Last week, without any real pomp, I brewed a couple beers for that thing in the desert. Turns out they were my 100th and 101st batches of homebrew. Yay! They’re both finished – or at least they’d better be, since I’m kegging them today. I had to use Wyeast 1056 (courtesy of DBC) for the […]
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Compare viagra cialis levitra side effectsCompare viagra cialis levitra side effectsCompare viagra cialis levitra side effectsCompare viagra cialis levitra side effectsRecent Activity for SBDs written for eligible drugs approved after September 1, 2012 will be updated to include post-authorization information. This information will be compiled in a Post-Authorization Activity Table (PAAT). The PAAT will include brief cheapest levitra summaries of activities such as submissions for new uses of the product, and whether Health Canada's decisions were negative or positive. PAATs will be updated regularly with post-authorization activity throughout the product's life cycle. Post-Authorization Activity Table (PAAT) for Post-Authorization Activity Table (PAAT) RowNum Activity/submission type, control number Date submitted Decision and date Summary of activities Summary Basis of Decision (SBD) for Date SBD issued. The following information relates to the cheapest levitra new drug submission for. Drug Identification Number (DIN). 1 What was approved?. 2 Why was approved? cheapest levitra. 3 What steps led to the approval of ?. Compare viagra cialis levitra side effects
Enrolling in an MSP - compare viagra cialis levitra side effects Automatic Enrollment &. Applications for People who Have Medicare What is Application Process?. 6. Enrolling in an MSP for People age 65+ who compare viagra cialis levitra side effects Do Not Qualify for Free Medicare Part A - the "Part A Buy-In Program" 7. What Happens After MSP Approved - How Part B Premium is Paid 8 Special Rules for QMBs - How Medicare Cost-Sharing Works 1. NO ASSET LIMIT!. Since April 1, 2008, none of the three MSP programs have resource limits in New York -- which means many Medicare beneficiaries who might compare viagra cialis levitra side effects not qualify for Medicaid because of excess resources can qualify for an MSP. 1.A. SUMMARY CHART OF MSP BENEFITS QMB SLIMB QI-1 Eligibility ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2021) Single Couple Single Couple Single Couple $1,094 $1,472 $1,308 $1,762 $1,469 $1,980 Federal Poverty Level 100% FPL 100 â 120% FPL 120 â 135% FPL Benefits Pays Monthly Part B premium?. YES, compare viagra cialis levitra side effects and also Part A premium if did not have enough work quarters and meets citizenship requirement. See âPart A Buy-Inâ YES YES Pays Part A &. B deductibles &. Co-insurance YES compare viagra cialis levitra side effects - with limitations NO NO Retroactive to Filing of Application?. Yes - Benefits begin the month after the month of the MSP application. 18 NYCRR §360-7.8(b)(5) Yes â Retroactive to 3rd month before month of application, if eligible in prior months Yes â may be retroactive to 3rd month before month of applica-tion, but only within the current calendar year. (No retro for January compare viagra cialis levitra side effects application). See GIS 07 MA 027. Can Enroll in MSP and Medicaid at Same Time?. YES YES compare viagra cialis levitra side effects NO!. Must choose between QI-1 and Medicaid. Cannot have both, not even Medicaid with a spend-down. 2 compare viagra cialis levitra side effects. INCOME LIMITS and RULES Each of the three MSP programs has different income eligibility requirements and provides different benefits. The income limits are tied to the Federal Poverty Level (FPL). 2021 FPL levels were compare viagra cialis levitra side effects released by NYS DOH in GIS 21 MA/06 - 2021 Federal Poverty Levels Attachment II NOTE. There is usually a lag in time of several weeks, or even months, from January 1st of each year until the new FPLs are release, and then before the new MSP income limits are officially implemented. During this lag period, local Medicaid offices should continue to use the previous year's FPLs AND count the person's Social Security benefit amount from the previous year - do NOT factor in the Social Security COLA (cost of living adjustment). Once the updated guidelines are released, districts will use the new FPLs and go compare viagra cialis levitra side effects ahead and factor in any COLA. See 2021 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples. N.Y. Soc. Serv. L. 367-a(3)(c)(2), NYS DOH 2000-ADM-7, 89-ADM-7 p.7. Gross income is counted, although there are certain types of income that are disregarded. The most common income disregards, also known as deductions, include. (a) The first $20 of your &. Your spouse's monthly income, earned or unearned ($20 per couple max). (b) SSI EARNED INCOME DISREGARDS. * The first $65 of monthly wages of you and your spouse, * One-half of the remaining monthly wages (after the $65 is deducted). * Other work incentives including PASS plans, impairment related work expenses (IRWEs), blind work expenses, etc. For information on these deductions, see The Medicaid Buy-In for Working People with Disabilities (MBI-WPD) and other guides in this article -- though written for the MBI-WPD, the work incentives apply to all Medicaid programs, including MSP, for people age 65+, disabled or blind. (c) monthly cost of any health insurance premiums but NOT the Part B premium, since Medicaid will now pay this premium (may deduct Medigap supplemental policies, vision, dental, or long term care insurance premiums, and the Part D premium but only to the extent the premium exceeds the Extra Help benchmark amount) (d) Food stamps not counted. You can get a more comprehensive listing of the SSI-related income disregards on the Medicaid income disregards chart. As for all benefit programs based on financial need, it is usually advantageous to be considered a larger household, because the income limit is higher. The above chart shows that Households of TWO have a higher income limit than households of ONE. The MSP programs use the same rules as Medicaid does for the Disabled, Aged and Blind (DAB) which are borrowed from the SSI program for Medicaid recipients in the âSSI-related category.â Under these rules, a household can be only ONE or TWO. 18 NYCRR 360-4.2. See DAB Household Size Chart. Married persons can sometimes be ONE or TWO depending on arcane rules, which can force a Medicare beneficiary to be limited to the income limit for ONE person even though his spouse who is under 65 and not disabled has no income, and is supported by the client applying for an MSP. EXAMPLE. Bob's Social Security is $1300/month. He is age 67 and has Medicare. His wife, Nancy, is age 62 and is not disabled and does not work. Under the old rule, Bob was not eligible for an MSP because his income was above the Income limit for One, even though it was well under the Couple limit. In 2010, NYS DOH modified its rules so that all married individuals will be considered a household size of TWO. DOH GIS 10 MA 10 Medicare Savings Program Household Size, June 4, 2010. This rule for household size is an exception to the rule applying SSI budgeting rules to the MSP program. Under these rules, Bob is now eligible for an MSP. When is One Better than Two?. Of course, there may be couples where the non-applying spouse's income is too high, and disqualifies the applying spouse from an MSP. In such cases, "spousal refusal" may be used SSL 366.3(a). (Link is to NYC HRA form, can be adapted for other counties). In NYC, if you have a Medicaid case with HRA, instead of submitting an MSP application, you only need to complete and submit MAP-751W (check off "Medicare Savings Program Evaluation") and fax to (917) 639-0837. (The MAP-751W is also posted in languages other than English in this link. (Updated 4/14/2021.)) 3. The Three Medicare Savings Programs - what are they and how are they different?. 1. Qualified Medicare Beneficiary (QMB). The QMB program provides the most comprehensive benefits. Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations. Part B premiums, Part A premiums, if there are any, and any and all deductibles and co-insurance. QMB coverage is not retroactive. The programâs benefits will begin the month after the month in which your client is found eligible. ** See special rules about cost-sharing for QMBs below - updated with new CMS directive issued January 2012 ** See NYC HRA QMB Recertification form ** Even if you do not have Part A automatically, because you did not have enough wages, you may be able to enroll in the Part A Buy-In Program, in which people eligible for QMB who do not otherwise have Medicare Part A may enroll, with Medicaid paying the Part A premium (Materials by the Medicare Rights Center). 2. Specifiedl Low-Income Medicare Beneficiary (SLMB). For those with incomes between 100% and 120% FPL, the SLMB program will cover Part B premiums only. SLMB is retroactive, however, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. 3. Qualified Individual (QI-1). For those with incomes between 120% and 135% FPL, and not receiving Medicaid, the QI-1 program will cover Medicare Part B premiums only. QI-1 is also retroactive, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. However, QI-1 retroactive coverage can only be provided within the current calendar year. (GIS 07 MA 027) So if you apply in January, you get no retroactive coverage. Q-I-1 recipients would be eligible for Medicaid with a spend-down, but if they want the Part B premium paid, they must choose between enrolling in QI-1 or Medicaid. They cannot be in both. It is their choice. DOH MRG p. 19. In contrast, one may receive Medicaid and either QMB or SLIMB. 4. Four Special Benefits of MSPs (in addition to NO ASSET TEST). Benefit 1. Back Door to Medicare Part D "Extra Help" or Low Income Subsidy -- All MSP recipients are automatically enrolled in Extra Help, the subsidy that makes Part D affordable. They have no Part D deductible or doughnut hole, the premium is subsidized, and they pay very low copayments. Once they are enrolled in Extra Help by virtue of enrollment in an MSP, they retain Extra Help for the entire calendar year, even if they lose MSP eligibility during that year. The "Full" Extra Help subsidy has the same income limit as QI-1 - 135% FPL. However, many people may be eligible for QI-1 but not Extra Help because QI-1 and the other MSPs have no asset limit. People applying to the Social Security Administration for Extra Help might be rejected for this reason. Recent (2009-10) changes to federal law called "MIPPA" requires the Social Security Administration (SSA) to share eligibility data with NYSDOH on all persons who apply for Extra Help/ the Low Income Subsidy. Data sent to NYSDOH from SSA will enable NYSDOH to open MSP cases on many clients. The effective date of the MSP application must be the same date as the Extra Help application. Signatures will not be required from clients. In cases where the SSA data is incomplete, NYSDOH will forward what is collected to the local district for completion of an MSP application. The State implementing procedures are in DOH 2010 ADM-03. Also see CMS "Dear State Medicaid Director" letter dated Feb. 18, 2010 Benefit 2. MSPs Automatically Waive Late Enrollment Penalties for Part B Generally one must enroll in Part B within the strict enrollment periods after turning age 65 or after 24 months of Social Security Disability. An exception is if you or your spouse are still working and insured under an employer sponsored group health plan, or if you have End Stage Renal Disease, and other factors, see this from Medicare Rights Center. If you fail to enroll within those short periods, you might have to pay higher Part B premiums for life as a Late Enrollment Penalty (LEP). Also, you may only enroll in Part B during the Annual Enrollment Period from January 1 - March 31st each year, with Part B not effective until the following July. Enrollment in an MSP automatically eliminates such penalties... For life.. Even if one later ceases to be eligible for the MSP. AND enrolling in an MSP will automatically result in becoming enrolled in Part B if you didn't already have it and only had Part A. See Medicare Rights Center flyer. Benefit 3. No Medicaid Lien on Estate to Recover MSP Benefits Paid Generally speaking, states may place liens on the Estates of deceased Medicaid recipients to recover the cost of Medicaid services that were provided after the recipient reached the age of 55. Since 2002, states have not been allowed to recover the cost of Medicare premiums paid under MSPs. In 2010, Congress expanded protection for MSP benefits. Beginning on January 1, 2010, states may not place liens on the Estates of Medicaid recipients who died after January 1, 2010 to recover costs for co-insurance paid under the QMB MSP program for services rendered after January 1, 2010. The federal government made this change in order to eliminate barriers to enrollment in MSPs. See NYS DOH GIS 10-MA-008 - Medicare Savings Program Changes in Estate Recovery The GIS clarifies that a client who receives both QMB and full Medicaid is exempt from estate recovery for these Medicare cost-sharing expenses. Benefit 4. SNAP (Food Stamp) benefits not reduced despite increased income from MSP - at least temporarily Many people receive both SNAP (Food Stamp) benefits and MSP. Income for purposes of SNAP/Food Stamps is reduced by a deduction for medical expenses, which includes payment of the Part B premium. Since approval for an MSP means that the client no longer pays for the Part B premium, his/her SNAP/Food Stamps income goes up, so their SNAP/Food Stamps go down. Here are some protections. Do these individuals have to report to their SNAP worker that their out of pocket medical costs have decreased?. And will the household see a reduction in their SNAP benefits, since the decrease in medical expenses will increase their countable income?. The good news is that MSP households do NOT have to report the decrease in their medical expenses to the SNAP/Food Stamp office until their next SNAP/Food Stamp recertification. Even if they do report the change, or the local district finds out because the same worker is handling both the MSP and SNAP case, there should be no reduction in the householdâs benefit until the next recertification. New Yorkâs SNAP policy per administrative directive 02 ADM-07 is to âfreezeâ the deduction for medical expenses between certification periods. Increases in medical expenses can be budgeted at the householdâs request, but NYS never decreases a householdâs medical expense deduction until the next recertification. Most elderly and disabled households have 24-month SNAP certification periods. Eventually, though, the decrease in medical expenses will need to be reported when the household recertifies for SNAP, and the household should expect to see a decrease in their monthly SNAP benefit. It is really important to stress that the loss in SNAP benefits is NOT dollar for dollar. A $100 decrease in out of pocket medical expenses would translate roughly into a $30 drop in SNAP benefits. See more info on SNAP/Food Stamp benefits by the Empire Justice Center, and on the State OTDA website. Some clients will be automatically enrolled in an MSP by the New York State Department of Health (NYSDOH) shortly after attaining eligibility for Medicare. Others need to apply. The 2010 "MIPPA" law introduced some improvements to increase MSP enrollment. See 3rd bullet below. Also, some people who had Medicaid through the Affordable Care Act before they became eligible for Medicare have special procedures to have their Part B premium paid before they enroll in an MSP. See below. WHO IS AUTOMATICALLY ENROLLED IN AN MSP. Clients receiving even $1.00 of Supplemental Security Income should be automatically enrolled into a Medicare Savings Program (most often QMB) under New York Stateâs Medicare Savings Program Buy-in Agreement with the federal government once they become eligible for Medicare. They should receive Medicare Parts A and B. Clients who are already eligible for Medicare when they apply for Medicaid should be automatically assessed for MSP eligibility when they apply for Medicaid. (NYS DOH 2000-ADM-7 and GIS 05 MA 033). Clients who apply to the Social Security Administration for Extra Help, but are rejected, should be contacted &. Enrolled into an MSP by the Medicaid program directly under new MIPPA procedures that require data sharing. Strategy TIP. Since the Extra Help filing date will be assigned to the MSP application, it may help the client to apply online for Extra Help with the SSA, even knowing that this application will be rejected because of excess assets or other reason. SSA processes these requests quickly, and it will be routed to the State for MSP processing. Since MSP applications take a while, at least the filing date will be retroactive. Note. The above strategy does not work as well for QMB, because the effective date of QMB is the month after the month of application. As a result, the retroactive effective date of Extra Help will be the month after the failed Extra Help application for those with QMB rather than SLMB/QI-1. Applying for MSP Directly with Local Medicaid Program. Those who do not have Medicaid already must apply for an MSP through their local social services district. (See more in Section D. Below re those who already have Medicaid through the Affordable Care Act before they became eligible for Medicare. If you are applying for MSP only (not also Medicaid), you can use the simplified MSP application form (theDOH-4328(Rev. 8/2017-- English) (2017 Spanish version not yet available). Either application form can be mailed in -- there is no interview requirement anymore for MSP or Medicaid. See 10 ADM-04. Applicants will need to submit proof of income, a copy of their Medicare card (front &. Back), and proof of residency/address. See the application form for other instructions. One who is only eligible for QI-1 because of higher income may ONLY apply for an MSP, not for Medicaid too. One may not receive Medicaid and QI-1 at the same time. If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for SLIMB or QMB instead of QI-1. Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person. Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare Those who, prior to becoming enrolled in Medicare, had Medicaid through Affordable Care Act are eligible to have their Part B premiums paid by Medicaid (or the cost reimbursed) during the time it takes for them to transition to a Medicare Savings Program. In 2018, DOH clarified that reimbursement of the Part B premium will be made regardless of whether the individual is still in a Medicaid managed care (MMC) plan. GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare ( PDF) provides, "Due to efforts to transition individuals who gain Medicare eligibility and who require LTSS, individuals may not be disenrolled from MMC upon receipt of Medicare. To facilitate the transition and not disadvantage the recipient, the Medicaid program is approving reimbursement of Part B premiums for enrollees in MMC." The procedure for getting the Part B premium paid is different for those whose Medicaid was administered by the NYS of Health Exchange (Marketplace), as opposed to their local social services district. The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability. Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification. NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods. IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare. IF they obtain Medicare because they turn age 65, they will receive a letter from their local district asking them to "renew" Medicaid through their local district. See 2014 LCM-02. Now, their Medicaid income limit will be lower than the MAGI limits ($842/ mo reduced from $1387/month) and they now will have an asset test. For this reason, some individuals may lose full Medicaid eligibility when they begin receiving Medicare. People over age 65 who obtain Medicare do NOT keep "Marketplace Medicaid" for 12 months (continuous eligibility) See GIS 15 MA/022 - Continuous Coverage for MAGI Individuals. Since MSP has NO ASSET limit. Some individuals may be enrolled in the MSP even if they lose Medicaid, or if they now have a Medicaid spend-down. If a Medicare/Medicaid recipient reports income that exceeds the Medicaid level, districts must evaluate the personâs eligibility for MSP. 08 OHIP/ADM-4 âIf you became eligible for Medicare based on disability and you are UNDER AGE 65, you are entitled to keep MAGI Medicaid for 12 months from the month it was last authorized, even if you now have income normally above the MAGI limit, and even though you now have Medicare. This is called Continuous Eligibility. EXAMPLE. Sam, age 60, was last authorized for Medicaid on the Marketplace in June 2016. He became enrolled in Medicare based on disability in August 2016, and started receiving Social Security in the same month (he won a hearing approving Social Security disability benefits retroactively, after first being denied disability). Even though his Social Security is too high, he can keep Medicaid for 12 months beginning June 2016. Sam has to pay for his Part B premium - it is deducted from his Social Security check. He may call the Marketplace and request a refund. This will continue until the end of his 12 months of continues MAGI Medicaid eligibility. He will be reimbursed regardless of whether he is in a Medicaid managed care plan. See GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare (PDF) When that ends, he will renew Medicaid and apply for MSP with his local district. Individuals who are eligible for Medicaid with a spenddown can opt whether or not to receive MSP. (Medicaid Reference Guide (MRG) p. 19). Obtaining MSP may increase their spenddown. MIPPA - Outreach by Social Security Administration -- Under MIPPA, the SSA sends a form letter to people who may be eligible for a Medicare Savings Program or Extra Help (Low Income Subsidy - LIS) that they may apply. The letters are. · Beneficiary has Extra Help (LIS), but not MSP · Beneficiary has no Extra Help (LIS) or MSP 6. Enrolling in MSP for People Age 65+ who do Not have Free Medicare Part A - the "Part A Buy-In Program" Seniors WITHOUT MEDICARE PART A or B -- They may be able to enroll in the Part A Buy-In program, in which people eligible for QMB who are age 65+ who do not otherwise have Medicare Part A may enroll in Part A, with Medicaid paying the Part A premium. See Step-by-Step Guide by the Medicare Rights Center). This guide explains the various steps in "conditionally enrolling" in Part A at the SSA office, which must be done before applying for QMB at the Medicaid office, which will then pay the Part A premium. See also GIS 04 MA/013. In June, 2018, the SSA revised the POMS manual procedures for the Part A Buy-In to to address inconsistencies and confusion in SSA field offices and help smooth the path for QMB enrollment. The procedures are in the POMS Section HI 00801.140 "Premium-Free Part A Enrollments for Qualified Medicare BenefiIaries." It includes important clarifications, such as. SSA Field Offices should explain the QMB program and conditional enrollment process if an individual lacks premium-free Part A and appears to meet QMB requirements. SSA field offices can add notes to the âRemarksâ section of the application and provide a screen shot to the individual so the individual can provide proof of conditional Part A enrollment when applying for QMB through the state Medicaid program. Beneficiaries are allowed to complete the conditional application even if they owe Medicare premiums. In Part A Buy-in states like NYS, SSA should process conditional applications on a rolling basis (without regard to enrollment periods), even if the application coincides with the General Enrollment Period. (The General Enrollment Period is from Jan 1 to March 31st every year, in which anyone eligible may enroll in Medicare Part A or Part B to be effective on July 1st). 