will be holding a legislative measure to require COVID-19 vaccination for in-person school attendance. CDPH notes that vaccines remain the most powerful weapon against hospitalization and serious illness due to COVID-19 and strongly encourages all eligible residents to receive their vaccine.

Upon full approval of the vaccine by the FDA for young children, CDPH will consider recommendations of the Advisory Committee on Immunization Practices of the U.S. Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics, and the American Academy of Family Physicians prior to implementing a school vaccine requirement.

Additional information is available here.

CDPH Announces $10 Million for KidsVaxGrant to Administer COVID-19 Vaccines for Youth

Today, the California Department of Public Health (CDPH) announced it is offering more than $10 million in grant funding through the newly launched KidsVaxGrant in an effort to expand COVID-19 vaccine access for youth throughout the state. The announcement of funding makes health care providers enrolled in the state’s Vaccine for Children (VFC) program eligible to receive funding of up to $25,000 per site to expand operating hours.

According to CDPH, since its inception in 1995, the VFC Program has played an essential role in vaccinating youth by equipping providers with vaccines for children at no additional cost to parents or guardians who may be unable to afford them. The state aims to increase access to the COVID-19 vaccine by recruiting additional providers into the California COVID-19 Vaccination Program and by helping providers expand operating hours to make vaccinations more convenient for families.

Newly enrolled VFC providers that are part of the COVID-19 vaccination program fcould be eligible for $10,000 in KidsVaxGrant funds per site to establish COVID-19 vaccination services. VFC providers already enrolled are also eligible to apply and could be awarded $15,000 grant per site. The deadline for applications is May 27, 2022.

To be considered, providers must expand their operating hours. Expanding the capacity of providers to open their doors beyond normal business hours allows for additional vaccination options for working families. Operating hours must be increased by a maximum of 15 hours outside of the standard operating hours during a 60-day period.

Additional information on the grant opportunity is available here.

CDPH, Community Partners Promote COVID-19 Vaccines for Youth

This week, the California Department of Public Health (CDPH) announced it will be partnering with key community-based organizations throughout the state to increase COVID-19 vaccination for youth ages five and up. From April 11 through June 5, CDPH will increase its ongoing youth vaccination efforts by pairing vaccination opportunities with fun activities for children and families.

The nine-week series of events will focus on brining free vaccinations and vaccine education for children and families to communities. Events will be held at after-school programs, libraries, local parks, and other recreational areas and involved pediatric medical providers.

Vaccines remain free for everyone and are the safest way to protect against the most serious outcomes from COVID-19, including severe illness, long COVID, hospitalization, and death.

Additional information is available here.

CDPH Issues Updated COVID-19 Guidance for Homeless Shelters

The California Department of Public Health (CDPH) this week issued updated guidance to local health departments, shelter operators, and other interested parties on COVID-19 infection control guidance for clients in congregate shelters, including shelters for persons experiencing homelessness. The latest updates to the guidance align isolation and quarantine recommendations with general public guidance, update physical distancing recommendations, and add a section on outbreaks.

The updated guidance is available here.

HHS Renews COVID-19 Public Health Emergency Declaration

On Wednesday, the U.S. Department of Health and Human Services (HHS) announced Secretary Xavier Becerra renewed the COVID-19 public health emergency declaration, effective April 16, 2022. The first U.S. public health emergency declaration for COVID-19 was issued in January 2020 as the global pandemic response began and has been renewed every 90 days in adherence to federal law.

According to HHS, renewing the public health emergency declaration ensures health care providers and state and territorial health departments have continued flexibilities to respond to the pandemic. HHS notes that it will provide states and territories with no less than 60 days’ notice prior to the termination of the public health emergency declaration for COVID-19.

Additional information from HHS is available here.

Feds Extend Face Mask Requirement for Transit, Announce Updates to Travel Health Notice System

The U.S. Transportation Security Administration (TSA) on Wednesday announced, at the recommendation of the U.S. Centers for Disease Control and Prevention (CDC), that it will extend its Security Directives and Emergency Amendment requiring the use of face masks on public transportation and transportation hubs for 15 days through May 3, 2022.

The move comes as the CDC continues to monitor the spread of the Omicron COVID-19 variant, especially the BA.2 subvariant that now comprises the overwhelming majority of U.S. cases. Since early April 2022, there have been increase in the seven-day moving average of COVID-19 cases in the U.S. According to the TSA, during the 15-day extension period, the CDC will assess the potential impact the recent rise of COVID-19 cases has on severe disease, including hospitalizations, deaths, and health system capacity. TSA will continue to closely coordinate with the CDC and communicate any changes to its requirement. Additional information from TSA is available here.

In addition to extending the mask requirement for transit, the CDC announced it will update its Travel Health Notice system for international designations. To help the public understand when the highest level of concern is most urgent, the CDC’s new system will reserve Level 4 travel health notices for special circumstances, such as rapidly escalating case trajectory or extremely high case counts, emergence of a new variant of concern, or health care infrastructure collapse. Levels 3, 2, and 1 will continue to be primarily by 28-day incidence or case counts. The new CDC level system will be effective on Monday, April 18. Additional information from the CDC is available here.

FDA Authorizes First COVID-19 Diagnostic Test Using Breath Samples

On Thursday, the U.S. Food and Drug Administration (FDA) issued an emergency use authorization (EUA) for the first COVID-19 diagnostic test that detects chemical compounds in breath samples associated with a SARS-CoV-2 infection. The test can be performed in environments where the patient specimen is both collected and analyzed, such as doctor offices, hospitals, and mobile testing sites, using an instrument about the size of a piece of carry-on luggage.

The test is performed by a qualified, trained operator under the supervision of a health care provider licensed or authorized by state law to prescribe tests. The test can provide results in less than three minutes.

The performance of the InspectIR COVID-19 Breathalyzer was validated in a large study of 2,409 individuals, including those with and without symptoms. In the study, the test was shown to have 91.2 percent sensitivity and 99.3 percent specificity. The study also showed that in a population with only 4.2 percent of individuals who are positive for the virus, the test had a negative predictive value of 99.6 percent. The test performed with similar sensitivity in a follow-up clinical study focused on the omicron variant.

When the InspectIR COVID-19 Breathalyzer detects the presence of volatile organic compounds (VOCs) associated with SARS-CoV-2, a presumptive positive test result is returned and should be confirmed with a molecular test. Negative results should be considered in the context of a patient’s recent exposures, history, and the presence of clinical signs and symptoms associated with COVID-19.

InspectIR anticipates producing approximately 100 instruments per week, which can each be used to evaluate approximately 160 samples per day. At this level of production, testing capacity using the InspectIR COVID-19 Breathalyzer is expected to increase by approximately 64,000 samples per month.

Additional information is available here.

Latest CDC Data Indicates Increases in STDs During First Year of COVID-19 Pandemic

According to data released this week from the U.S. Centers for Disease Control and Prevention (CDC), reported cases of sexually transmitted diseases (STDs) in the U.S. decreased during the early months of the COVID-19 pandemic in 2020, but most resurged by the end of that year. Ultimately, reported cases of gonorrhea, syphilis, and congenital syphilis surpassed 2019 levels, while chlamydia declined. The newly released data provide the clearest picture yet of COVID-19’s impact on the U.S. STD epidemic.

The 2020 STD Surveillance Report found that at the end of 2020:

  • Reported cases of gonorrhea and primary and secondary syphilis were up 10 percent and 7 percent, respectively, compared to 2019
  • Syphilis among newborns (i.e., congenital syphilis) also increased, with reported cases up nearly 15 percent from 2019 and 235 percent from 2016; early data indicate primary and secondary syphilis and congenital syphilis cases continued to increase in 2021, as well
  • Reported cases of chlamydia declined 13 percent from 2019

Chlamydia historically accounts for the largest proportion of reported STDs in the U.S. The decline in reported chlamydia cases is likely due to decreased STD screening and underdiagnosis during the pandemic rather than a true reduction in new infections. This also contributed to an overall decrease in the number of reported STDs in 2020, from 2.5 million reported cases in 2019 to 2.4 million cases in 2020.