7. What happens after the MSP approval - How is Part B premium paid For all three MSP programs, the Medicaid program is now responsible for paying the Part B premiums, even though the MSP enrollee is not necessarily a recipient of Medicaid. The local Medicaid office (DSS/HRA) transmits the MSP approval to the NYS Department of Health â that information gets shared w/ SSA and CMS SSA stops deducting the Part B premiums out of the beneficiaryâs Social Security check. SSA also refunds any amounts owed to the recipient. ) CMS âdeemsâ the MSP recipient eligible for Part D Extra Help/ Low Income Subsidy (LIS). âCan the MSP be retroactive like Medicaid, back to 3 months before the application?. âThe answer is different for the 3 MSP programs. QMB -No Retroactive Eligibility â Benefits begin the month after the month of the MSP application. 18 NYCRR § 360-7.8(b)(5) SLIMB - YES - Retroactive Eligibility up to 3 months before the application, if was eligible This means applicant may be reimbursed for the 3 months of Part B benefits prior to the month of application. QI-1 - YES up to 3 months but only in the same calendar year. No retroactive eligibility to the previous year. 7. QMBs -Special Rules on Cost-Sharing. QMB is the only MSP program which pays not only the Part B premium, but also the Medicare co-insurance. However, there are limitations. First, co-insurance will only be paid if the provide accepts Medicaid. Not all Medicare provides accept Medicaid. Second, under recent changes in New York law, Medicaid will not always pay the Medicare co-insurance, even to a Medicaid provider. But even if the provider does not accept Medicaid, or if Medicaid does not pay the full co-insurance, the provider is banned from "balance billing" the QMB beneficiary for the co-insurance. Some consumers may be eligible for the Medicare Insurance Premium Payment why not try here (MIPP) Program, instead of MSP cheapest levitra. See this article for more info. TOPICS COVERED IN THIS ARTICLE 1. No Asset Limit 1A cheapest levitra. Summary Chart of MSP Programs 2. Income Limits &. Rules and Household cheapest levitra Size 3. The Three MSP Programs - What are they and how are they Different?. 4. FOUR Special Benefits of cheapest levitra MSP Programs. Back Door to Extra Help with Part D MSPs Automatically Waive Late Enrollment Penalties for Part B - and allow enrollment in Part B year-round outside of the short Annual Enrollment Period No Medicaid Lien on Estate to Recover Payment of Expenses Paid by MSP Food Stamps/SNAP not reduced by Decreased Medical Expenses when Enroll in MSP - at least temporarily 5. Enrolling in an MSP - Automatic Enrollment &. Applications for cheapest levitra People who Have Medicare What is Application Process?. 6. Enrolling in an MSP for People age 65+ who Do Not Qualify for Free Medicare Part A - the "Part A Buy-In Program" 7. What Happens After MSP Approved cheapest levitra - How Part B Premium is Paid 8 Special Rules for QMBs - How Medicare Cost-Sharing Works 1. NO ASSET LIMIT!. Since April 1, 2008, none of the three MSP programs have resource limits in New York -- which means many Medicare beneficiaries who might not qualify for Medicaid because of excess resources can qualify for an MSP. 1.A cheapest levitra. SUMMARY CHART OF MSP BENEFITS QMB SLIMB QI-1 Eligibility ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2021) Single Couple Single Couple Single Couple $1,094 $1,472 $1,308 $1,762 $1,469 $1,980 Federal Poverty Level 100% FPL 100 â 120% FPL 120 â 135% FPL Benefits Pays Monthly Part B premium?. YES, and also Part A premium if did not have enough work quarters and meets citizenship requirement. See âPart A Buy-Inâ YES YES cheapest levitra Pays Part A &. B deductibles &. Co-insurance YES - with limitations NO NO Retroactive to Filing of Application?. Yes - Benefits begin the month after the month of the MSP cheapest levitra application. 18 NYCRR §360-7.8(b)(5) Yes â Retroactive to 3rd month before month of application, if eligible in prior months Yes â may be retroactive to 3rd month before month of applica-tion, but only within the current calendar year. (No retro for January application). See GIS 07 MA cheapest levitra 027. Can Enroll in MSP and Medicaid at Same Time?. YES YES NO!. Must choose between QI-1 cheapest levitra and Medicaid. Cannot have both, not even Medicaid with a spend-down. 2. INCOME LIMITS and RULES Each of the three MSP programs has different income eligibility cheapest levitra requirements and provides different benefits. The income limits are tied to the Federal Poverty Level (FPL). 2021 FPL levels were released by NYS DOH in GIS 21 MA/06 - 2021 Federal Poverty Levels Attachment II NOTE. There is usually a lag in time of several weeks, or even months, from January cheapest levitra 1st of each year until the new FPLs are release, and then before the new MSP income limits are officially implemented. During this lag period, local Medicaid offices should continue to use the previous year's FPLs AND count the person's Social Security benefit amount from the previous year - do NOT factor in the Social Security COLA (cost of living adjustment). Once the updated guidelines are released, districts will use the new FPLs and go ahead and factor in any COLA. See 2021 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The cheapest levitra rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples. N.Y. Soc. Serv. L. 367-a(3)(c)(2), NYS DOH 2000-ADM-7, 89-ADM-7 p.7. Gross income is counted, although there are certain types of income that are disregarded. The most common income disregards, also known as deductions, include. (a) The first $20 of your &. Your spouse's monthly income, earned or unearned ($20 per couple max). (b) SSI EARNED INCOME DISREGARDS. * The first $65 of monthly wages of you and your spouse, * One-half of the remaining monthly wages (after the $65 is deducted). * Other work incentives including PASS plans, impairment related work expenses (IRWEs), blind work expenses, etc. For information on these deductions, see The Medicaid Buy-In for Working People with Disabilities (MBI-WPD) and other guides in this article -- though written for the MBI-WPD, the work incentives apply to all Medicaid programs, including MSP, for people age 65+, disabled or blind. (c) monthly cost of any health insurance premiums but NOT the Part B premium, since Medicaid will now pay this premium (may deduct Medigap supplemental policies, vision, dental, or long term care insurance premiums, and the Part D premium but only to the extent the premium exceeds the Extra Help benchmark amount) (d) Food stamps not counted. You can get a more comprehensive listing of the SSI-related income disregards on the Medicaid income disregards chart. As for all benefit programs based on financial need, it is usually advantageous to be considered a larger household, because the income limit is higher. The above chart shows that Households of TWO have a higher income limit than households of ONE. The MSP programs use the same rules as Medicaid does for the Disabled, Aged and Blind (DAB) which are borrowed from the SSI program for Medicaid recipients in the âSSI-related category.â Under these rules, a household can be only ONE or TWO. 18 NYCRR 360-4.2. See DAB Household Size Chart. Married persons can sometimes be ONE or TWO depending on arcane rules, which can force a Medicare beneficiary to be limited to the income limit for ONE person even though his spouse who is under 65 and not disabled has no income, and is supported by the client applying for an MSP. EXAMPLE. Bob's Social Security is $1300/month. He is age 67 and has Medicare. His wife, Nancy, is age 62 and is not disabled and does not work. Under the old rule, Bob was not eligible for an MSP because his income was above the Income limit for One, even though it was well under the Couple limit. In 2010, NYS DOH modified its rules so that all married individuals will be considered a household size of TWO. DOH GIS 10 MA 10 Medicare Savings Program Household Size, June 4, 2010. This rule for household size is an exception to the rule applying SSI budgeting rules to the MSP program. Under these rules, Bob is now eligible for an MSP. When is One Better than Two?. Of course, there may be couples where the non-applying spouse's income is too high, and disqualifies the applying spouse from an MSP. In such cases, "spousal refusal" may be used SSL 366.3(a). (Link is to NYC HRA form, can be adapted for other counties). In NYC, if you have a Medicaid case with HRA, instead of submitting an MSP application, you only need to complete and submit MAP-751W (check off "Medicare Savings Program Evaluation") and fax to (917) 639-0837. (The MAP-751W is also posted in languages other than English in this link. (Updated 4/14/2021.)) 3. The Three Medicare Savings Programs - what are they and how are they different?. 1. Qualified Medicare Beneficiary (QMB). The QMB program provides the most comprehensive benefits. Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations. Part B premiums, Part A premiums, if there are any, and any and all deductibles and co-insurance. QMB coverage is not retroactive. The programâs benefits will begin the month after the month in which your client is found eligible. ** See special rules about cost-sharing for QMBs below - updated with new CMS directive issued January 2012 ** See NYC HRA QMB Recertification form ** Even if you do not have Part A automatically, because you did not have enough wages, you may be able to enroll in the Part A Buy-In Program, in which people eligible for QMB who do not otherwise have Medicare Part A may enroll, with Medicaid paying the Part A premium (Materials by the Medicare Rights Center). 2. Specifiedl Low-Income Medicare Beneficiary (SLMB). For those with incomes between 100% and 120% FPL, the SLMB program will cover Part B premiums only. SLMB is retroactive, however, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. 3. Qualified Individual (QI-1). For those with incomes between 120% and 135% FPL, and not receiving Medicaid, the QI-1 program will cover Medicare Part B premiums only. QI-1 is also retroactive, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. However, QI-1 retroactive coverage can only be provided within the current calendar year. (GIS 07 MA 027) So if you apply in January, you get no retroactive coverage. Q-I-1 recipients would be eligible for Medicaid with a spend-down, but if they want the Part B premium paid, they must choose between enrolling in QI-1 or Medicaid. They cannot be in both. It is their choice. DOH MRG p. 19. In contrast, one may receive Medicaid and either QMB or SLIMB. 4. Four Special Benefits of MSPs (in addition to NO ASSET TEST). Benefit 1. Back Door to Medicare Part D "Extra Help" or Low Income Subsidy -- All MSP recipients are automatically enrolled in Extra Help, the subsidy that makes Part D affordable. They have no Part D deductible or doughnut hole, the premium is subsidized, and they pay very low copayments. Once they are enrolled in Extra Help by virtue of enrollment in an MSP, they retain Extra Help for the entire calendar year, even if they lose MSP eligibility during that year. The "Full" Extra Help subsidy has the same income limit as QI-1 - 135% FPL. However, many people may be eligible for QI-1 but not Extra Help because QI-1 and the other MSPs have no asset limit. People applying to the Social Security Administration for Extra Help might be rejected for this reason. Recent (2009-10) changes to federal law called "MIPPA" requires the Social Security Administration (SSA) to share eligibility data with NYSDOH on all persons who apply for Extra Help/ the Low Income Subsidy. Data sent to NYSDOH from SSA will enable NYSDOH to open MSP cases on many clients. The effective date of the MSP application must be the same date as the Extra Help application. Signatures will not be required from clients. In cases where the SSA data is incomplete, NYSDOH will forward what is collected to the local district for completion of an MSP application. The State implementing procedures are in DOH 2010 ADM-03. Also see CMS "Dear State Medicaid Director" letter dated Feb. 18, 2010 Benefit 2. MSPs Automatically Waive Late Enrollment Penalties for Part B Generally one must enroll in Part B within the strict enrollment periods after turning age 65 or after 24 months of Social Security Disability. An exception is if you or your spouse are still working and insured under an employer sponsored group health plan, or if you have End Stage Renal Disease, and other factors, see this from Medicare Rights Center. If you fail to enroll within those short periods, you might have to pay higher Part B premiums for life as a Late Enrollment Penalty (LEP). Also, you may only enroll in Part B during the Annual Enrollment Period from January 1 - March 31st each year, with Part B not effective until the following July. Enrollment in an MSP automatically eliminates such penalties... For life.. Even if one later ceases to be eligible for the MSP. AND enrolling in an MSP will automatically result in becoming enrolled in Part B if you didn't already have it and only had Part A. See Medicare Rights Center flyer. Benefit 3. No Medicaid Lien on Estate to Recover MSP Benefits Paid Generally speaking, states may place liens on the Estates of deceased Medicaid recipients to recover the cost of Medicaid services that were provided after the recipient reached the age of 55. Since 2002, states have not been allowed to recover the cost of Medicare premiums paid under MSPs. In 2010, Congress expanded protection for MSP benefits. Beginning on January 1, 2010, states may not place liens on the Estates of Medicaid recipients who died after January 1, 2010 to recover costs for co-insurance paid under the QMB MSP program for services rendered after January 1, 2010. The federal government made this change in order to eliminate barriers to enrollment in MSPs. See NYS DOH GIS 10-MA-008 - Medicare Savings Program Changes in Estate Recovery The GIS clarifies that a client who receives both QMB and full Medicaid is exempt from estate recovery for these Medicare cost-sharing expenses. Benefit 4. SNAP (Food Stamp) benefits not reduced despite increased income from MSP - at least temporarily Many people receive both SNAP (Food Stamp) benefits and MSP. Income for purposes of SNAP/Food Stamps is reduced by a deduction for medical expenses, which includes payment of the Part B premium. Since approval for an MSP means that the client no longer pays for the Part B premium, his/her SNAP/Food Stamps income goes up, so their SNAP/Food Stamps go down. Here are some protections. Do these individuals have to report to their SNAP worker that their out of pocket medical costs have decreased?. And will the household see a reduction in their SNAP benefits, since the decrease in medical expenses will increase their countable income?. The good news is that MSP households do NOT have to report the decrease in their medical expenses to the SNAP/Food Stamp office until their next SNAP/Food Stamp recertification. Even if they do report the change, or the local district finds out because the same worker is handling both the MSP and SNAP case, there should be no reduction in the householdâs benefit until the next recertification. New Yorkâs SNAP policy per administrative directive 02 ADM-07 is to âfreezeâ the deduction for medical expenses between certification periods. Increases in medical expenses can be budgeted at the householdâs request, but NYS never decreases a householdâs medical expense deduction until the next recertification. Most elderly and disabled households have 24-month SNAP certification periods. Eventually, though, the decrease in medical expenses will need to be reported when the household recertifies for SNAP, and the household should expect to see a decrease in their monthly SNAP benefit. It is really important to stress that the loss in SNAP benefits is NOT dollar for dollar. A $100 decrease in out of pocket medical expenses would translate roughly into a $30 drop in SNAP benefits. See more info on SNAP/Food Stamp benefits by the Empire Justice Center, and on the State OTDA website. Some clients will be automatically enrolled in an MSP by the New York State Department of Health (NYSDOH) shortly after attaining eligibility for Medicare. Others need to apply. The 2010 "MIPPA" law introduced some improvements to increase MSP enrollment. See 3rd bullet below. Also, some people who had Medicaid through the Affordable Care Act before they became eligible for Medicare have special procedures to have their Part B premium paid before they enroll in an MSP. See below. WHO IS AUTOMATICALLY ENROLLED IN AN MSP. Clients receiving even $1.00 of Supplemental Security Income should be automatically enrolled into a Medicare Savings Program (most often QMB) under New York Stateâs Medicare Savings Program Buy-in Agreement with the federal government once they become eligible for Medicare. They should receive Medicare Parts A and B. Clients who are already eligible for Medicare when they apply for Medicaid should be automatically assessed for MSP eligibility when they apply for Medicaid. (NYS DOH 2000-ADM-7 and GIS 05 MA 033). Clients who apply to the Social Security Administration for Extra Help, but are rejected, should be contacted &. Enrolled into an MSP by the Medicaid program directly under new MIPPA procedures that require data sharing. Strategy TIP. Since the Extra Help filing date will be assigned to the MSP application, it may help the client to apply online for Extra Help with the SSA, even knowing that this application will be rejected because of excess assets or other reason. SSA processes these requests quickly, and it will be routed to the State for MSP processing. Since MSP applications take a while, at least the filing date will be retroactive. Note. The above strategy does not work as well for QMB, because the effective date of QMB is the month after the month of application. As a result, the retroactive effective date of Extra Help will be the month after the failed Extra Help application for those with QMB rather than SLMB/QI-1. Applying for MSP Directly with Local Medicaid Program. Those who do not have Medicaid already must apply for an MSP through their local social services district. (See more in Section D. Below re those who already have Medicaid through the Affordable Care Act before they became eligible for Medicare. If you are applying for MSP only (not also Medicaid), you can use the simplified MSP application form (theDOH-4328(Rev. 8/2017-- English) (2017 Spanish version not yet available). Either application form can be mailed in -- there is no interview requirement anymore for MSP or Medicaid. See 10 ADM-04. Applicants will need to submit proof of income, a copy of their Medicare card (front &. Back), and proof of residency/address. See the application form for other instructions. One who is only eligible for QI-1 because of higher income may ONLY apply for an MSP, not for Medicaid too. One may not receive Medicaid and QI-1 at the same time. If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for SLIMB or QMB instead of QI-1. Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person. Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare Those who, prior to becoming enrolled in Medicare, had Medicaid through Affordable Care Act are eligible to have their Part B premiums paid by Medicaid (or the cost reimbursed) during the time it takes for them to transition to a Medicare Savings Program. In 2018, DOH clarified that reimbursement of the Part B premium will be made regardless of whether the individual is still in a Medicaid managed care (MMC) plan. GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare ( PDF) provides, "Due to efforts to transition individuals who gain Medicare eligibility and who require LTSS, individuals may not be disenrolled from MMC upon receipt of Medicare. To facilitate the transition and not disadvantage the recipient, the Medicaid program is approving reimbursement of Part B premiums for enrollees in MMC." The procedure for getting the Part B premium paid is different for those whose Medicaid was administered by the NYS of Health Exchange (Marketplace), as opposed to their local social services district. The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability. Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification. NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods. IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare. IF they obtain Medicare because they turn age 65, they will receive a letter from their local district asking them to "renew" Medicaid through their local district. See 2014 LCM-02. Now, their Medicaid income limit will be lower than the MAGI limits ($842/ mo reduced from $1387/month) and they now will have an asset test. For this reason, some individuals may lose full Medicaid eligibility when they begin receiving Medicare. People over age 65 who obtain Medicare do NOT keep "Marketplace Medicaid" for 12 months (continuous eligibility) See GIS 15 MA/022 - Continuous Coverage for MAGI Individuals. Since MSP has NO ASSET limit. Some individuals may be enrolled in the MSP even if they lose Medicaid, or if they now have a Medicaid spend-down. If a Medicare/Medicaid recipient reports income that exceeds the Medicaid level, districts must evaluate the personâs eligibility for MSP. 08 OHIP/ADM-4 âIf you became eligible for Medicare based on disability and you are UNDER AGE 65, you are entitled to keep MAGI Medicaid for 12 months from the month it was last authorized, even if you now have income normally above the MAGI limit, and even though you now have Medicare. This is called Continuous Eligibility. EXAMPLE. Sam, age 60, was last authorized for Medicaid on the Marketplace in June 2016. He became enrolled in Medicare based on disability in August 2016, and started receiving Social Security in the same month (he won a hearing approving Social Security disability benefits retroactively, after first being denied disability). Even though his Social Security is too high, he can keep Medicaid for 12 months beginning June 2016. Sam has to pay for his Part B premium - it is deducted from his Social Security check. He may call the Marketplace and request a refund. This will continue until the end of his 12 months of continues MAGI Medicaid eligibility. He will be reimbursed regardless of whether he is in a Medicaid managed care plan. See GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare (PDF) When that ends, he will renew Medicaid and apply for MSP with his local district. Individuals who are eligible for Medicaid with a spenddown can opt whether or not to receive MSP. (Medicaid Reference Guide (MRG) p. 19). Obtaining MSP may increase their spenddown. MIPPA - Outreach by Social Security Administration -- Under MIPPA, the SSA sends a form letter to people who may be eligible for a Medicare Savings Program or Extra Help (Low Income Subsidy - LIS) that they may apply. The letters are. · Beneficiary has Extra Help (LIS), but not MSP · Beneficiary has no Extra Help (LIS) or MSP 6. Enrolling in MSP for People Age 65+ who do Not have Free Medicare Part A - the "Part A Buy-In Program" Seniors WITHOUT MEDICARE PART A or B -- They may be able to enroll in the Part A Buy-In program, in which people eligible for QMB who are age 65+ who do not otherwise have Medicare Part A may enroll in Part A, with Medicaid paying the Part A premium. See Step-by-Step Guide by the Medicare Rights Center). This guide explains the various steps in "conditionally enrolling" in Part A at the SSA office, which must be done before applying for QMB at the Medicaid office, which will then pay the Part A premium. See also GIS 04 MA/013. In June, 2018, the SSA revised the POMS manual procedures for the Part A Buy-In to to address inconsistencies and confusion in SSA field offices and help smooth the path for QMB enrollment. The procedures are in the POMS Section HI 00801.140 "Premium-Free Part A Enrollments for Qualified Medicare BenefiIaries." It includes important clarifications, such as. SSA Field Offices should explain the QMB program and conditional enrollment process if an individual lacks premium-free Part A and appears to meet QMB requirements. SSA field offices can add notes to the âRemarksâ section of the application and provide a screen shot to the individual so the individual can provide proof of conditional Part A enrollment when applying for QMB through the state Medicaid program. Beneficiaries are allowed to complete the conditional application even if they owe Medicare premiums. In Part A Buy-in states like NYS, SSA should process conditional applications on a rolling basis (without regard to enrollment periods), even if the application coincides with the General Enrollment Period. (The General Enrollment Period is from Jan 1 to March 31st every year, in which anyone eligible may enroll in Medicare Part A or Part B to be effective on July 1st). 7. What happens after the MSP approval - How is Part B premium paid For all three MSP programs, the Medicaid program is now responsible for paying the Part B premiums, even though the MSP enrollee is not necessarily a recipient of Medicaid. The local Medicaid office (DSS/HRA) transmits the MSP approval to the NYS Department of Health â that information gets shared w/ SSA and CMS SSA stops deducting the Part B premiums out of the beneficiaryâs Social Security check. SSA also refunds any amounts owed to the recipient. (Note. This process can take awhile!. !. !. ) CMS âdeemsâ the MSP recipient eligible for Part D Extra Help/ Low Income Subsidy (LIS). âCan the MSP be retroactive like Medicaid, back to 3 months before the application?. âThe answer is different for the 3 MSP programs. QMB -No Retroactive Eligibility â Benefits begin the month after the month of the MSP application. How should Levitra be used?Take vardenafil tablets by mouth with or without food. The dose is usually taken about 1 hour before sexual activity. Swallow the tablets with a drink of water. Do not take double or extra doses. Overdosage: If you think you have taken too much of Levitra contact a poison control center or emergency room at once. NOTE: Levitra is only for you. Do not share Levitra with others.
Levitra 20mg best priceThe NSW Government has announced the site for the $300 million Rouse Hill Hospital, to be built on the north-eastern side of Windsor Road.Health Minister Brad Hazzard said the new site, located near Commercial Road, ensures ideal transport and road links for Western Sydneyâs growing population.âI want to thank the local community for their patience as the experts have worked through a number of levitra 20mg best price challenging obstacles to select a site which will offer the best outcome for the people of Rouse Hill and Western Sydney,â Mr Hazzard said.âI am thrilled to see us move to the next stage in delivering this vital health infrastructure project. The final site has better access and allows for more land use opportunities compared with the previously announced site, and allows levitra 20mg best price us to better meet the future health needs of Western Sydney.â Member for Riverstone Kevin Conolly said the new hospital will be a tremendous asset for generations.âI am excited that we are still on track to get construction underway before the next election. To have a new hospital built in the right location is what our communities deserve,â Mr Conolly said.Member for Castle Hill Ray Williams said it would be a huge advantage for our patients, staff and carers to have good connectivity to the Rouse Hill Town Centre and a Sydney Metro station so close.âGood public transport and road access is essential. Not just for patients levitra 20mg best price and their families but also for the thousands of staff who will get jobs at this new hospital,â Mr Williams said.The site acquisition process is underway and construction will start in this term of Government, prior to March 2023. The NSW Government has committed $10.7 billion in health infrastructure investment over four years. Since 2011, the NSW Government has levitra 20mg best price completed more than 150 health capital projects across the state.The NSW Government has released the final report into improvements to security in hospitals. Health Minister Brad Hazzard thanked former Labor Health and Police Minister Peter Anderson for his statewide review and its recommendations to improve safety for staff, patients and visitors to hospitals. ÂPeter Anderson visited rural, regional and metropolitan health facilities and spoke at length to levitra 20mg best price frontline staff with one goal in mind. To help make our hospitals as safe as they possibly can be,â Mr Hazzard said. The review identifies measures including:the need to better design and construct treatment spaces so that staff and levitra 20mg best price patient safety is improvedthe need to improve access to mental health assessmentsthe need for clinicians, allied health staff and security officers to act as a team when faced with the threat of or actual violencethe need for better protection and better compliance, eg wearing of duress alarms in Emergency Departmentsthe need for a trial of capsicum foam sprays and other equipment to help de-escalate threatening situations.The review involved extensive consultation with. Frontline staff from 44 hospitals across NSW. Representatives from levitra 20mg best price health unions. And members of the NSW Police Force, NSW Corrective Services and Safework NSW. The review made 107 recommendations, which were generally supported, and NSW Health will levitra 20mg best price continue to work closely with staff, unions and other Government agencies to see these recommendations are actioned and implemented. Mr Hazzard said he will also be introducing additional measures building on the Anderson Review. These include:ensuring Local Health Districts significantly reduce their use of contract security staff and invest in permanent staff members as a priorityenhancing security numbers in emergency departments of some rural and regional hospitals.As part of the NSW Governmentâs $800 million investment to support the health systemâs response to the erectile dysfunction treatment levitra, $15 million levitra 20mg best price will go towards additional temporary security at hospitals with erectile dysfunction treatment clinics. Another $8.5 million is being spent on employing 86 patient experience officers at 53 hospitals across the State to 30 June 2021 to support emergency departments and associated erectile dysfunction treatment clinics.The NSW Government has already invested $19 million to improve security in emergency departments at public hospitals, upgrading CCTV systems, improving access controls between public and staff and installing remote locking to public access doors. Another $5 million has been spent to upgrade duress alarms for staff in levitra 20mg best price emergency departments, which they are mandated to wear while on duty, and there are more than 3,000 CCTV cameras in operation in NSW public hospitals. Mr Hazzard said he has had recent discussions with the Health Services Union about powers for security staff working in hospitals, and NSW Health would engage with the Department of Communities and Justice and NSW Police Force on that issue.The report can be found at Improvements to security in hospitals.. The NSW Government has announced the site for the $300 million Rouse Hill Hospital, to be built on the north-eastern side of Windsor Road.Health Minister Brad Hazzard said the new site, located near Commercial Road, ensures ideal transport and road links for Western Sydneyâs how do i get a prescription for levitra growing population.âI want to thank the local community for their patience as the experts have worked through a number of challenging obstacles to select a site which will offer the best cheapest levitra outcome for the people of Rouse Hill and Western Sydney,â Mr Hazzard said.âI am thrilled to see us move to the next stage in delivering this vital health infrastructure project. The final site has better access and allows for more land use opportunities compared with the previously announced site, and allows us to better meet the future health needs of Western Sydney.â cheapest levitra Member for Riverstone Kevin Conolly said the new hospital will be a tremendous asset for generations.âI am excited that we are still on track to get construction underway before the next election. To have a new hospital built in the right location is what our communities deserve,â Mr Conolly said.Member for Castle Hill Ray Williams said it would be a huge advantage for our patients, staff and carers to have good connectivity to the Rouse Hill Town Centre and a Sydney Metro station so close.âGood public transport and road access is essential. Not just for patients and their families but also for the thousands of staff who will get cheapest levitra jobs at this new hospital,â Mr Williams said.The site acquisition process is underway and construction will start in this term of Government, prior to March 2023. The NSW Government has committed $10.7 billion in health infrastructure investment over four years. Since 2011, the NSW Government cheapest levitra has completed more than 150 health capital projects across the state.The NSW Government has released the final report into improvements to security in hospitals. Health Minister Brad Hazzard thanked former Labor Health and Police Minister Peter Anderson for his statewide review and its recommendations to improve safety for staff, patients and visitors to hospitals. ÂPeter Anderson visited rural, regional and metropolitan health facilities and cheapest levitra spoke at length to frontline staff with one goal in mind. To help make our hospitals as safe as they possibly can be,â Mr Hazzard said. The review identifies measures including:the need to better design and construct treatment spaces so that staff and patient safety is improvedthe need to improve access to mental health assessmentsthe need for clinicians, allied health staff and security officers to act as a team when faced with the threat of or actual violencethe need for better protection and better compliance, eg wearing of duress alarms in Emergency Departmentsthe need for a trial of capsicum foam sprays and other equipment to help cheapest levitra de-escalate threatening situations.The review involved extensive consultation with. Frontline staff from 44 hospitals across NSW. Representatives from health cheapest levitra unions. And members of the NSW Police Force, NSW Corrective Services and Safework NSW. The review made 107 recommendations, which were generally supported, and NSW Health will continue to work closely with staff, unions and other Government agencies to see these recommendations cheapest levitra are actioned and implemented. Mr Hazzard said he will also be introducing additional measures building on the Anderson Review. These include:ensuring Local Health Districts significantly reduce their use of contract security staff and invest in permanent staff members as a priorityenhancing security numbers in emergency departments of some rural and regional hospitals.As part cheapest levitra of the NSW Governmentâs $800 million investment to support the health systemâs response to the erectile dysfunction treatment levitra, $15 million will go towards additional temporary security at hospitals with erectile dysfunction treatment clinics. Another $8.5 million is being spent on employing 86 patient experience officers at 53 hospitals across the State to 30 June 2021 to support emergency departments and associated erectile dysfunction treatment clinics.The NSW Government has already invested $19 million to improve security in emergency departments at public hospitals, upgrading CCTV systems, improving access controls between public and staff and installing remote locking to public access doors. Another $5 million has been spent to upgrade duress alarms for staff in emergency cheapest levitra departments, which they are mandated to wear while on duty, and there are more than 3,000 CCTV cameras in operation in NSW public hospitals. Mr Hazzard said he has had recent discussions with the Health Services Union about powers for security staff working in hospitals, and NSW Health would engage with the Department of Communities and Justice and NSW Police Force on that issue.The report can be found at Improvements to security in hospitals.. Where to buy levitraIntroductionThe lymphatic system is a network of vessels important Cialis generic best price for whole body fluid homeostasis, lipid absorption and immune cell trafficking.1 2 Lymphoedema is caused by lymphatic dysfunction, which leads to a build-up of interstitial fluid within where to buy levitra the tissues. This manifests with swelling of the extremities, usually of the legs but may involve other regions or segments of the body such as the upper limbs, face, trunk or genital area. There is an increased risk of due to disturbances in immune cell trafficking within the segment of compromised lymph drainage.3 Lymphatic dysfunction within the thorax and abdomen, here referred to as systemic/internal involvement (but can be referred to as visceral or central involvement), may present with pleural or pericardial effusions or ascites, any of which may be chylous, as well as intestinal or pulmonary lymphangiectasia, protein losing enteropathy or chylous reflux.The International Society for the Study of Vascular Anomalies (ISSVA) updated their classification for vascular anomalies in 2018.4 The vascular malformations where to buy levitra are subgrouped into âcombinedâ, which include more than one type of vessel, âsimpleâ (only involving one vessel type), and those âassociated with other anomaliesâ.Lymphoedema due to a presumed genetic developmental fault in the structure or function of lymph conducting pathways is called primary lymphoedema.5 Some developmental faults can lead to overt structural defects of the lymph conducting pathways and are called lymphatic malformations. Such malformations if interfering with lymph drainage cause lymphoedema (truncal malformations) but some lymphatic malformations remain as isolated anomalies with no connection to main lymph drainage pathways and do not cause lymphoedema (non-truncal malformations).6 A primary lymphatic anomaly is an umbrella term referring to all lymphatic abnormalities arising from a developmental fault.For a long time, the diagnosis of primary lymphoedema was based largely on the age of presentation of the swelling, congenital, pubertal and late onset, with limited differentiation between the phenotypes. The discovery of the first causal gene, vascular endothelial growth factor receptor 3 for Milroy disease, indicated that a molecular diagnosis was possible.7 The first St Georgeâs classification algorithm of primary lymphoedema and other primary lymphatic disorders was an attempt to guide a clearer where to buy levitra categorisation of phenotypes and enable the discovery of further causal genes.8 Age of onset remained a key criterion, but the sites affected and associated features, for example, dysmorphology, distichiasis (aberrant eyelashes), varicose veins, vascular malformations and limb overgrowth were also considered, as was internal or systemic involvement, for example, fetal hydrops, intestinal lymphangiectasia, pleural and pericardial effusions and chylous reflux. A family history of lymphoedema with determination of the mode of inheritance was considered useful.More rigorous phenotyping facilitated the identification of subgroups of patients with the same broad category of primary lymphatic anomaly. These cohorts were then used for molecular studies to where to buy levitra identify more causal genes. Once the genotype was known then crosschecking of the clinical characteristics, natural history and inheritance patterns was possible and an accurate phenotype defined. Investigations such as lymphoscintigraphy where to buy levitra helped to refine the phenotype further and give insight into the mechanisms for the development of the lymphatic disorder. A first update of the classification was published in 2013.9The St Georgeâs classification algorithm is intended to help clinicians categorise their patients and guide testing towards, where possible, a molecular diagnosis. This algorithm is criteria matching, that is, using certain key findings for classification through a multistep process where to buy levitra of history taking, examination findings, mutation testing, etc. The next step using the information gathered is to advise on natural history, prognosis and risk (including genetic counselling) and to guide management. While a molecular diagnosis should provide the most specific and accurate diagnosis, it can be seen particularly with the postzygotic mosaic disorders that one genotype can be clinically where to buy levitra very heterogenous so there will probably always be a place for good clinical phenotyping supported by investigation to guide management.Here, we present a second update of the St Georgeâs classification algorithm to include newly discovered genes and to bring it in-line with the 2018 ISSVA classification for vascular anomalies.4 The results of an audit, the purpose of which was to determine how well the algorithm was performing as a diagnostic aid to classify patients with primary lymphatic anomalies and guide molecular testing are also presented.MethodsSt Georgeâs classification algorithm of primary lymphatic anomaliesThe St Georgeâs classification algorithm was updated (figure 1) and then applied, retrospectively, to all patients presenting to the national multidisciplinary âPrimary and Paediatric Lymphoedemaâ Clinic held at St Georgeâs Hospital over a 1-year period. Careful phenotyping was undertaken both on clinical grounds and after selective investigations, for example, lymphoscintigraphy. Where possible where to buy levitra and appropriate, targeted genetic testing was performed (this was prior to the introduction of a lymphoedema gene panel in our unit) for some of the genes listed in table 1.St Georgeâs classification algorithm for primary lymphatic anomalies. The five main groupings (colour coded) with their various clinical subtypes of disease. Primary lymphoedema is the major clinical feature in the where to buy levitra green, pink and purple sections. Text in red indicates the suggested genetic test and/or differential diagnosis for the subgroup, however, the indicated genes do not explain the cause of disease in all patients in each grouping. For example, where to buy levitra only 70% of patients with Milroy disease are explained by mutations in FLT4/VEGFR3.33 FH, family history. +ve, positive. Âve, negative. (Image shared by St Georgeâs Lymphovascular Research Group under the CC BY-SA 4.0 International licence on Wikimedia Commons)." data-icon-position where to buy levitra data-hide-link-title="0">Figure 1 St Georgeâs classification algorithm for primary lymphatic anomalies. The five main groupings (colour coded) with their various clinical subtypes of disease. Primary lymphoedema is where to buy levitra the major clinical feature in the green, pink and purple sections. Text in red indicates the suggested genetic test and/or differential diagnosis for the subgroup, however, the indicated genes do not explain the cause of disease in all patients in each grouping. For example, only 70% of patients with Milroy disease are explained by mutations in FLT4/VEGFR3.33 FH, family history where to buy levitra. +ve, positive. Âve, negative where to buy levitra. (Image shared by St Georgeâs Lymphovascular Research Group under the CC BY-SA 4.0 International licence on Wikimedia Commons).View this table:Table 1 An overview of genetic disorders with primary lymphoedema as a frequent and dominant feature, categorised by inheritance and age of onsetWithin the St Georgeâs classification algorithm (figure 1), there are five main categories of primary lymphatic anomalies. These are presented in the form of colour-coded sections with the individual subtypes (including genotypes) within where to buy levitra the categories. For definitions of some of the terms used, see Glossary of Terms (see online supplementary section).Supplemental materialFirst, the yellow section includes the âvascular malformations associated with other anomaliesâ and the âlymphatic malformationsâ (as defined in the âIntroductionâ section).Second, the patient is assessed for syndromes that have lymphoedema as a non-dominant feature (blue section), for example, the patient is dysmorphic with learning difficulties and possibly has other abnormalities.Then if not obviously syndromic, and the lymphatic problems are the dominant feature, further assessment and investigations for systemic/internal lymphatic dysfunction or central conducting anomalies (eg, chylothoraces, chylopericardial effusions, ascites or protein losing enteropathy) are undertaken (pink section). These include a careful medical history asking specifically about prenatal history (eg, hydrothoraces, fetal hydrops), chronic diarrhoea, abdominal bloating or discomfort with fatty foods, where to buy levitra weight loss or faltering growth (in a child) or shortness of breath on exertion. Blood investigations (including serum albumin, immunoglobulins, lymphocyte subsets, faecal levels of calprotectin or alpha-1-antitrysin), echocardiograms and chest radiographs are helpful if central lymphatic dysfunction is suspected.Where none of the above features is present, then the age of onset is used to determine the grouping. The green section deals with congenital-onset primary lymphoedema (includes where to buy levitra syndromes where lymphoedema is the dominant clinical problem, and which is present at birth or develops within the first year of life but is not associated with systemic/internal lymphatic dysfunction). The purple section addresses late-onset primary lymphoedema (ie, lymphoedema that is the dominant clinical problem, and which develops after the first year of life but is not associated with systemic/internal lymphatic dysfunction). It was decided not to differentiate between pubertal onset (praecox) and later onset in life (tarda) when it was discovered that one genotype such as FOXC2 can cause both.It where to buy levitra is important to note that the specific diagnosis may be difficult in a neonate presenting with isolated congenital primary lymphoedema. A baby born with lymphoedema may later present with developmental delay, systemic involvement, progressive segmental overgrowth or a vascular malformation, which could suggest a diagnosis in one of the other categories. It should also be where to buy levitra emphasised that each colour-coded section is not exclusive. Some somatic overgrowth anomalies may possess significant internal involvement. Also, lymphoedema distichiasis syndrome is allocated to the purple late-onset lymphoedema section because the dominant feature is the late-onset lymphoedema not the associated features, which make it a syndrome. The blue âsyndromicâ section refers to conditions with a collection of features where lymphoedema is where to buy levitra not the main characteristic. The algorithm is intended to guide a clinical diagnosis and target gene testing.Genetic methodologyFor the purposes of the audit, targeted genetic testing of FOXC2, VEGFR3, CCBE1, SOX18, RASopathy genes and PIK3CA was performed by Sanger sequencing of DNA extracted from lymphocytes or skin fibroblasts in patients in whom a specific genetic diagnosis was suspected. This was before the where to buy levitra introduction of a lymphoedema gene panel. Some patients, who were either negative for the targeted genes or did not fit the relevant phenotypes of those genes, were included in Whole Exome Sequencing (WES) cohorts after classification, which then led to the identification of new disease genes such as EPHB4, GATA2, PIEZO1, GJC2 and FAT4.Retrospective audit of the St Georgeâs Clinic for 2016A 12-month retrospective audit for the year 2016 (1 January 2016â31 December 2016) was performed. The aim of the audit was to look at the proportion of patients in each category of where to buy levitra the classification algorithm and to look at the success of making a molecular diagnosis through use of the algorithm. The audit criteria required the patients to be seen in our specialist clinic, at any age, with a diagnosis of a primary lymphatic anomaly with data collected from medical records and laboratory results.ResultsResults of the retrospective auditOver a 12-month period in 2016, 227 patients were seen (age range 2 weeks to 70 years), 25.6% (n=58/227) of which were new patients. Over one-third (38%) where to buy levitra of patients seen in the clinic had a family history of primary lymphoedema.Few patients had received genetic testing prior to referral to the clinic. Targeted genetic testing was completed in 63% (n=143) of the patients seen. At that time, a lymphoedema gene panel was not available, patients were only tested if the clinician felt there was a reasonable chance where to buy levitra of finding a molecular cause, that is, testing was targeted.Of those tested, the underlying genetic cause was identified in 41% (n=59/143). Overall, a molecular diagnosis was made in 26% (59/227) of all the patients seen in 2016.Vascular malformations with associated anomalies and lymphatic malformations (yellow)This group presents with malformations in the structure and organisation of blood and lymphatic vessels with a patchy, segmental distribution. Lymphoedema may develop in combination with vascular malformations and segmental overgrowth (or occasionally, undergrowth) where to buy levitra of tissues within the swollen limb, for example, muscle, skeletal or adipose tissues (figure 2A). The combination of lymphatic and vascular malformations in this group reflects the mutual embryological origins of the two vascular systems.A graphic representation of the 227 audited patients seen in clinic in 2016 and their distribution across the five categories from figure 1 (pie chart). (AâG) Images show features of where to buy levitra each category. (A) Patients with postzygotic mutations often present with asymmetrical swelling and segmental overgrowth as this patient, who is mosaic for a mutation in KRAS. (B) Webbed where to buy levitra neck in Noonan syndrome. (C) In rare cases, swellings can be widespread affecting all segments of the body such as in this child with biallelic CCBE1 mutations. (D) In milder forms, often just the dorsum of the foot is affected as in this baby where to buy levitra with a VEGFR3 mutation. (E, F) Lower limb swelling and distichiasis (arrowheads in F) in a patient with a FOXC2 mutation. (G) Lymphoedema is a major cause of skin disease and affected patients suffer from severe and recurrent episodes of cutaneous , especially HPV-associated warts as seen in patients with GATA2 mutations. GLD, generalised lymphatic dysplasia." data-icon-position data-hide-link-title="0">Figure 2 A graphic representation of the 227 audited patients seen in clinic in 2016 and their distribution across where to buy levitra the five categories from figure 1 (pie chart). (AâG) Images show features of each category. (A) Patients with postzygotic mutations where to buy levitra often present with asymmetrical swelling and segmental overgrowth as this patient, who is mosaic for a mutation in KRAS. (B) Webbed neck in Noonan syndrome. (C) In rare cases, swellings can be widespread affecting all segments of the body such as in this child with where to buy levitra biallelic CCBE1 mutations. (D) In milder forms, often just the dorsum of the foot is affected as in this baby with a VEGFR3 mutation. (E, F) Lower limb swelling and distichiasis where to buy levitra (arrowheads in F) in a patient with a FOXC2 mutation. (G) Lymphoedema is a major cause of skin disease and affected patients suffer from severe and recurrent episodes of cutaneous , especially HPV-associated warts as seen in patients with GATA2 mutations. GLD, generalised lymphatic dysplasia.These conditions are usually due where to buy levitra to postzygotic mutations, for example, PIK3CA-related overgrowth spectrum (PROS)). Exceptions to this are capillary malformation-arteriovenous malformation (MIM 608354) such as Parkes-Weber syndrome, which may be caused by heterozygous, germline mutations in RASA1.10Of the 227 patients seen in 2016, 17% (n=39) had lymphoedema associated with vascular malformations and/or segmental overgrowth (or undergrowth) (figure 2, pie chart) in comparison with 15% in 2010.8 It has been shown that postzygotic, gain of function mutations in PIK3CA may be responsible for many of the mosaic segmental overgrowth spectrum disorders.11 Postzygotic mutations are rarely identified in blood samples and therefore require a skin biopsy of the affected region. In the 2016 cohort, only 10 patients (26%) provided skin biopsies where to buy levitra for genetic analysis, producing just one molecular diagnosis. More research in this field is required to identify the genetic basis for some of the conditions in this category. However, since the last revision, we have gained a much better understanding of the classification of some of these postzygotic mosaic conditions, therefore a brief review of the latest developments in this area is given where to buy levitra in the online supplementary section.Syndromic lymphoedema (blue)Syndromes associated with primary lymphatic anomalies are listed in table 2 and include chromosomal abnormalities, single gene disorders and imprinting disorders. Patients attending the clinic with syndromic primary lymphoedema made up 13% (n=29) (figure 2, pie chart), similar to the 15% reported by Connell et al.8 Nearly three-quarters (72%, n=21) of this cohort had a molecular or chromosomal diagnosis. The most frequently seen syndromes were Noonan syndrome (n=8) (figure 2B), Turner syndrome (n=4) and Phelan McDermid syndrome (n=3).View this table:Table 2 An overview of âKnown Syndromesâ with primary lymphoedema as a non-dominant association as referred to in the St Georgeâs classification algorithm (figure where to buy levitra 1, blue section)Lymphoedema with prenatal or postnatal systemic involvement (pink)In some conditions, lymphoedema may be associated with internal (systemic or visceral) disturbances of the lymphatic system within thorax or abdomen, for example, fetal hydrops, intestinal lymphangiectasia (presenting as protein-losing enteropathy), pulmonary lymphangiectasia or with pericardial and/or pleural effusions (often chylous), or chylous reflux (often into the genitalia). Broadly, there are two types of lymphoedema with systemic involvement. (A) âwidespreadâ swelling affecting all segments of the body (figure 2C), where to buy levitra such as that seen in generalised lymphatic dysplasia (GLD). Due to faulty development, the structural or functional abnormality of the lymphatic system is affecting the whole body. One type is Hennekam-lymphangiectasia-lymphoedema syndrome12. (B) âpatchyâ areas of swelling, for example, left arm and right leg, which have been named âmultisegmental lymphatic dysplasiaâ (MLD) (figure 1).Prenatally, these conditions may present with pleural effusions (hydrothoraces), or as non-immune fetal hydrops (the accumulation of fluid in at least two compartments of a fetus such as the abdominal cavity, pleura where to buy levitra or subcutaneous oedema). Fifteen per cent of non-immune cases of hydrops are the result of lymphatic disorders, and approximately 20% are idiopathic, some of which may be due to, as yet, unidentified lymphatic abnormalities.13In our audit, this cohort accounted for 12% (n=27) of patients (figure 2, pie chart), slightly higher than the 8% reported in 2010.8 Molecular testing was carried out in 17 patients. Nine of those tested had where to buy levitra GLD, and pathogenic variants were identified in seven (78%). Five had biallelic variants in the PIEZO1 gene and one each with biallelic variants in FAT4 and SOX18. Interestingly, two where to buy levitra of the families described by Connell et al, cases 3 and 4, have subsequently been found to be caused by biallelic variants in the PIEZO1 gene.8 14None of the eight patients, who presented with âpatchyâ distribution of lymphoedema (MLD), had an identifiable molecular diagnosis. It is suspected that these patients could have a postzygotic mosaic mutation or WILD syndrome.15Since the last revision of the St Georgeâs classification algorithm was published,9 five new causal genes associated with GLD and/or non-immune fetal hydrops have been identified. ADAMTS3,16 EPHB4,17 where to buy levitra FAT4,18 FBXL719 and PIEZO114 20 and are reviewed in the online supplementary section.Congenital onset lymphoedema (green)In this category, congenital onset is defined as lymphoedema that is present at birth or develops within the first year of life. Bilateral lower limb swelling is the most frequent presentation (figure 2D), but the swelling may be unilateral and/or involve the arms, genitalia and/or face, depending on the underlying cause. There are a where to buy levitra number of different genetic disorders presenting with congenital lymphoedema (table 1). Milroy disease (ORPHA79452. OMIM 153100) is the most common form, occurring as a result of pathogenic variants in FLT4/VEGFR3.21 22 The mutation may occur de novo, so a family history is not essential for this diagnosis where to buy levitra. The lymphoedema is always confined to the lower limbs but may be unilateral, and may (rarely) involve the genitalia. Approximately 10% of mutation carriers where to buy levitra do not have lymphoedema. Fetuses with Milroy disease may present antenatally with pedal oedema in the third trimester, and, in a few cases, with bilateral hydrothoraces, which resolve before birth.Pathogenic variants in VEGFC, the ligand for VEGFR3, have also been identified in association with congenital primary lymphoedema of Gordon (OMIM 615907), also affecting the lower limbs.23â26The congenital category represents 21% (n=47) of the patients seen in 2016 (figure 2, pie chart) compared with 24% in 2010.8 A pathogenic variant was identified in 19 of the 47 (40%) patients genetically tested in this category. The majority (n=18) had pathogenic variants identified in FLT4/VEGFR3 and, in one patient, a pathogenic variant where to buy levitra in the GJC2 gene. A GJC2 mutation in a patient presenting with lymphoedema at birth is unusual but shows the variability of the phenotype.Many of the conditions listed under the other categories in the classification algorithm may initially present with congenital lymphoedema but systemic involvement, progressive overgrowth or vascular malformation may present later and are so reclassified. Likewise, some syndromic forms may present with congenital lymphoedema before any where to buy levitra other manifestations, making diagnosis difficult at times. Thus, the diagnosis of âisolatedâ congenital primary lymphoedema may be difficult in a neonate presenting with pedal oedema. Therefore, a molecular diagnosis in the neonatal period is clinically very useful in the management of these patients.Late-onset lymphoedema (purple)âLate-onsetâ lymphoedema is defined as presenting after the first year of life. Swelling can range from where to buy levitra being unilateral, bilateral or can involve all four limbs and can present from early childhood up to adulthood (figures 1 and 2E). Some may present with unilateral swelling, but the contralateral limb may become involved later or show abnormalities on lymphoscintigram even when clinically uninvolved. The phenotypes where to buy levitra also range from mild to severe. There are currently five genes known to be associated with late-onset lymphoedema. FOXC2 (figure where to buy levitra 2F),27 GJC2,28 29 GATA2 (figure 2G),30 HGF31 and CELSR132 (table 1). For many patients the molecular cause remains elusive, particularly in those patients with Meige disease and late-onset (usually pubertal) unilateral lower limb lymphoedema.Late-onset primary lymphoedema accounted for 37% (n=85) in 2016 (figure 2, pie chart) comparable to the 36% reported in 2010.8 This category has a low number of molecular diagnoses (n=12. 14%) as there are currently no causative genes for Meige disease, which made up 36% (n=31) of patients where to buy levitra in this category.DiscussionThis review presents an updated St Georgeâs classification algorithm of primary lymphatic anomalies and brings it in-line with the ISSVA classification for vascular anomalies. It cites eight new causative genes since the last publication and highlights the areas where the genetic basis is still not known. This rapidly evolving field demonstrates that primary lymphoedema and vascular malformations are highly heterogenous.The audit reports an overall successful molecular diagnosis in 26% of patients seen in the clinic, but 41% where to buy levitra of those patients selected for molecular testing. This is a considerable improvement on the rate of a molecular diagnosis since the algorithm was first published in 2010. Only two causal genes were where to buy levitra known at that time. We can conclude from the audit that the algorithm works well in targeting mutation testing. Furthermore, use of the algorithm has led to the discovery of a number of where to buy levitra causal genes. While it could be argued that the introduction of the lymphoedema gene panel obviates any need for targeted gene tests, we believe that matching a phenotype to a likely gene reduces wasteful testing and helps enormously in the interpretation of variants of unknown significance, which are becoming an increasing problem in the era of next-generation sequencing.Although providing a molecular diagnosis in one-quarter of all the patients with primary lymphoedema represents a considerable improvement from when the algorithm was last reviewed, the molecular diagnosis is still not identified in the majority of patients seen in the St Georgeâs Clinic. In the diagnostic setting, the introduction of next-generation sequencing with a targeted (virtual) âlymphoedema gene panelâ may improve the diagnostic rate and broaden the phenotypic spectrum of many of where to buy levitra the known genetic disorders. Understanding of the natural history of the disorder will enable appropriate surveillance of, for example, leukaemia in Emberger syndrome (GATA2), and allow investigations for known associated problems, for example, congenital heart disease in patients with lymphoedema distichiasis syndrome (FOXC2). Prenatal diagnosis where to buy levitra for the more serious conditions also becomes possible. Knowledge of causal genes, and mechanisms of pathophysiology, provide an opportunity for new, improved treatments (personalised medicine) (eg, mammalian target of rapamycin inhibitors for progressive overgrowth disorders).In conclusion, the St Georgeâs classification algorithm for primary lymphatic anomalies has been further refined. With this review, we have provided insight into the most recently discovered genotypes and how this algorithm can be used in the clinic to guide management of patients with primary lymphoedema.. IntroductionThe lymphatic system cheapest levitra is a network of vessels important for whole body fluid homeostasis, lipid absorption and immune cell trafficking.1 2 Lymphoedema is caused by lymphatic dysfunction, which leads to a build-up of interstitial fluid within the tissues. This manifests with swelling of the extremities, usually of the legs but may involve other regions or segments of the body such as the upper limbs, face, trunk or genital area. There is an increased risk of due to disturbances in immune cell trafficking within the segment of compromised lymph drainage.3 Lymphatic dysfunction within the thorax and abdomen, cheapest levitra here referred to as systemic/internal involvement (but can be referred to as visceral or central involvement), may present with pleural or pericardial effusions or ascites, any of which may be chylous, as well as intestinal or pulmonary lymphangiectasia, protein losing enteropathy or chylous reflux.The International Society for the Study of Vascular Anomalies (ISSVA) updated their classification for vascular anomalies in 2018.4 The vascular malformations are subgrouped into âcombinedâ, which include more than one type of vessel, âsimpleâ (only involving one vessel type), and those âassociated with other anomaliesâ.Lymphoedema due to a presumed genetic developmental fault in the structure or function of lymph conducting pathways is called primary lymphoedema.5 Some developmental faults can lead to overt structural defects of the lymph conducting pathways and are called lymphatic malformations. Such malformations if interfering with lymph drainage cause lymphoedema (truncal malformations) but some lymphatic malformations remain as isolated anomalies with no connection to main lymph drainage pathways and do not cause lymphoedema (non-truncal malformations).6 A primary lymphatic anomaly is an umbrella term referring to all lymphatic abnormalities arising from a developmental fault.For a long time, the diagnosis of primary lymphoedema was based largely on the age of presentation of the swelling, congenital, pubertal and late onset, with limited differentiation between the phenotypes. The discovery of the first causal gene, vascular endothelial growth factor receptor 3 for Milroy disease, indicated that a molecular cheapest levitra diagnosis was possible.7 The first St Georgeâs classification algorithm of primary lymphoedema and other primary lymphatic disorders was an attempt to guide a clearer categorisation of phenotypes and enable the discovery of further causal genes.8 Age of onset remained a key criterion, but the sites affected and associated features, for example, dysmorphology, distichiasis (aberrant eyelashes), varicose veins, vascular malformations and limb overgrowth were also considered, as was internal or systemic involvement, for example, fetal hydrops, intestinal lymphangiectasia, pleural and pericardial effusions and chylous reflux. A family history of lymphoedema with determination of the mode of inheritance was considered useful.More rigorous phenotyping facilitated the identification of subgroups of patients with the same broad category of primary lymphatic anomaly. These cohorts were then used for molecular studies to cheapest levitra identify more causal genes. Once the genotype was known then crosschecking of the clinical characteristics, natural history and inheritance patterns was possible and an accurate phenotype defined. Investigations such as lymphoscintigraphy helped to refine the phenotype further and give insight into the mechanisms for the development cheapest levitra of the lymphatic disorder. A first update of the classification was published in 2013.9The St Georgeâs classification algorithm is intended to help clinicians categorise their patients and guide testing towards, where possible, a molecular diagnosis. This algorithm is criteria matching, that cheapest levitra is, using certain key findings for classification through a multistep process of history taking, examination findings, mutation testing, etc. The next step using the information gathered is to advise on natural history, prognosis and risk (including genetic counselling) and to guide management. While a molecular diagnosis should provide the most specific and accurate diagnosis, it cheapest levitra can be seen particularly with the postzygotic mosaic disorders that one genotype can be clinically very heterogenous so there will probably always be a place for good clinical phenotyping supported by investigation to guide management.Here, we present a second update of the St Georgeâs classification algorithm to include newly discovered genes and to bring it in-line with the 2018 ISSVA classification for vascular anomalies.4 The results of an audit, the purpose of which was to determine how well the algorithm was performing as a diagnostic aid to classify patients with primary lymphatic anomalies and guide molecular testing are also presented.MethodsSt Georgeâs classification algorithm of primary lymphatic anomaliesThe St Georgeâs classification algorithm was updated (figure 1) and then applied, retrospectively, to all patients presenting to the national multidisciplinary âPrimary and Paediatric Lymphoedemaâ Clinic held at St Georgeâs Hospital over a 1-year period. Careful phenotyping was undertaken both on clinical grounds and after selective investigations, for example, lymphoscintigraphy. Where possible and appropriate, targeted genetic testing was performed (this cheapest levitra was prior to the introduction of a lymphoedema gene panel in our unit) for some of the genes listed in table 1.St Georgeâs classification algorithm for primary lymphatic anomalies. The five main groupings (colour coded) with