According to the CDC, several factors likely contributed to the initial decline in reported STD cases during the first part of 2020, including:

  • Reduced frequency of in-person health care services as routine visits decreased, resulting in less-frequent STD screening
  • Diversion of public health staff from STD work to respond to the COVID-19 pandemic
  • STD test and laboratory supply shortages
  • Lapses in health insurance coverage due to unemployment
  • Telemedicine practices that led to some infections not being captured in national data

While STDs are increasing across many groups, the 2020 STD data indicate that some racial and ethnic minority groups, gay and bisexual men, and youth and young adults continue to experience higher rates of STDs. This trend shows that longstanding factors, such as lack of access to regular medical care, discrimination, and stigma, continue to be barriers to quality sexual health care services for all individuals in need. The CDC notes efforts must be prioritized and focused to regain lost group against STDs.

Additional information is available here.

Biden-Harris Administration Releases Over 90 Agency Equity Action Plans

On Thursday, the Biden-Harris Administration released Equity Action Plans from more than 90 federal agencies, including all Cabinet-level agencies, that identify more than 300 concrete strategies and commitments to address systemic barriers in policies and programs that disproportionately impact underserved communities. The equity plans are pursuant to Executive Order 13985 issued by President Joseph R. Biden, Jr. on his first day in office, directing the whole of federal government to advance an equity and racial justice agenda.

Agencies throughout the federal government have detailed actions to expand federal investment and support in communities that have been historically marginalized, including communities of color, Tribal communities, rural communities, and more. Relevant new agency commitments include:

  • The Department of Health and Human Services is increasing outreach to communities of color to encourage enrollment in free and low-cost health care and is addressing the maternal mortality crisis that disproportionately impacts Black and Native families, including by working with states to extend postpartum coverage in Medicaid and the Children’s Health Insurance Program (CHIP).
  • The U.S. Department of Agriculture is expanding equitable access to nutrition assistance programs and strengthening gender equity by implementing a national awareness campaign and expanding implementation of online ordering in the Women, Infants, and Children (WIC) nutrition program.
  • The Department of Housing and Urban Development is working to eliminate the racial gap in homeownership, address disproportionate rates of homelessness in underserved communities, and reduce bias in home appraisals through the interagency Task Force on Property Appraisal and Valuation Equity.
  • The Environmental Protection Agency is developing a comprehensive framework for evaluating the cumulative impacts of pollution on underserved, low-income communities. The EPA will also reinvigorate civil rights enforcement to ensure environmental justice is at the core of the agency’s mission.
  • The Department of Veterans Affairs is advancing health equity by further addressing the social and economic determinants of health for underserved veterans and launching a Data for Equity Strategy to synchronize data on health care, disability benefits, and other services to identify and address gaps.
  • The Federal Emergency Management Agency is closing the flood insurance gap to increase financial resilience of flood-prone, low-income households and promoting equitable outcomes for disaster survivors by increasing eligibility for and access to assistance programs for underserved and vulnerable applicants.
  • The Department of Commerce is investing nearly $50 billion in broadband infrastructure deployment, affordability, and digital inclusion efforts to help close the digital divide, particularly for rural and Tribal communities.
  • The Department of Energy is ensuring equitable access to weatherization assistance programs so that low-income households have increased access to energy security.

Additional information on the Biden-Harris Administration’s agency equity plans is available here. Further information on HHS’ equity action plan is available here.

Biden-Harris Administration Announces New Actions on Medical Debt

This week, the Biden-Harris Administration announced a series of new actions to protect consumers and lessen the burden of medical debt on American families. According to the Administration, one-in-three adults in the U.S. have medical debt with implications on financial, physical, and mental health.

As part of the Administration’s efforts to strengthen access to affordable, quality health care coverage, Vice President Kamala Harris unveiled reforms across four areas to address the burden of medical debt. These actions include:

  • Holding Providers and Collectors Accountable – Health and Human Services (HHS) Secretary Xavier Becerra has directed HHS to evaluate how providers’ billing practices impact access and affordability of care and the accrual of medical debt. HHS will request data from more than 2,000 providers on medical bill collection practices, lawsuits against patients, financial assistance, financial product offerings, and third-party contracting or debt buying practices. For the first time, HHS will weigh this information in grantmaking decisions, publish topline data and policy recommendations for the public, and share potential violations with relevant enforcement agencies. Separately, the Consumer Financial Protection Bureau (CFPB) will investigate credit reporting companies and debt collectors that violate patient and family rights.
  • Improving Government Underwriting Practices – The Biden-Harris Administration is providing guidance to all federal agencies to eliminate medical debt as a factor for underwriting in credit programs whenever possible and consistent with the law. Americans with medical debt can apply for a variety of public services and benefits, including from the U.S. Department of Agriculture, Department of Veterans Affairs, and the Small Business Administration, without fear that medical debt will prevent them from accessing benefits.
  • Supporting Veterans in Financial Hardship – The Department of Veterans Affairs has cancelled or refunded approximately $1 billion in copayments to over 1.5 million veterans since the beginning of the pandemic. The VA will additionally be streamlining its processes for medical debt relief and cease reporting unfavorable debt, including medical debt, to consumer reporting agencies.
  • Helping Consumers Know Their Rights – The CFPB will ramp up its consumer education tools aimed at helping families navigate the medical billing landscape. A wide range of tools are already available from the CFPB, and additional tools and information will be made available.

Additional information from the Biden-Harris Administration is available here.

HHS Announces $226.5 Million Community Health Worker Training Program

The U.S. Department of Health and Human Services (HHS), through its Health Resources and Services Administration (HRSA), this week announced the availability of $226.5 million in American Rescue Plan Act (ARPA) funding to launch the Community Health Worker Training Program. The new program aims to increase the number of community health workers who play a critical role in connecting people to care, including COVID-19 case, mental health and substance use disorder prevention, treatment and recovery services, chronic disease care, and other important health services.

The Community Health Worker Training Program is a new multiyear program focused n education and on-the-job training to build the pipeline of public health workers. The effort will support training and apprenticeship programs to help more people enter the health workforce and serve the critical role of trusted messengers to connect people to care and support, help patients follow-up on their provider’s recommendations, and focus on preventive and protective factors that can improve health and well-being.

Through this program, HRSA plans to train 13,000 community health workers. Applications for the program are due June 14, 2022.

Additional information is available here.

CMS Unveils Actions to Reduce Maternal Morbidity and Mortality

The U.S. Centers for Medicare and Medicaid Services (CMS) this week, in observance of Black Maternal Health Week, announced a series of actions aimed at reducing maternal morbidity and mortality in the U.S. CMS released additional details about its proposed “Birthing-Friendly” hospital designation intended to drive improvements in maternal health outcomes.

According to CMS, the new designation would assist consumers in selecting hospitals that have demonstrated a commitment to maternal health and the delivery of high-quality maternity care. Initially, the designation would be based on a hospital’s attestation to the Hospital Inpatient Quality Reporting (IQR) Program’s Maternal Morbidity Structural Measure, which CMS identifies as a first step in capturing hospitals’ commitments to the quality and safety of maternity care they deliver. The reporting period began in October 2021, and data will be submitted by hospitals for the first time in May 2022. CMS will post the Maternal Morbidity Structural Measure data for October to December 2021 in fall 2022, and initial results for the hospital designation will be posted beginning fall 2023. In the future, CMS intends to expand criteria for which the designation would be awarded.

In addition to the “Birthing-Friendly” hospital designation, CMS announced additional states have begun offering Medicaid and Children’s Health Insurance Program (CHIP) coverage for 12 months after pregnancy. CMS is also working with another 11 states and the District of Columbia, including California, to extend postpartum coverage.

Additional information is available here.

Feds Propose Rule to Promote Safety and Quality in Nursing Homes

On Monday, the U.S. Centers for Medicare and Medicaid Services (CMS) issued its FY 2023 Skilled Nursing Facilities Prospective Payment System (SNF PPS) proposed rule seeking public feedback on how staffing in nursing homes and health equity improvements could lead to better health outcomes. According to CMS, the proposed rule builds upon the Biden-Harris Administration’s commitment to advance health equity, drive high-quality person-centered care, and promote sustainability of its programs.

The SNF PPS providers Medicare payments to over 15,000 nursing homes serving more than 1.5 million people. Through its proposed rule, CMS is continuing to transform the SNF payment system to a more patient-centered model by making payments based on the needs of the whole patient rather than focusing on the volume of certain services the patient receives.