their various clinical subtypes of disease. Primary lymphoedema is the major clinical feature in the green, pink and cheapest levitra purple sections. Text in red indicates the suggested genetic test and/or differential diagnosis for the subgroup, however, the indicated genes do not explain the cause of disease in all patients in each grouping. For example, only 70% of patients with Milroy disease are explained cheapest levitra by mutations in FLT4/VEGFR3.33 FH, family history. +ve, positive. Âve, negative. (Image shared by St Georgeâs Lymphovascular Research Group under the CC BY-SA 4.0 International licence on Wikimedia Commons)." data-icon-position data-hide-link-title="0">Figure 1 St Georgeâs classification algorithm for primary lymphatic anomalies cheapest levitra. The five main groupings (colour coded) with their various clinical subtypes of disease. Primary lymphoedema is the major clinical feature in the green, pink and cheapest levitra purple sections. Text in red indicates the suggested genetic test and/or differential diagnosis for the subgroup, however, the indicated genes do not explain the cause of disease in all patients in each grouping. For example, only cheapest levitra 70% of patients with Milroy disease are explained by mutations in FLT4/VEGFR3.33 FH, family history. +ve, positive. Âve, negative cheapest levitra. (Image shared by St Georgeâs Lymphovascular Research Group under the CC BY-SA 4.0 International licence on Wikimedia Commons).View this table:Table 1 An overview of genetic disorders with primary lymphoedema as a frequent and dominant feature, categorised by inheritance and age of onsetWithin the St Georgeâs classification algorithm (figure 1), there are five main categories of primary lymphatic anomalies. These are presented in cheapest levitra the form of colour-coded sections with the individual subtypes (including genotypes) within the categories. For definitions of some of the terms used, see Glossary of Terms (see online supplementary section).Supplemental materialFirst, the yellow section includes the âvascular malformations associated with other anomaliesâ and the âlymphatic malformationsâ (as defined in the âIntroductionâ section).Second, the patient is assessed for syndromes that have lymphoedema as a non-dominant feature (blue section), for example, the patient is dysmorphic with learning difficulties and possibly has other abnormalities.Then if not obviously syndromic, and the lymphatic problems are the dominant feature, further assessment and investigations for systemic/internal lymphatic dysfunction or central conducting anomalies (eg, chylothoraces, chylopericardial effusions, ascites or protein losing enteropathy) are undertaken (pink section). These include a careful medical history asking specifically about prenatal history (eg, hydrothoraces, fetal hydrops), chronic diarrhoea, abdominal bloating or discomfort with fatty foods, weight loss or faltering growth cheapest levitra (in a child) or shortness of breath on exertion. Blood investigations (including serum albumin, immunoglobulins, lymphocyte subsets, faecal levels of calprotectin or alpha-1-antitrysin), echocardiograms and chest radiographs are helpful if central lymphatic dysfunction is suspected.Where none of the above features is present, then the age of onset is used to determine the grouping. The green section deals with congenital-onset primary lymphoedema (includes syndromes where cheapest levitra lymphoedema is the dominant clinical problem, and which is present at birth or develops within the first year of life but is not associated with systemic/internal lymphatic dysfunction). The purple section addresses late-onset primary lymphoedema (ie, lymphoedema that is the dominant clinical problem, and which develops after the first year of life but is not associated with systemic/internal lymphatic dysfunction). It was decided not to differentiate between pubertal onset (praecox) and later onset in life (tarda) when it was discovered cheapest levitra that one genotype such as FOXC2 can cause both.It is important to note that the specific diagnosis may be difficult in a neonate presenting with isolated congenital primary lymphoedema. A baby born with lymphoedema may later present with developmental delay, systemic involvement, progressive segmental overgrowth or a vascular malformation, which could suggest a diagnosis in one of the other categories. It should also be emphasised that each cheapest levitra colour-coded section is not exclusive. Some somatic overgrowth anomalies may possess significant internal involvement. Also, lymphoedema distichiasis syndrome is allocated to the purple late-onset lymphoedema section because the dominant feature is the late-onset lymphoedema not the associated features, which make it a syndrome. The blue âsyndromicâ section refers to conditions cheapest levitra with a collection of features where lymphoedema is not the main characteristic. The algorithm is intended to guide a clinical diagnosis and target gene testing.Genetic methodologyFor the purposes of the audit, targeted genetic testing of FOXC2, VEGFR3, CCBE1, SOX18, RASopathy genes and PIK3CA was performed by Sanger sequencing of DNA extracted from lymphocytes or skin fibroblasts in patients in whom a specific genetic diagnosis was suspected. This was cheapest levitra before the introduction of a lymphoedema gene panel. Some patients, who were either negative for the targeted genes or did not fit the relevant phenotypes of those genes, were included in Whole Exome Sequencing (WES) cohorts after classification, which then led to the identification of new disease genes such as EPHB4, GATA2, PIEZO1, GJC2 and FAT4.Retrospective audit of the St Georgeâs Clinic for 2016A 12-month retrospective audit for the year 2016 (1 January 2016â31 December 2016) was performed. The aim of the audit cheapest levitra was to look at the proportion of patients in each category of the classification algorithm and to look at the success of making a molecular diagnosis through use of the algorithm. The audit criteria required the patients to be seen in our specialist clinic, at any age, with a diagnosis of a primary lymphatic anomaly with data collected from medical records and laboratory results.ResultsResults of the retrospective auditOver a 12-month period in 2016, 227 patients were seen (age range 2 weeks to 70 years), 25.6% (n=58/227) of which were new patients. Over one-third cheapest levitra (38%) of patients seen in the clinic had a family history of primary lymphoedema.Few patients had received genetic testing prior to referral to the clinic. Targeted genetic testing was completed in 63% (n=143) of the patients seen. At that time, a lymphoedema gene panel was not available, patients were only tested if the clinician felt there was a reasonable chance of finding a molecular cause, that is, testing was targeted.Of those tested, the underlying genetic cause was cheapest levitra identified in 41% (n=59/143). Overall, a molecular diagnosis was made in 26% (59/227) of all the patients seen in 2016.Vascular malformations with associated anomalies and lymphatic malformations (yellow)This group presents with malformations in the structure and organisation of blood and lymphatic vessels with a patchy, segmental distribution. Lymphoedema may develop in combination with vascular malformations and segmental overgrowth (or occasionally, undergrowth) of tissues within the swollen limb, for cheapest levitra example, muscle, skeletal or adipose tissues (figure 2A). The combination of lymphatic and vascular malformations in this group reflects the mutual embryological origins of the two vascular systems.A graphic representation of the 227 audited patients seen in clinic in 2016 and their distribution across the five categories from figure 1 (pie chart). (AâG) Images show features of each cheapest levitra category. (A) Patients with postzygotic mutations often present with asymmetrical swelling and segmental overgrowth as this patient, who is mosaic for a mutation in KRAS. (B) Webbed cheapest levitra neck in Noonan syndrome. (C) In rare cases, swellings can be widespread affecting all segments of the body such as in this child with biallelic CCBE1 mutations. (D) In cheapest levitra milder forms, often just the dorsum of the foot is affected as in this baby with a VEGFR3 mutation. (E, F) Lower limb swelling and distichiasis (arrowheads in F) in a patient with a FOXC2 mutation. (G) Lymphoedema is a major cause of skin disease and affected patients suffer from severe and recurrent episodes of cutaneous , especially HPV-associated warts as seen in patients with GATA2 mutations. GLD, generalised lymphatic dysplasia." data-icon-position data-hide-link-title="0">Figure cheapest levitra 2 A graphic representation of the 227 audited patients seen in clinic in 2016 and their distribution across the five categories from figure 1 (pie chart). (AâG) Images show features of each category. (A) Patients with postzygotic mutations cheapest levitra often present with asymmetrical swelling and segmental overgrowth as this patient, who is mosaic for a mutation in KRAS. (B) Webbed neck in Noonan syndrome. (C) In rare cases, swellings can be widespread cheapest levitra affecting all segments of the body such as in this child with biallelic CCBE1 mutations. (D) In milder forms, often just the dorsum of the foot is affected as in this baby with a VEGFR3 mutation. (E, F) Lower limb swelling and distichiasis (arrowheads in cheapest levitra F) in a patient with a FOXC2 mutation. (G) Lymphoedema is a major cause of skin disease and affected patients suffer from severe and recurrent episodes of cutaneous , especially HPV-associated warts as seen in patients with GATA2 mutations. GLD, generalised lymphatic dysplasia.These conditions are usually due to postzygotic mutations, cheapest levitra for example, PIK3CA-related overgrowth spectrum (PROS)). Exceptions to this are capillary malformation-arteriovenous malformation (MIM 608354) such as Parkes-Weber syndrome, which may be caused by heterozygous, germline mutations in RASA1.10Of the 227 patients seen in 2016, 17% (n=39) had lymphoedema associated with vascular malformations and/or segmental overgrowth (or undergrowth) (figure 2, pie chart) in comparison with 15% in 2010.8 It has been shown that postzygotic, gain of function mutations in PIK3CA may be responsible for many of the mosaic segmental overgrowth spectrum disorders.11 Postzygotic mutations are rarely identified in blood samples and therefore require a skin biopsy of the affected region. In the 2016 cheapest levitra cohort, only 10 patients (26%) provided skin biopsies for genetic analysis, producing just one molecular diagnosis. More research in this field is required to identify the genetic basis for some of the conditions in this category. However, since the last revision, we have cheapest levitra gained a much better understanding of the classification of some of these postzygotic mosaic conditions, therefore a brief review of the latest developments in this area is given in the online supplementary section.Syndromic lymphoedema (blue)Syndromes associated with primary lymphatic anomalies are listed in table 2 and include chromosomal abnormalities, single gene disorders and imprinting disorders. Patients attending the clinic with syndromic primary lymphoedema made up 13% (n=29) (figure 2, pie chart), similar to the 15% reported by Connell et al.8 Nearly three-quarters (72%, n=21) of this cohort had a molecular or chromosomal diagnosis. The most frequently seen syndromes were Noonan syndrome (n=8) (figure 2B), Turner syndrome (n=4) and Phelan McDermid cheapest levitra syndrome (n=3).View this table:Table 2 An overview of âKnown Syndromesâ with primary lymphoedema as a non-dominant association as referred to in the St Georgeâs classification algorithm (figure 1, blue section)Lymphoedema with prenatal or postnatal systemic involvement (pink)In some conditions, lymphoedema may be associated with internal (systemic or visceral) disturbances of the lymphatic system within thorax or abdomen, for example, fetal hydrops, intestinal lymphangiectasia (presenting as protein-losing enteropathy), pulmonary lymphangiectasia or with pericardial and/or pleural effusions (often chylous), or chylous reflux (often into the genitalia). Broadly, there are two types of lymphoedema with systemic involvement. (A) âwidespreadâ swelling affecting all segments cheapest levitra of the body (figure 2C), such as that seen in generalised lymphatic dysplasia (GLD). Due to faulty development, the structural or functional abnormality of the lymphatic system is affecting the whole body. One type is Hennekam-lymphangiectasia-lymphoedema syndrome12. (B) âpatchyâ areas of swelling, for cheapest levitra example, left arm and right leg, which have been named âmultisegmental lymphatic dysplasiaâ (MLD) (figure 1).Prenatally, these conditions may present with pleural effusions (hydrothoraces), or as non-immune fetal hydrops (the accumulation of fluid in at least two compartments of a fetus such as the abdominal cavity, pleura or subcutaneous oedema). Fifteen per cent of non-immune cases of hydrops are the result of lymphatic disorders, and approximately 20% are idiopathic, some of which may be due to, as yet, unidentified lymphatic abnormalities.13In our audit, this cohort accounted for 12% (n=27) of patients (figure 2, pie chart), slightly higher than the 8% reported in 2010.8 Molecular testing was carried out in 17 patients. Nine of those tested had GLD, and pathogenic variants were cheapest levitra identified in seven (78%). Five had biallelic variants in the PIEZO1 gene and one each with biallelic variants in FAT4 and SOX18. Interestingly, two of cheapest levitra the families described by Connell et al, cases 3 and 4, have subsequently been found to be caused by biallelic variants in the PIEZO1 gene.8 14None of the eight patients, who presented with âpatchyâ distribution of lymphoedema (MLD), had an identifiable molecular diagnosis. It is suspected that these patients could have a postzygotic mosaic mutation or WILD syndrome.15Since the last revision of the St Georgeâs classification algorithm was published,9 five new causal genes associated with GLD and/or non-immune fetal hydrops have been identified. ADAMTS3,16 EPHB4,17 FAT4,18 FBXL719 and PIEZO114 20 and are reviewed in the online supplementary section.Congenital onset lymphoedema (green)In this category, congenital onset is defined as lymphoedema that is present at birth or develops within the first year of cheapest levitra life. Bilateral lower limb swelling is the most frequent presentation (figure 2D), but the swelling may be unilateral and/or involve the arms, genitalia and/or face, depending on the underlying cause. There are a number of different genetic disorders presenting with congenital lymphoedema cheapest levitra (table 1). Milroy disease (ORPHA79452. OMIM 153100) is cheapest levitra the most common form, occurring as a result of pathogenic variants in FLT4/VEGFR3.21 22 The mutation may occur de novo, so a family history is not essential for this diagnosis. The lymphoedema is always confined to the lower limbs but may be unilateral, and may (rarely) involve the genitalia. Approximately 10% cheapest levitra of mutation carriers do not have lymphoedema. Fetuses with Milroy disease may present antenatally with pedal oedema in the third trimester, and, in a few cases, with bilateral hydrothoraces, which resolve before birth.Pathogenic variants in VEGFC, the ligand for VEGFR3, have also been identified in association with congenital primary lymphoedema of Gordon (OMIM 615907), also affecting the lower limbs.23â26The congenital category represents 21% (n=47) of the patients seen in 2016 (figure 2, pie chart) compared with 24% in 2010.8 A pathogenic variant was identified in 19 of the 47 (40%) patients genetically tested in this category. The majority (n=18) had pathogenic variants identified in FLT4/VEGFR3 and, in one patient, a pathogenic variant in the GJC2 gene cheapest levitra. A GJC2 mutation in a patient presenting with lymphoedema at birth is unusual but shows the variability of the phenotype.Many of the conditions listed under the other categories in the classification algorithm may initially present with congenital lymphoedema but systemic involvement, progressive overgrowth or vascular malformation may present later and are so reclassified. Likewise, some syndromic forms may present cheapest levitra with congenital lymphoedema before any other manifestations, making diagnosis difficult at times. Thus, the diagnosis of âisolatedâ congenital primary lymphoedema may be difficult in a neonate presenting with pedal oedema. Therefore, a molecular diagnosis in the neonatal period is clinically very useful in the management of these patients.Late-onset lymphoedema (purple)âLate-onsetâ lymphoedema is defined as presenting after the first year of life. Swelling can range from being unilateral, bilateral or can involve all four limbs and can present from early childhood up to adulthood (figures cheapest levitra 1 and 2E). Some may present with unilateral swelling, but the contralateral limb may become involved later or show abnormalities on lymphoscintigram even when clinically uninvolved. The phenotypes cheapest levitra also range from mild to severe. There are currently five genes known to be associated with late-onset lymphoedema. FOXC2 (figure 2F),27 GJC2,28 29 GATA2 (figure 2G),30 HGF31 cheapest levitra and CELSR132 (table 1). For many patients the molecular cause remains elusive, particularly in those patients with Meige disease and late-onset (usually pubertal) unilateral lower limb lymphoedema.Late-onset primary lymphoedema accounted for 37% (n=85) in 2016 (figure 2, pie chart) comparable to the 36% reported in 2010.8 This category has a low number of molecular diagnoses (n=12. 14%) as there are currently no causative genes for Meige disease, which made up 36% (n=31) of patients cheapest levitra in this category.DiscussionThis review presents an updated St Georgeâs classification algorithm of primary lymphatic anomalies and brings it in-line with the ISSVA classification for vascular anomalies. It cites eight new causative genes since the last publication and highlights the areas where the genetic basis is still not known. This rapidly evolving field demonstrates that primary lymphoedema and vascular malformations are highly heterogenous.The audit reports an overall successful molecular diagnosis in cheapest levitra 26% of patients seen in the clinic, but 41% of those patients selected for molecular testing. This is a considerable improvement on the rate of a molecular diagnosis since the algorithm was first published in 2010. Only two causal genes were known at cheapest levitra that time. We can conclude from the audit that the algorithm works well in targeting mutation testing. Furthermore, use of the algorithm has led to the cheapest levitra discovery of a number of causal genes. While it could be argued that the introduction of the lymphoedema gene panel obviates any need for targeted gene tests, we believe that matching a phenotype to a likely gene reduces wasteful testing and helps enormously in the interpretation of variants of unknown significance, which are becoming an increasing problem in the era of next-generation sequencing.Although providing a molecular diagnosis in one-quarter of all the patients with primary lymphoedema represents a considerable improvement from when the algorithm was last reviewed, the molecular diagnosis is still not identified in the majority of patients seen in the St Georgeâs Clinic. In the diagnostic setting, the introduction of next-generation sequencing with a targeted (virtual) âlymphoedema gene panelâ may improve the diagnostic cheapest levitra rate and broaden the phenotypic spectrum of many of the known genetic disorders. Understanding of the natural history of the disorder will enable appropriate surveillance of, for example, leukaemia in Emberger syndrome (GATA2), and allow investigations for known associated problems, for example, congenital heart disease in patients with lymphoedema distichiasis syndrome (FOXC2). Prenatal diagnosis for the more serious conditions cheapest levitra also becomes possible. Knowledge of causal genes, and mechanisms of pathophysiology, provide an opportunity for new, improved treatments (personalised medicine) (eg, mammalian target of rapamycin inhibitors for progressive overgrowth disorders).In conclusion, the St Georgeâs classification algorithm for primary lymphatic anomalies has been further refined. With this review, we have provided insight into the most recently discovered genotypes and how this algorithm can be used in the clinic to guide management of patients with primary lymphoedema.. Can you get levitra without a prescriptionAbout This TrackerThis tracker provides the number of confirmed cases and deaths from novel erectile dysfunction can you get levitra without a prescription by country, the trend in confirmed case and death counts by country, and a global map showing which countries have confirmed cases and deaths. The data are drawn from the Johns Hopkins University (JHU) erectile dysfunction Resource Centerâs erectile dysfunction treatment Map and the World Health Organizationâs (WHO) erectile dysfunction Disease (erectile dysfunction treatment-2019) situation reports.This tracker will be updated regularly, as new data are released.Related Content. About erectile dysfunction treatment erectile dysfunctionIn late 2019, a new erectile dysfunction emerged in central China can you get levitra without a prescription to cause disease in humans. Cases of this disease, known as erectile dysfunction treatment, have since been reported across around the globe. On January can you get levitra without a prescription 30, 2020, the World Health Organization (WHO) declared the levitra represents a public health emergency of international concern, and on January 31, 2020, the U.S. Department of Health and Human Services declared it to be a health emergency for the United States.Global Health Legislation During the 117th Congress(as of Aug. 2, 2021)TitleDate IntroducedBill #SponsorStatusTopicSummary of Global Health-Related ProvisionsAbortion is Health Care Everywhere Act of 2021To amend the Foreign Assistance Act of 1961 to authorize the use of funds for comprehensive reproductive health care services, and for other purposes.3/9/2021H.R. 1670Rep. Janice Schakowsky (D-IL-9)Referred to HFACAbortion, Helms amendmentIncludes statement of U.S. Policy regarding safe abortion and working to end unsafe abortion. Repeals the Helms Amendment (which prohibits the use of foreign assistance to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortion). States that notwithstanding any other provision of law, certain funds may be used to provide comprehensive reproductive health care services, including abortion services, training, and equipment.Advancing Emergency Preparedness Through One Health Act of 2021To establish an interagency One Health Program, and for other purposes.3/18/2021S. 861Sen. Tina Smith (D-MN)Read twice and referred to S. HELPOne Health, global health securityRequires the heads of HHS, USDA, USAID, DoD, and certain other agencies to develop, publish, and submit to Congress a national One Health Framework for coordinated federal activities under the One Health Program not later than one year after enactment. Among other things, states the framework must describe existing efforts and contain recommendations for building upon and complementing the activities of the CDC, the FDA, USAID, NIH, and certain others and also establish specific federal goals and priorities and describe specific activities required to achieve these. Requires the submission of an addendum to the framework not later than three years after its original submission, describing progress in advancing these activities. Authorizes to be appropriated such sums as necessary to develop the framework above. Requires GAO to submit a report to Congress not later than two years after the addendum is submitted, detailing existing collaborative efforts among certain agencies for this purpose and containing an evaluation of the framework and its specified activities.American Medical Investment Generating Overseas Security Act(AMIGOS Act)To prohibit the President from taking any action to support the waiver of obligations of members of the World Trade Organization under the Agreement on Trade-Related Aspects of Intellectual Property Rights in relation to the prevention, containment, mitigation, or treatment of erectile dysfunction treatmentâ19 unless a statute is enacted expressly authorizing such a waiver with respect to the prevention, containment, mitigation, or treatment of erectile dysfunction treatmentâ19, and for other purposes.5/14/2021H.R. 3236Maria Elvira Salazar (R-FL-27)Referred to HFAC and H. Ways and MeansTRIPS, WTO, intellectual property rights, erectile dysfunction treatmentsStates the President may not take any action to support waiver of obligations of WRO members under the TRIPS agreement in relation to the prevention, containment, mitigation, or treatment of erectile dysfunction treatment unless a statute is enacted expressly authorizing such a waiver with respect to such. Requires the President to allocate excess U.S. erectile dysfunction treatments in a specified order of priority, with certain exceptions, and to monitor the allocation of such to ensure assisted governments provide treatments to their peoples in a timely manner and do not otherwise withhold them. Requires such treatments provided to foreign countries to be marked as assistance from the American people or the U.S. Government and to include a depiction of the flag of the U.S. If appropriate.American Rescue Plan Act of 2021To provide for reconciliation pursuant to title II of S. Con. Res. 5.2/24/2021H.R. 1319Rep. John Yarmuth (D-KY-3)Became law (P.L. 117-2)erectile dysfunction treatment, Global FundSee KFF summary.American Values ActTo permanently enact certain appropriations Act restrictions on the use of funds for abortions and involuntary sterilizations, and for other purposes.2/4/2021S. 239Sen. James Risch (R-ID)Read twice and referred to SFRCAbortion, involuntary sterilization amendment, Siljander amendment, Kemp-Kasten amendment, Peace Corps provision, Helms amendment, Biden amendmentAmends the Foreign Assistance Act of 1961 to codify in permanent law the Siljander amendment, which prohibits the use of funds to lobby for or against abortion, and the Kemp-Kasten amendment, which prohibits funding any organization or program, as determined by the President, that supports or participates in the management of a program of coercive abortion or involuntary sterilization. Restates the Helms amendment, the Involuntary Sterilization amendment (which prohibits the use of funds to pay for involuntary sterilizations as a method of family planning or to coerce or provide a financial incentive to anyone to undergo sterilization), and the Biden amendment (which states that funds may not be used for biomedical research related to methods of or the performance of abortion or involuntary sterilization as a means of family planning) that are already in permanent law. Also amends the Peace Corps Act to codify in permanent law the Peace Corps provision, which prohibits Peace Corps funding from paying for an abortion for a Peace Corps volunteer or trainee, except in cases where the life of the woman is endangered by pregnancy or in cases of rape or incest. In the past these have been included only in annual State-Foreign Operations appropriations language. See also the KFF fact sheet on FP/RH statutory requirements and policies and the KFF explainer on UNFPA funding and Kemp-Kasten.Binational Health Strategies Act of 2021To amend the United States-Mexico Border Health Commission Act, with respect to preparedness for erectile dysfunction treatmentâ19 and other infectious diseases in the border region, and for other purposes.3/03/2021H.R. 1538Rep.. Veronica Escobar (D-TX-16)Referred to H. Energy and HFACMexicoAuthorizes and directs the President to seek to begin negotiations with Mexico to amend an existing agreement addressing infectious disease preparedness in the U.S.-Mexico Border Area, with respect to erectile dysfunction treatment and other infectious diseases, specifically requiring the U.S.-Mexico Border Health Commission to submit a report on the border areaâs response to erectile dysfunction treatment and requiring it to also develop and publicly publish a binational strategic plan that addresses how the area should strengthen its erectile dysfunction treatment response, sharing relevant health data, and how a erectile dysfunction treatment should be disbursed throughout the area, among other things. Requires the Commission to publish what actions federal agencies in the U.S. And Mexico will take to facilitate implementation of the strategic plan and then to submit a report on actions taken each year. Requires the Commission to develop and publish a plan to prepare and respond to infectious diseases (other than erectile dysfunction treatment) within the border area, to update the plan at least once every three years for as long as necessary, and to publish what actions federal agencies in the U.S. And Mexico will take to facilitate implementation of this plan, with a report on actions taken each year required to be submitted.BLUE Pacific ActTo establish a comprehensive, long-term United States strategy and policy for the Pacific Islands, and for other purposes.5/4/2021H.R. 2967Rep. Ed Case (D-HI-1)Referred to HFAC, H. Ways and Means, H. Natural ResourcesPublic health capacity building, erectile dysfunction treatment, gender-based violenceStates U.S. Policy is to develop and commit to a comprehensive, multifaceted, and principled U.S. Policy in the Pacific Islands that, among other things, assists the Pacific Islands in preventing and containing the spread of the erectile dysfunction treatment levitra. Requires the USAID Administrator, in coordination with the Secretary of States, to develop and implement a strategy to assist the Pacific Islands in improving public health outcomes and building public health capacity, including in response to the erectile dysfunction treatment levitra. Requires the strategy include programming to address maternal and child health, family planning and reproductive health, gender-based violence, food security and nutrition, NCDs, NTDs, tuberculosis, HIV/AIDS, STDs, and zoonotic and emerging infectious disease threats, clean water, sanitation, and hygiene (WASH), health system strengthening, and other activities. Requires a report not later than 180 days after enactment with strategy. Authorizes to be appropriated $20 million for each FY22-FY26 to carry out these efforts. Requires the Secretary of State and USAID Administrator to develop and implement an initiative to encourage and support efforts by the Pacific Island to reduce and combat gender-based violence.Climate Change Health Protection and Promotion Act of 2021To direct the Secretary of Health and Human Services to develop and implement a national strategic action plan and program to assist health professionals and systems in preparing for and responding to the public health effects of climate change, and for other purposes.5/17/2021H.R. 3271Rep. Matt Cartwright (D-PA-8)Referred to H. Energy and CommerceClimate change, global healthDirects Secretary of HHS to publish a strategic action plan and establish a climate change and health program (at CDC, in collaboration with other agencies, as appropriate) to ensure the public health and health care systems are prepared for and can respond to the impacts of climate change on health in the U.S. And other nations. Requires the action plan include an assessment of U.S. Capacity to address climate change including, among other things, providing technical assistance and support for preparedness and response plans for the health threats of climate change in developing countries, and developing or strengthening domestic and international disease surveillance systems and monitoring capacity to respond to health-related impacts of climate change. Describes priority health actions for the climate and health program, including with regard to global health aspects of climate change. Requires periodic updates of action plan. Establishes science advisory board and its functions, including with regarding to international impacts of climate change on health. And directs HHS Secretary to have National Academies prepare reports on topic, with the first due in one year and then every 4 years thereafter.Climate Change Health Protection and Promotion Act of 2021To direct the Secretary of Health and Human Services to develop and implement a national strategic action plan and program to assist health professionals and systems in preparing for and responding to the public health effects of climate change, and for other purposes.5/19/2021S. 1702Sen. Edward Markey (D-MA)Read twice and referred to S. HELPClimate change, global healthDirects Secretary of HHS to publish a strategic action plan and establish a climate change and health program (at CDC, in collaboration with other agencies, as appropriate) to ensure the public health and health care systems are prepared for and can respond to the impacts of climate change on health in the U.S. And other nations. Requires the action plan include an assessment of U.S. Capacity to address climate change including, among other things, providing technical assistance and support for preparedness and response plans for the health threats of climate change in developing countries, and developing or strengthening domestic and international disease surveillance systems and monitoring capacity to respond to health-related impacts of climate change. Describes priority health actions for the climate and health program, including with regard to global health aspects of climate change. Requires periodic updates of action plan. Establishes science advisory board and its functions, including with regarding to international impacts of climate change on health. And directs HHS Secretary to have National Academies prepare reports on topic, with the first due in one year and then every 4 years thereafter.Curbing Chinaâs treatment Diplomacy ActTo prioritize the international distribution of erectile dysfunction treatment doses, and for other purposes.7/6/2021H.R.4362Rep. Carlos Gimenez (R-FL-26)Referred to HFACerectile dysfunction treatment, treatmentsRequires the Secretary of States to prioritize, in carrying out the international distribution of erectile dysfunction treatment doses, distribution to Taiwan and crucial Latin American allies, subject first to Administration certification to Congress that it has determined all Americans have been afforded ample opportunity to be fully vaccinated against erectile dysfunction treatment. Requires the Secretary to ensure that not less than 25% of the total number of erectile dysfunction treatment doses intended for international distribution are reserved for and distributed to Taiwan and crucial Latin American allies and states the Secretary may not distribute any doses to other recipients or countries until the above have each received at least a first shipment of their reserved doses. States the Secretary may not distribute erectile dysfunction treatment doses to any country which has a government that has been determined to have engaged in systemic or widespread human rights abuses. Terminates five days after the date on which the Secretary determines the above have each achieved 40% vaccination rates of their respective populations.Department of State, Foreign Operations, and Related Programs Appropriations Act, 2022(State/Foreign Ops â SFOPS Approps)Making appropriations for the Department of State, foreign operations, and related programs for the fiscal year ending September 30, 2022, and for other purposes.7/6/2021H.R. 4373Rep. Barbara Lee (D-CA-13)Passed House, received in the SenateAppropriationsSee KFF summary. Includes the text of the Global Health, Empowerment, and Rights (Global HER) Act (H.R. 556), which codifies prohibition of the expanded Mexico City policy (rescinded by President Biden in Jan. 2021, see KFF explainer). Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2022(Labor/HHS â LHHS Approps)Making appropriations for the Departments of Labor, Health and Human Services, and Education, and related agencies for the fiscal year ending September 30, 2022, and for other purposes.7/19/2021H.R. 4502Rep. Rosa DeLauro (D-CT-3)Passed HouseAppropriationsSee KFF summary.Global Autism ActTo establish a Global Autism Assistance Program.6/24/2021H.R. 4160Rep. Christopher Smith (R-NJ-4)Referred to HFACAutismEstablishes a health and education grant program known as the Global Autism Assistance Program at USAID to support activities focused on autism spectrum disorder (ASD) in developing countries and to establish a program, known as Train the Trainers, to train health and education professionals working with children with ASD in developing countries. Outlines designation of eligible regions and selection of implementing NGO and activities it may carry out with the grant. Requires the implementing NGO to establish a Project Advisory Board to review local applications for content and appropriateness. To carry out this program, requires the USAID Administrator to allocate amounts that have been appropriated or otherwise made available to USAID. Requires an annual report on activities.Global Health, Empowerment and Rights Act(Global HER Act) To prohibit the application of certain restrictive eligibility requirements to foreign nongovernmental organizations with respect to the provision of assistance under part I of the Foreign Assistance Act of 1961.1/28/2021H.R. 556Rep. Barbara Lee (D-CA-13)Referred to HFACAbortion, Mexico City policyCodifies prohibition of the expanded Mexico City policy (rescinded by President Biden in Jan. 2021, see KFF explainer). States that notwithstanding any provision of law, regulation, or policy, foreign non-governmental organizations (NGOs) shall not be ineligible for certain foreign aid under the Foreign Assistance Act solely on the basis of health or medical services provided with non-U.S. Funds (insofar as legal in country where provided and under U.S. Law) and shall not be subject to requirements relating to their use of non-U.S. Funds for advocacy and lobbying activities.*Global Health, Empowerment and Rights Act(Global HER Act) To prohibit the application of certain restrictive eligibility requirements to foreign nongovernmental organizations with respect to the provision of assistance under part I of the Foreign Assistance Act of 1961.1/28/2021S. 142Sen. Jeanne Shaheen (D-NH)Read twice and referred to SFRCAbortion, Mexico City policyCodifies prohibition of the expanded Mexico City policy (rescinded by President Biden in Jan. 2021, see KFF explainer). States that notwithstanding any provision of law, regulation, or policy, foreign non-governmental organizations (NGOs) shall not be ineligible for certain foreign aid under the Foreign Assistance Act solely on the basis of health or medical services provided with non-U.S. Funds (insofar as legal in country where provided and under U.S. Law) and shall not be subject to requirements relating to their use of non-U.S. Funds for advocacy and lobbying activities.*Global Health Security Act of 2021To authorize a comprehensive, strategic approach for United States foreign assistance to developing countries to strengthen global health security, and for other purposes.1/21/2021H.R. 391Rep. Gerald Connolly (D-VA-11)Passed House, read twice and referred to SFRCGlobal health security, global health emergenciesStates it is U.S. Policy to promote and invest in global health security and levitra preparedness as a core national security interest. Establishes a Global Health Security Agenda Interagency Review Council, designates members, responsibilities, and frequency of meetings. Designates a U.S. Coordinator for Global Health Security responsible for coordination of the interagency process for responding to global health security emergencies. Express Sense of Congress that the President should consider appointing an individual with significant background and expertise in public health or emergency response management to such position. Requires a U.S. Global health security strategy, its implementation (including agency-specific plans), and an annual report on status of implementation. Directs the Secretary of State, Treasury Secretary, USAID Administrator, and HHS Secretary, among others, to seek to enter into negotiations with donors, relevant U.N. Agencies (including WHO), and other stakeholders to establish a fund for global health security and levitra preparedness as a multilateral, catalytic financing mechanism. Describes Fundâs Advisory Board, purpose, Executive Board and its makeup and duties. Creates a Coordinator of U.S. Government activities to advance global health security, who shall be appointed by the President to represent the U.S. On the Executive Board. Outlines eligible partner country definition and Fund program objectives, supported activities, administration, including appointment of an Administrator appointed by the Executive Board, and transparency and accountability requirements. Requires reports to Congress on the Fund including a 6 month status report and then annual reports after the Fundâs establishment. And authorizes U.S. Contributions to the Fund with a limit that the U.S. Share not exceed 33% of total contributions to the Fund cumulatively.Global Malnutrition Prevention and Treatment Act of 2021To advance targeted and evidence-based interventions for the prevention and treatment of global malnutrition and to improve the coordination of such programs, and for other purposes.07/26/2021H.R. 4693Rep. Michael McCaul (R-TX-10)Passed HFAC (Ordered to be Reported by Voice Vote)MalnutritionAuthorizes the USAID Administrator to support efforts to prevent and treat malnutrition globally, including by targeting resources and nutrition interventions to support the most vulnerable populations susceptible to severe malnutrition, including children under the age of 5 and pregnant and lactating women. Directs the Administrator and others to coordinate with bilateral and multilateral donors, governments of partner countries, U.N. Agencies, and others to prevent and treat malnutrition globally. Requires the Administrator and others to seek to leverage additional resources to this end by increasing interagency cooperation among relevant departments and agencies represented in the Global Nutrition Coordination Plan. Requires the selection of priority countries and outlines criteria. Express Sense of Congress that efforts to undertake nutrition interventions in countries not selected as priority countries should continue. Authorizes the establishment of the Nutrition Leadership Council within USAID and outlines its duties and membership. Requires the development of an implementation plan. Requires an annual progress report for five years.Global levitra Prevention and Biosecurity ActTo establish a global zoonotic disease task force, and for other purposes. 5/20/2021H.R. 3424Rep. Grace Meng (D-NY-6)Referred to HFAClevitra, zoonotic diseases, One Health, global health security, biosecurityRequires the Secretary of State and USAID Administrator to work with certain relevant agency heads to coordinate, work with, and engage governments, multilateral entities, and certain others to prevent zoonotic spillover events through various actions such as addressing the commercial trade in wildlife, strengthening global capacity for detection of zoonotic diseases with levitra potential, and supporting the development of One Health systems at the community level. Establishes the global zoonotic disease task force and outlines its membership and their terms, duties (including developing and publishing a plan for global biosecurity and zoonotic disease prevention and response and expanding the scope of the global health security strategy to more robustly support the prevention of zoonotic spillover and to respond to zoonotic disease investigations and outbreaks by establishing a 10 year strategy), required reports from agencies to the task force as well as from the task force to Congress, and its termination date 7 years after the date of enactment or a later date that is not later than two years after that.Global levitra Prevention and Biosecurity ActTo establish a global zoonotic disease task force, and for other purposes. 5/20/2021S.1737Sen. Chris Coons (D-DE)Read twice and referred to SFRClevitra, zoonotic diseases, One Health, global health security,biosecurityRequires the Secretary of State and USAID Administrator to work with certain relevant agency heads to coordinate, work with, and engage governments, multilateral entities, and certain others to prevent zoonotic spillover events through various actions such as addressing the commercial trade in wildlife, strengthening global capacity for detection of zoonotic diseases with levitra potential, and supporting the development of One Health systems at the community level. Establishes the global zoonotic disease task force and outlines its membership and their terms, duties (including developing and publishing a plan for global biosecurity and zoonotic disease prevention and response and expanding the scope of the global health security strategy to more robustly support the prevention of zoonotic spillover and to respond to zoonotic disease investigations and outbreaks by establishing a 10 year strategy), required reports from agencies to the task force as well as from the task force to Congress, and its termination date 7 years after the date of enactment or a later date that is not later than two years after that.Greater Leadership Overseas for the Benefit of Equality Act of 2021(GLOBE Act of 2021)To protect human rights and enhance opportunities for LGBTQI people around the world, and for other purposes. 