In the proposed rule, CMS is soliciting input to help the agency establish minimum staffing requirements that nursing homes will need to meet to ensure all residents are provided safe, high-quality care, and nursing home workers have the support they need. The input will be used in conjunction with a new research study being conducted by CMS to determine the optimal level and type of nursing home staffing needs. The agency intends to issue proposed rules on a minimum staffing level requirement for nursing homes within one year.

Additionally, CMS is requesting stakeholder input on a measure to examine staff turnover levels in nursing homes for possible inclusion in CMS’ SNF Value-Based Purchasing (VBP) Program, which rewards facilities with incentive payments based on the quality of care they provide to people with Medicare. The proposed rule also considers the adoption of three new measures into the SNF VBP Program, including infection prevention and management, total nursing hours per resident day, and successful community discharge.

Last, CMS is proposing a 3.9 percent, or $1.4 billion, update to payment rates for nursing homes and a proposed adjustment to payment rates as the result of the transition to SNF payment case-mix classification model.

Additional information from CMS is available here.

CDPH to Host Healthy Aging California Convening on June 24

The California Department of Public Health Healthy Aging Initiative has announced it will host a virtual convening on Thursday, June 24, 2022. The event will feature presentations and a keynote address by Dr. Reginald Tucker-Seely and Shonta Chambers focused on aging and health equity, measurement, and defining success.

The meeting will bring together state and local aging partners to identify health equity strategies that address older adult health, including professionals from local public health programs, community-based organizations, area agencies on aging, or programs that address issues impacting older adults and/or their caregivers.

An invitation and registration link will be forthcoming. Questions about the convening can be directed to healthyaging@cdph.ca.gov.

UCLA CHPR Issues Policy Paper on Health, Housing, and Homelessness

The University of California, Los Angeles (UCLA) Center for Health Policy Research (CHPR) recently published a policy paper entitled, “Opening Doors for All: Improving Health in Housing and Homelessness.” The policy paper follows a 2021 virtual event convened by UCLA CHPR focused on the intersection of health and homelessness, emphasizing lessons learned to inform California decision-makers.

UCLA CHPR notes California’s current homelessness crisis is unprecedented as over 160,000 persons experienced homelessness on any given day in early 2020, representing a 40 percent increase since 2015. Effects on individuals experiencing homelessness and housing insecurity and the community’s public health have been profound, according to CHPR, including recent outbreaks of hepatitis A and typhus in communities experiencing homelessness.

Key takeaway findings from the UCLA CHPR policy paper include:

  • Good health is not possible without housing – Lack of housing leads to deterioration of mental and physical health due to high stress, exposure to elements, inadequate sanitation, lack of access to hygiene supplies, and poor nutrition.
  • Homelessness is often the result of structural issues rather than individual characteristics – The primary driver of homelessness in California is the lack of affordable housing. Other drivers of homelessness including historical discrimination and structural racism.
  • To address the effects of structural racism, any new project should begin with a racial equity analysis –An analysis should assess potential effect on different racial and ethnic groups to reduce inequities and avoid unintended negative consequences that affect marginalized groups.
  • Persons experiencing homelessness need privacy, autonomy, and safety – Small single cabins (tiny homes) where individuals can secure their belongings, get sleep without interruption, bring a spouse, partner, children, or pets, and be linked with services and permanent housing is a better option than traditional congregate shelter.
  • Permanent supportive housing should be the goal – This model provides long-term housing coupled with intensive case management services linking individuals with medical, psychological, and other important social services.
  • Programs to assist persons experiencing homelessness funded by federal, state, and local governments have varied and inconsistent requirements for entry – Programs may exclusively target veterans, mothers with children, or persons with disabilities. While well-intended, this approach leads to “tweezing” the homeless population, extracting individuals from their community support systems and neglecting some chronically unhoused individuals.
  • Private funded initiatives have more flexibility than publicly funded programs, which are also sometimes limited – Due to fewer rules and regulations, private aid may result in more innovation and experimentation than possible in public programs.
  • Importantly, policy and program development should always involve persons with lived experience – Individuals’ historical exclusive from these discussions has resulted in missed opportunities and wasted resources.

The full UCLA CHPR report details structural causes of homelessness, intersections of housing security and health, homelessness prevention, and supportive services, among others.

The full report is available here.