6/9/2021S. 1996Sen. Edward Markey (D-MA)Read twice and referred to SFRCLGBTQI health, HIV, Mexico City policyRequires equal access of all elements of the population to programs funded by U.S. Assistance, including global health programs.Also requires PEPFAR to. Be implemented in a way that equitably serves LGBTQI people, submit a report to Congress describing international prosecutions for sex work or consensual sexual activity based on commodities provided by PEPFAR or other U.S. Support, and submit a report to Congress on HIV/AIDS-related index testing. Requires GAO to submit a report to Congress that describes the impact of the implementation and enforcement of any iteration of the Mexico City Policy on the global LGBTQI community. And expresses Sense of Congress regarding the U.S. Engaging international organizations in efforts to eliminate LGBTQI discrimination.Greater Leadership Overseas for the Benefit of Equality Act of 2021(GLOBE Act of 2021)To protect human rights and enhance opportunities for LGBTQI people around the world, and for other purposes. 6/8/2021H.R. 3800Rep. Dina Titus (D-NV-1)Referred to HFAC, H. JudiciaryLGBTQI health, HIV, Mexico City policyRequires equal access of all elements of the population to programs funded by U.S. Assistance, including global health programs.Also requires PEPFAR to. Be implemented in a way that equitably serves LGBTQI people, submit a report to Congress describing international prosecutions for sex work or consensual sexual activity based on commodities provided by PEPFAR or other U.S. Support, and submit a report to Congress on HIV/AIDS-related index testing. Requires GAO to submit a report to Congress that describes the impact of the implementation and enforcement of any iteration of the Mexico City Policy on the global LGBTQI community. Expresses Sense of Congress regarding the U.S. Engaging international organizations in efforts to eliminate LGBTQI discrimination. And repeals the Mexico City policy by removing certain limitations on eligibility for foreign assistance.Honoring OCEANIA ActTo strengthen United States engagement in the Oceania region and enhance the security and resilience of allies and partners of the Oceania community, and for other purposes.5/20/2021H.R. 3373Rep. Ami Bera (D-CA-7)Referred to HFAC, H. Veteransâ Affairs, H. Natural Resources, H. Armed Services, H. Financial Services, H. Judiciary, H. Transportation and Infrastructure, H. Homeland SecurityPublic health capacity building, global health securityStates it is U.S. Policy to, among other things, improve the local capacity of the countries of Oceania to address public health challenges and improve global health security. Requires the Secretary of State, in consultation with the HHS Secretary, to establish a program to support building public health capacity and improving access to care and local health outcomes in Oceania related to maternal and child health, STDs, HIV/AIDS, tuberculosis, malaria, NTDs, NCDs, gender-based violence, substance use disorder, mortality due to epidemics, disasters, and the impacts from severe weather and environmental change, and other health issues. Requires a report on these efforts annually. Authorizes to be appropriated such sums as may be necessary to carry out the program. Requires amounts appropriated or made available to remain available under expended.Honoring OCEANIA ActTo strengthen United States engagement in the Oceania region and enhance the security and resilience of allies and partners of the Oceania community, and for other purposes.5/20/2021S. 1774Sen. Brian Schatz (D-HI)Read twice and referred to SFRCPublic health capacity building, global health securityStates it is U.S. Policy to, among other things, improve the local capacity of the countries of Oceania to address public health challenges and improve global health security. Requires the Secretary of State, in consultation with the HHS Secretary, to establish a program to support building public health capacity and improving access to care and local health outcomes in Oceania related to maternal and child health, STDs, HIV/AIDS, tuberculosis, malaria, NTDs, NCDs, gender-based violence, substance use disorder, mortality due to epidemics, disasters, and the impacts from severe weather and environmental change, and other health issues. Requires a report on these efforts annually. Authorizes to be appropriated such sums as may be necessary to carry out the program. Requires amounts appropriated or made available to remain available under expended.International Human Rights Defense Act of 2021To establish in the Bureau of Democracy, Human Rights, and Labor of the Department of State a Special Envoy for the Human Rights of LGBTI Peoples, and for other purposes.2/22/2021H.R. 1201Rep. Alan Lowenthal (D-CA-47)Referred to HFACLGBTI health, HIVIncludes statement of U.S. Policy regarding LGBTI issues globally, including employing a multisectoral approach to preventing and responding to criminalization, discrimination, and violence against LGBTI people internationally, including activities in the health sector. Authorizes the provision of U.S. Assistance to prevent and respond to these issues internationally, including enhancement of health sector capacity related to violence against LGBTI people and communities and to combat HIV.International Human Rights Defense Act of 2021To establish in the Bureau of Democracy, Human Rights, and Labor of the Department of State a Special Envoy for the Human Rights of LGBTI Peoples, and for other purposes.2/24/2021S. 424Sen. Edward Markey (D-MA)Read twice and referred to SFRCLGBTI health, HIVIncludes statement of U.S. Policy regarding LGBTI issues globally, including employing a multisectoral approach to preventing and responding to criminalization, discrimination, and violence against LGBTI people internationally, including activities in the health sector. Authorizes the provision of U.S. Assistance to prevent and respond to these issues internationally, including enhancement of health sector capacity related to violence against LGBTI people and communities and to combat HIV.International levitra Preparedness and erectile dysfunction treatment Response Act of 2021To improve global health, and for other purposes.6/24/2021S. 2297Sen. James Risch (R-ID)Placed on Senate Legislative Calendar under General Orderslevitra preparedness, erectile dysfunction treatment, treatments, WHO, health systems strengthening, CEPI, global health security, Global Fund to Fight AIDS, Tuberculosis and malariaRequires a report describing certain foreign assistance obligated/expended under the American Rescue Plan Act of 2021 and a plan for certain remaining funds. Requires development of a strategy to expand access to, and accelerate the global distribution of, erectile dysfunction treatments to other countries. Requires a report that assesses the global humanitarian response to erectile dysfunction treatment and outlines specific elements of the U.S. Governmentâs country-level response to the erectile dysfunction treatment levitra. In the event of an infectious disease outbreak outside the U.S. With levitra potential, states the President should designate the Department of State to serve as the lead for diplomatic engagement and related foreign policy efforts, USAID to serve as the key lead agency for design and implementation of the U.S. International response, relief, and recovery assistance, and the CDC to serve as the public health lead for the international response such as building up (in coordination with USAID) emergency operation centers. Allows certain foreign assistance funding to be used to support USAID disaster surge capacity. Requires a U.S. Global health security strategy and report. Authorizes to be established a committee on global health security and levitra and biological threats within the National Security Council (NSC) led by the Special Advisor for Global Health Security of the NSC. Within the Department of State, establishes a Special Representative for U.S. International activities to advance global health security and diplomacy overseas, to be appointed by the President and report to the Secretary of State and to lead in developing a global levitra prevention, preparedness and response framework. Authorizes the Representative to transfer and allocate certain U.S. Foreign assistance funding to the relevant departments and agencies implementing the U.S. Global health security strategy. Authorizes to be appropriated $3 billion for the five-year period beginning Oct. 1, 2022, to support enhancing preparedness in partner countries, replenishing the USAID Emergency Reserve Fund, U.S. Contributions to the World Bank Health Emergency Preparedness and Response Multi-Donor Fund, and U.S. Contributions to a new multilateral, catalytic financing mechanism for global health security and levitra prevention and preparedness (see âthe Fundâ below). Requires U.S. Global health program leadership identify areas of collaboration and coordination to ensure that such activities contribute to health systems strengthening. Directs the Secretary of State, with the USAID Administrator, to work with the Global Fund to Fight AIDS, Tuberculosis and Malaria, Gavi, the treatment Alliance, bilateral donors, and others to develop shared core indicators for strengthened health systems. Authorizes the U.S. To participate in the Coalition for Epidemic Preparedness Innovations (CEPI). Expresses Sense of Congress that the President should make an immediate contribution to CEPI of $300 million to expand research and development of treatments to combat the spread of erectile dysfunction treatment variants. Requires an annual National Intelligence Estimate (for five years) regarding the risks posed to the national security interests of the U.S. By the emergence, reemergence, and overseas transmission of pathogens with levitra potential. Requires the Secretary of State and others to work with WHO and other key stakeholders to establish or strengthen effective early warning systems for infectious disease threats with epidemic and levitra potential. Directs the Secretary of State, with the HHS Secretary, to work with WHO and like-minded member states to adopt an approach toward assessing infectious disease threats under the International Health Regulations (2005) for the WHO to identify and transparently communicate on an ongoing basis varying levels of risk leading up to, and during and after, a public health emergency of international concern (PHEIC) declaration. Directs the Secretary of State and others to seek to enter into negotiations to establish âthe Fund;â authorizes the President to make available for U.S. Contributions to the Fund such funds as may be appropriated or otherwise made available for such purpose. Limits the U.S. Contribution to the Fund to not exceed 33% of the total contributions from all sources.Mental Health in International Development and Humanitarian Settings Act(MINDS Act)To enhance mental health and psychosocial support within United States foreign assistance programs.6/17/2021H.R. 3988Rep. Theodore Deutch (D-FL-22)Referred to HFACMental health, children in adversity, erectile dysfunction treatmentExpresses Sense of Congress that mental health is integral and essential to overall health outcomes and other development objectives. Codifies the position of USAID coordinator for mental health and psychosocial support and describes the positionâs duties, including establishing a Mental Health and Psychosocial Support Working Group. Describes the Groupâs duties and members. States U.S. Policy is to integrate mental health and psychosocial support across all foreign assistance programs funded by the U.S.. Requires USAID and the Department of State regional bureaus and missions to utilize such policy for local capacity building, as appropriate and that such programming be evidence-based and culturally competent and respond to the specific needs of children in adversity. Requires USAID to brief Congress on progress and challenges to implementation, including programming in conflict and humanitarian settings, as well as the impact of erectile dysfunction treatment on programming. Requires the USAID Administrator in consultation with the OMB Director to brief Congress annually for five years (FY22 â FY26) on spending for this programming in U.S. Foreign assistance.Mental Health in International Development and Humanitarian Settings Act(MINDS Act)To enhance mental health and psychosocial support within United States foreign assistance programs.6/17/2021S. 2105Sen. Robert Casey (D-PA)Read twice and referred to SFRCMental health, children in adversity, erectile dysfunction treatmentExpresses Sense of Congress that mental health is integral and essential to overall health outcomes and other development objectives. Codifies the position of USAID coordinator for mental health and psychosocial support and describes the positionâs duties, including establishing a Mental Health and Psychosocial Support Working Group. Describes the Groupâs duties and members. States U.S. Policy is to integrate mental health and psychosocial support across all foreign assistance programs funded by the U.S.. Requires USAID and the Department of State regional bureaus and missions to utilize such policy for local capacity building, as appropriate and that such programming be evidence-based and culturally competent and respond to the specific needs of children in adversity. Requires USAID to brief Congress on progress and challenges to implementation, including programming in conflict and humanitarian settings, as well as the impact of erectile dysfunction treatment on programming. Requires the USAID Administrator in consultation with the OMB Director to brief Congress annually for five years (FY22 â FY26) on spending for this programming in U.S. Foreign assistance.Nullifying Opportunities for Variants to Infect and Decimate Act(NOVID Act)To establish a program to oversee the global erectile dysfunction treatment response and prepare for future levitras, and for other purposes.6/8/2021H.R. 3778Rep. Raja Krishnamoorthi (D-IL-8)Referred to HFAC and H. Energy and Commerceerectile dysfunction treatment, global health security, levitra preparedness and responseEstablishes the levitra preparedness and response program to be responsible for and provide oversight over the U.S. Global health response to the erectile dysfunction treatment levitra and protect Americans from the emergence of erectile dysfunction treatment variants and other pathogens with levitra potential. Require President to appoint program director who will coordinate the work of identified agencies, including USAID, CDC, and the Department of State, among others. Requires development of a comprehensive strategy to end the erectile dysfunction treatment levitra worldwide as well as a long-term strategy for preventing future levitras. Authorizes to be appropriated $34 billion for these efforts, and expresses Sense of Congress that $25 billion be made available to scale treatment manufacturing capacity and produce treatments, $8.5 billion to cover the cost of end-to-end delivery and administration of treatments in target countries, and $500 million to establish a global disease surveillance network to protect against future levitras. Describes implementation of comprehensive strategy, including requiring director to ensure immediate release of 80 million treatment doses that the U.S. Has already committed to send abroad and to reassess the U.S. treatment stockpile to determine whether further treatments can be sent abroad and to coordinate with BARDA to rapidly scale manufacturing capacity around the world to produce 8 billion treatment doses as soon as possible. Also requires director to ensure equitable access to treatments in collaboration with COVAX and to work with international partners to provide enough treatments to lower- and middle-income countries to fully vaccinate at least 60% of their respective populations, especially 92 countries identified by COVAX as being most in need of assistance. Requires the program to, among other things, build on PEPFAR and other existing U.S. Programs and relationships bilaterally and multilaterally. Express Sense of Congress that in the face of a global health emergency, the U.S. Government has broad authority, including under the Defense Production Act and the âBayh-Dole Actâ, to ensure adequate supply of treatments, necessary components, and raw materials through technology sharing and direct collaboration with manufacturers around the world.Nullifying Opportunities for Variants to Infect and Decimate Act(NOVID Act) To establish a program to oversee the global erectile dysfunction treatment response and prepare for future levitras, and for other purposes.6/8/2021S. 1976Sen. Jeff Merkley (D-OR)Read twice and referred to SFRCerectile dysfunction treatment, global health security, levitra preparedness and responseEstablishes the levitra preparedness and response program to be responsible for and provide oversight over the U.S. Global health response to the erectile dysfunction treatment levitra and protect Americans from the emergence of erectile dysfunction treatment variants and other pathogens with levitra potential. Require President to appoint program director who will coordinate the work of identified agencies, including USAID, CDC, and the Department of State, among others. Requires development of a comprehensive strategy to end the erectile dysfunction treatment levitra worldwide as well as a long-term strategy for preventing future levitras. Authorizes to be appropriated $34 billion for these efforts, and expresses Sense of Congress that $25 billion be made available to scale treatment manufacturing capacity and produce treatments, $8.5 billion to cover the cost of end-to-end delivery and administration of treatments in target countries, and $500 million to establish a global disease surveillance network to protect against future levitras. Describes implementation of comprehensive strategy, including requiring director to ensure immediate release of 80 million treatment doses that the U.S. Has already committed to send abroad and to reassess the U.S. treatment stockpile to determine whether further treatments can be sent abroad and to coordinate with BARDA to rapidly scale manufacturing capacity around the world to produce 8 billion treatment doses as soon as possible. Also requires director to ensure equitable access to treatments in collaboration with COVAX and to work with international partners to provide enough treatments to lower- and middle-income countries to fully vaccinate at least 60% of their respective populations, especially 92 countries identified by COVAX as being most in need of assistance. Requires the program to, among other things, build on PEPFAR and other existing U.S. Programs and relationships bilaterally and multilaterally. Express Sense of Congress that in the face of a global health emergency, the U.S. Government has broad authority, including under the Defense Production Act and the âBayh-Dole Actâ, to ensure adequate supply of treatments, necessary components, and raw materials through technology sharing and direct collaboration with manufacturers around the world.Preventing Foreign Attempts To Erode Healthcare Innovation ActTo prohibit the use of funds to support a measure at the World Trade Organization waiving intellectual property rights, and for other purposes.5/18/2021S. 1683Sen. Tim Scott (R-SC)Read twice and referred to S. FinanceTRIPS, WTO, intellectual property rights, erectile dysfunction treatmentsExpresses Sense of Congress that U.S. Should continue to promote strong international [sic] property rights internationally and that it is in the national interest of the U.S. To oppose efforts to transfer U.S. Intellectual property and technology to China or other countries seeking to profit off U.S. Investments. Prohibits use of funds to support, allow, or facilitate the negotiation or approval of the TRIPS waiver for the prevention, containment, and treatment of erectile dysfunction treatment proposed by India and South Africa or any other measure at the WTO to waive intellectual property rights.Preventing Future levitras Act of 2021To address the public health risks posed by wildlife markets, and for other purposes.1/4/2021H.R. 151Rep. Mike Quigley (D-IL-5)Referred to HFAC, H. Energy and Commerce, H. Judiciary, H. Ways and Means, H. Financial Services, H. Natural ResourcesGlobal health security, One Health, zoonotic diseasesRequires the HHS Secretary to enter into an agreement with the National Academies of Sciences, Engineering, and Medicine for it to conduct a study on the risk of wildlife markets on the emergency of novel viral pathogens, to be submitted not later than one year after the date of agreement. Expresses Sense of Congress that global institutions, including WHO, and others including USAID should promote the paradigm of One Health. States U.S. Policy is to facilitate international cooperation to close high risk wildlife markets around that world and to work to develop agreements and protocols to close these markets. Allows the President to impose sanctions on any country (or nationals of a country) continuing to license or enable commercial wildlife markets or engaged in certain activities. Authorizes FY 2021 â FY 2030 funding for USAID activities related to sustainable food systems. Requires the USAID administrator to increase activities related to biodiversity, global health, and resilience, among other things, in order to address the threats and causes of zoonotic disease outbreaks.. Requires reporting from the Department of State and USAID describing these efforts.Preventing Future levitras Act of 2021To address the public health risks posed by wildlife markets, and for other purposes.1/25/2021S. 37Sen. John Cornyn (R-TX)Read twice and referred to SFRCGlobal health security, One Health, zoonotic diseasesRequires the HHS Secretary to enter into an agreement with the National Academies of Sciences, Engineering, and Medicine for it to conduct a study on the risk of wildlife markets on the emergency of novel viral pathogens, to be submitted not later than one year after the date of agreement. Expresses Sense of Congress that global institutions, including WHO, and others including USAID should promote the paradigm of One Health. States U.S. Policy is to facilitate international cooperation to close high risk wildlife markets around that world and to work to develop agreements and protocols to close these markets. Allows the President to impose sanctions on any country (or nationals of a country) continuing to license or enable commercial wildlife markets or engaged in certain activities. Authorizes FY 2021 â FY 2030 funding for USAID activities related to sustainable food systems. Requires the USAID administrator to increase activities related to biodiversity, global health, and resilience, among other things, in order to address the threats and causes of zoonotic disease outbreaks.. Requires reporting from the Department of State and USAID describing these efforts.Protecting Life in Foreign Assistance ActTo restrict the availability of Federal funds to organizations associated with the abortion industry.1/28/2021H.R. 534Rep. Virginia Foxx (R-NC-5)Referred to HFACAbortion, Mexico City policyCodifies the expanded Mexico City policy (rescinded by President Biden in Jan. 2021. See KFF explainer) and expands it to apply more broadly to federal funding made available for purposes outside of the U.S. To 1) any foreign nonprofit organization, foreign nongovernmental organization, foreign multilateral organization, or foreign quasi-autonomous nongovernmental organization that carries out certain activities, and 2) any domestic nonprofit organization or domestic nongovernmental organization that carries out certain activities.Protecting Life in Foreign Assistance ActTo restrict the availability of Federal funds to organizations associated with the abortion industry.1/28/2021S. 137Sen. Mike Lee (R-UT)Read twice and referred to SFRCAbortion, Mexico City policyCodifies the expanded Mexico City policy (rescinded by President Biden in Jan. 2021. See KFF explainer) and expands it to apply more broadly to federal funding made available for purposes outside of the U.S. To 1) any foreign nonprofit organization, foreign nongovernmental organization, foreign multilateral organization, or foreign quasi-autonomous nongovernmental organization that carries out certain activities, and 2) any domestic nonprofit organization or domestic nongovernmental organization that carries out certain activities.Reach Every Mother and Child ActTo amend the Foreign Assistance Act of 1961 to implement policies to end preventable maternal, newborn, and child deaths globally.4/29/2021S. 1451Sen. Susan Collins (R-ME)Read twice and referred to SFRCMaternal health, child healthIncludes statement of U.S. Policy to establish and implement a coordinated, integrated, and comprehensive strategy to end preventable child and maternal deaths and ensure healthy and productive lives. Requires the establishment and implementation of a five-year comprehensive strategy to contribute toward the global goal of ending preventable child and maternal deaths by 2030. States the President should designate a Child and Maternal Survival Coordinator and describes their duties. Requires an annual report on progress.Reproductive Rights are Human Rights Act of 2021To amend the Foreign Assistance Act of 1961 to require a section on reproductive rights in the Annual Country Reports on Human Rights Practices.5/28/2021H.R. 3576Rep. Katherine Clark (D-MA-5)Referred to HFACState Dept. Annual human rights report, family planning/reproductive health (FP/RH), maternal mortality, abortion, violence against womenAmends existing law to require annual reporting by the Department of State on human rights to include, among other things. The status of reproductive rights in each country. Description of the rates and causes of pregnancy-related injuries and deaths (including deaths due to unsafe abortions), violence against women, and access to family planning. Requires that civil society and multilateral organizationsâ representatives in the U.S. And countries included in such reporting be consulted with during the preparation of annual reporting.Reproductive Rights are Human Rights Act of 2021To amend the Foreign Assistance Act of 1961 to require a section on reproductive rights in the Annual Country Reports on Human Rights Practices.5/26/2021S. 1864Sen. Robert Menendez (D-NJ)Read twice and referred to SFRCState Dept. Annual human rights report, family planning/reproductive health (FP/RH), maternal mortality, abortion, violence against womenAmends existing law to require annual reporting by the Department of State on human rights to include, among other things. The status of reproductive rights in each country. Description of the rates and causes of pregnancy-related injuries and deaths (including deaths due to unsafe abortions), violence against women, and access to family planning. Requires that civil society and multilateral organizationsâ representatives in the U.S. And countries included in such reporting be consulted with during the preparation of annual reporting.Robust International Response to levitra ActTo provide support for a robust global response to the erectile dysfunction treatment levitra.2/11/2021H.R. 986Rep. Jesus âChuyâ Garcia (D-IL-4)Referred to H. Financial Serviceserectile dysfunction treatmentDirects the Secretary of the Treasury to instruct U.S. Executive Directors at international financial institutions to ensure international financial institution support for a robust international response to the global erectile dysfunction treatment levitra, including to oppose the approval or endorsement of any loan, grant, document, or strategy that would lead to a decrease in health care spending or in any other spending that would impede the ability of any country to prevent or contain the spread of, or treat persons who are or may be infected with, the erectile dysfunction treatment levitra.Securing America From Epidemics Act(SAFE Act) To authorize United States participation in the Coalition for Epidemic Preparedness Innovations, and for other purposes.3/23/2021H.R. 2118Rep. Ami Bera (D-CA-7)Passed House, read twice and referred to SFRCResearch &. Development (R&D), global health security, levitra, epidemicAuthorizes U.S. Participation in the Coalition for Epidemic Preparedness Innovation (CEPI). Reports to Congress required to be submitted by the President not later than 180 days after enactment of the Act and to outline planned U.S. Contributions to CEPI, the manner and extent to which the U.S. Will participate in the governance of CEPI, and how participation in CEPI supports relevant U.S. Strategies and programs in health security and biodefense, among other things. Authorizes certain appropriated funding to be made available for U.S. Contributions to CEPI.Strategic Competition Act of 2021To address issues involving the Peopleâs Republic of China. 4/15/2021S. 1169Sen. Robert Menendez (D-NJ)Placed on Senate Legislative Calendar under General Orderserectile dysfunction treatment, health cooperation, WHO, global health security, abortion, forced sterilization, debt reliefExpresses sense of Congress that the U.S. Government should encourage other foreign governments to use the official and scientific names for the erectile dysfunction treatment levitra. States U.S. Policy is to deepen cooperation between and among the U.S., Japan, South Korea, the Philippines, Thailand, and Australia, including through scientific and health partnerships. Expresses sense of Congress that recent pledge from the first-ever Quad (Australia, India, Japan, U.S.) leaders meeting on March 12, 2021, to respond to the economic and health impacts of erectile dysfunction treatment, including expanding treatment production and equitable access, further advances cooperation among Quad nations. States it is U.S. Policy to stand with the nations of ASEAN as they respond to erectile dysfunction treatment and support greater cooperation in building capacity to prepare for and respond to levitras and other public health challenges. States it is U.S. Policy to advocate and actively advance Taiwanâs meaningful participation in the World Health Assembly, among other bodies. Requires report on the origins of the erectile dysfunction treatment levitra to be submitted by the Director of National Intelligence, in coordination with the Secretary of State, HHS Secretary, and others, not later than 180 days after enactment. Requires strategies that describe how the U.S. Will enhance cooperation with Canada, the European Union, NATO, and European partner countries in managing relations with China, including detailing diplomatic efforts to work with them to track and counter Chinese attempts to exert influence across the multilateral system, including at WHO. Requires a strategy for countering and limiting Chinese influence in, and access to, the Middle East and North Africa, including efforts to encourage U.S. Private sector and public-private partnerships in healthcare technology, among other things. States it is U.S. Policy to work with Australia, New Zealand, and Japan to advance shared alliance goals of the Oceania region concerning health, among other things, and to improve the local capacity of the countries of Oceania to address public health challenges and improve global health security. Address the imposition of sanctions with respect to systematic rape, coercive abortion, forced sterilization, or involuntary contraceptive implantation in the Xinjiang Uyghur Autonomous Region. Addresses reporting related to debt relief via the International Development Association (IDA) for certain countries to respond to the erectile dysfunction treatment levitra.Support for Global Financial Institution levitra Response Act of 2021To support efforts by international financial institutions to provide a robust global response to the erectile dysfunction treatmentâ19 levitra.1/27/2021S. 67Sen. Richard Durbin (D-IL)Read twice and referred to SFRCerectile dysfunction treatmentDirects the Secretary of the Treasury to instruct U.S. Executive Directors at international financial institutions to ensure international financial institution support for a robust international response to the global erectile dysfunction treatment levitra, including to oppose the approval or endorsement of any loan, grant, document, or strategy that would lead to a decrease in health care spending or in any other spending that would impede the ability of any country to prevent or contain the spread of, or treat persons who are or may be infected with, the erectile dysfunction treatment levitra.Support UNFPA Funding ActTo authorize contributions to the United Nations Population Fund, and for other purposes.6/16/2021H.R. 3938Rep. Chrissy Houlahan (D-PA-6)Referred to HFACUNFPA, family planning/reproductive health (FP/RH)Includes statement of U.S. Policy regarding financial support for UNFPA as a crucial part of U.S. Global health commitment. Authorizes appropriations for five years for an annual contribution to UNFPA to support core functions and programs.To amend the National Security Act of 1947 to require the President to designate an employee of the National Security Council to be responsible for levitra prevention and response, and for other purposes.2/8/2021S. 290Sen. Edward Markey (D-MA)Read twice and referred to HSGAClevitraRequires the President to designate an employee of the National Security Council to be the permanent coordinator for levitra prevention and response for the federal government, outlines duties, and grants them authority to represent the U.S. In bilateral and multilateral discussions and agreements on relevant matters.To direct the Secretary of State to develop a strategy to regain observer status for Taiwan in the World Health Organization, and for other purposes.2/18/2021H.R. 1145Rep. Young Kim (R-CA-39)Passed HFAC (Ordered to be Reported in the Nature of a Substitute by Voice Vote)WHO, TaiwanDirects the Department of State to include additional information in its annual reports concerning Taiwanâs participation at WHOâs World Health Assembly as an observer.To direct the Secretary of State to develop a strategy to regain observer status for Taiwan in the World Health Organization, and for other purposes.3/17/2021S. 812Sen. Robert Menendez (D-NJ)Placed on Senate Legislative Calendar Under General OrdersWHO, TaiwanDirects the Department of State to include additional information in its annual reports concerning Taiwanâs participation at WHOâs World Health Assembly as an observer.To prohibit the use of funds to seek membership in the World Health Organization or to provide assessed or voluntary contributions to the World Health Organization.1/28/2021H.R. 497Rep. Jodey Arrington (R-TX-19)Referred to HFACWHOProhibits the use of federal funds to seek membership by the U.S. In WHO or to provide assessed or voluntary U.S. Contributions to WHO until such time as the President certifies that WHO meets certain conditions, including. WHO has adopted meaningful reforms to ensure that humanitarian assistance is not politicized and is to be provided to those with the most need, WHO is not under the control or significant malign influence of the Chinese Communist party, WHO is not involved in a coverup of the Chinese Communist Partyâs response to the erectile dysfunction treatment levitra, WHO grants observer status to Taiwan, WHO does not divert humanitarian or medical supplies to Iran, North Korea, or Syria, and WHO has put in place mechanisms to increase transparency and accountability in its operations and eliminate waste, fraud, and abuse.United States Climate Leadership in International Mitigation, Adaptation, and Technology Enhancement Act of 2021(U.S. CLIMATE Act) To restore the United States international leadership on climate change and clean energy, and for other purposes. 4/19/2021S. 1201Sen. Robert Menendez (D-NJ)Read twice and referred to SFRCClimate change, global healthRequires the Secretary of State, in consultation with other relevant agencies, to conduct biennial comprehensive evaluations of present and ongoing disruptions to the global climate system, including the scarcity of global natural resources including fresh water, global food, health, and energy insecurities and conditions that contribute to gender-based violence, among other things. Requires these evaluations to be used by the Secretary of State to inform the development and implementation of a climate security strategy, and to develop and implement plans to account for the impacts of climate change on global human health, fresh water, and marginalized groups. States U.S. Policy is to ensure that the International Climate Change Adaptation, Mitigation, and Security Program (required to be established under the act by the Secretary of State, in coordination with the Secretary of the Treasury and the Administrator of USAID) provide resources to developing countries to support efforts that reduce the vulnerability and increase the resilience capacities of communities to the effects of climate change, including effects on water availability and health and diseases. Directs the Secretary of the Treasury to use the influence of the U.S. To ensure that the Green Climate Fund requires country recipients to submit investment plan that describes how adaptation projects will advance public health outcomes, among other things. Incorporates the Women and Climate Change Act.Uyghur Stop Oppressive Sterilizations Act(Uyghur SOS Act) To address state-sanctioned violence against women in the Peopleâs Republic of China, including rape and torture in detention and forced sterilizations, forced abortions, and other coercive birth restriction policies, particularly in the Xinjiang Uyghur Autonomous Region, and for other purposes.5/18/2021H.R. 3306Rep. Vicky HartzlerReferred to HFAC and H. JudiciaryForced sterilization, abortionStates U.S. Policy is to regard the prevention of genocide and other atrocity crimes as a national interest particularly when those actions target certain groups in the Xinjiang Uyghur Autonomous Region through, among other things, forced sterilizations, forced abortions and other coercive birth restrictions policies, and sexual violence and other torture in detention, to raise the issue of state-sanctioned violence against women, including rape, torture, and coercively enforced population control policies in China in all multilateral organizations where the U.S. And China are members, including at the U.N. Security Council, and to consider state-sanctioned violence against women, including forced sterilizations and forced abortions and the systematic use of rape and torture in mass internment camps in the Region as a gross violation of internationally-recognized human rights. Expresses the Sense of Congress that all governments, including the U.S., and international organizations, such as the U.N., should call the atrocities perpetuated by the government of China, including forced sterilizations and forced abortions and other sexual violence, as genocide and crimes against humanity and that the U.S. Should strongly condemn the intimidation and threats targeting Uyghur and Kazakh women who provide public evidence of sexual violence and forced sterilizations and forced abortions in mass internment camps and the journalist who report these stories. Also expresses Sense of Congress that U.N. Member states should condemn such atrocities by demanding that China end all forced sterilization, forced abortions, and other state-sanctioned violence against women, among other things. Requires the president to submit a strategy for ending atrocity crimes in the Region. Requires the Secretary of State to provide all appropriate assistance to women who belong to certain groups and who experienced sexual violence, torture, forced sterilizations and forced abortions in China in order for them to receive needed medical care and psychological support. Requires all existing authorities to be used to allow such women to at least temporarily enter the U.S.Women and Climate Change Act of 2021To address the disparate impact of climate change on women and support the efforts of women globally to address climate change, and for other purposes.1/11/2021H.R. 260Rep. Barbara Lee (D-CA-13)Referred to HFAC, H. Energy &. CommerceClimate change, global health, reproductive healthAddresses climate change and its effects on women and girls. Establishes the Federal Interagency Working Group on Women and Climate Change within the Department of State and outlines its functions, such as identifying best practices for collecting data on the disparate impact of climate change on women â including in access to comprehensive health care, including reproductive health and rights. Requires the Department of Stateâs Office of Global Womenâs Issues (GWI) to submit a strategy (and shortly thereafter an implementation plan and budget) to prevent and respond to the effects of climate change on women, including effective action to promote public health. Requires the Ambassador-at-Large of GWI to designate a Senior Coordinator for Women and Climate Change. Requires the GWI Ambassador and the Senior Coordinator to submit to the appropriate congressional committees an assessment of the human and financial resources necessary to carry out the Act.World Health Organization Accountability ActTo prohibit the availability of United States contributions to the World Health Organization until Congress receives a full report on China and the erectile dysfunction treatmentâ19 levitra, and for other purposes.1/21/2021H.R. 374Rep. Lauren Boebert (R-CO-3)Referred to HFACWHO, erectile dysfunction treatmentProhibits the use of federal funds for U.S. Contributions to WHO or U.S. Participation in any of the activities of WHO until the Secretary of State and HHS Secretary jointly submit a report to Congress describing the manner and extent to which the handling of the erectile dysfunction treatment outbreak prior to March 11, 2020, by WHO and China contributed to the emergency of the levitra.NOTES. SFRC means Senate Committee on Foreign Relations. HFAC means the House Committee on Foreign Affairs. SFOPS means Department of State, foreign operations, and related programs. LGBTI means lesbian, gay, bisexual, transgender, or intersex. WHO is the World Health Organization. ASEAN is the Association of Southeast Asian Nations. * Other than those that apply to U.S. NGOs receiving certain foreign aid under the Foreign Assistance Act.. About This TrackerThis tracker provides the number of confirmed cases and deaths from novel erectile dysfunction by country, the trend in cheapest levitra confirmed case and death counts by country, and a global map showing which countries have confirmed cases and deaths. The data are drawn from the Johns Hopkins University (JHU) erectile dysfunction Resource Centerâs erectile dysfunction treatment Map and the World Health Organizationâs (WHO) erectile dysfunction Disease (erectile dysfunction treatment-2019) situation reports.This tracker will be updated regularly, as new data are released.Related Content. About erectile dysfunction treatment erectile dysfunctionIn late 2019, a new erectile dysfunction emerged in central cheapest levitra China to cause disease in humans. Cases of this disease, known as erectile dysfunction treatment, have since been reported across around the globe. On January 30, 2020, the World cheapest levitra Health Organization (WHO) declared the levitra represents a public health emergency of international concern, and on January 31, 2020, the U.S. Department of Health and Human Services declared it to be a health emergency for the United States.Global Health Legislation During the 117th Congress(as of Aug. 2, 2021)TitleDate IntroducedBill #SponsorStatusTopicSummary of Global Health-Related ProvisionsAbortion is Health Care Everywhere Act of 2021To amend the Foreign Assistance Act of 1961 to authorize the use of funds for comprehensive reproductive health care services, and for other purposes.3/9/2021H.R. 1670Rep. Janice Schakowsky (D-IL-9)Referred to HFACAbortion, Helms amendmentIncludes statement of U.S. Policy regarding safe abortion and working to end unsafe abortion. Repeals the Helms Amendment (which prohibits the use of foreign assistance to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortion). States that notwithstanding any other provision of law, certain funds may be used to provide comprehensive reproductive health care services, including abortion services, training, and equipment.Advancing Emergency Preparedness Through One Health Act of 2021To establish an interagency One Health Program, and for other purposes.3/18/2021S. 861Sen. Tina Smith (D-MN)Read twice and referred to S. HELPOne Health, global health securityRequires the heads of HHS, USDA, USAID, DoD, and certain other agencies to develop, publish, and submit to Congress a national One Health Framework for coordinated federal activities under the One Health Program not later than one year after enactment. Among other things, states the framework must describe existing efforts and contain recommendations for building upon and complementing the activities of the CDC, the FDA, USAID, NIH, and certain others and also establish specific federal goals and priorities and describe specific activities required to achieve these. Requires the submission of an addendum to the framework not later than three years after its original submission, describing progress in advancing these activities. Authorizes to be appropriated such sums as necessary to develop the framework above. Requires GAO to submit a report to Congress not later than two years after the addendum is submitted, detailing existing collaborative efforts among certain agencies for this purpose and containing an evaluation of the framework and its specified activities.American Medical Investment Generating Overseas Security Act(AMIGOS Act)To prohibit the President from taking any action to support the waiver of obligations of members of the World Trade Organization under the Agreement on Trade-Related Aspects of Intellectual Property Rights in relation to the prevention, containment, mitigation, or treatment of erectile dysfunction treatmentâ19 unless a statute is enacted expressly authorizing such a waiver with respect to the prevention, containment, mitigation, or treatment of erectile dysfunction treatmentâ19, and for other purposes.5/14/2021H.R. 3236Maria Elvira Salazar (R-FL-27)Referred to HFAC and H. Ways and MeansTRIPS, WTO, intellectual property rights, erectile dysfunction treatmentsStates the President may not take any action to support waiver of obligations of WRO members under the TRIPS agreement in relation to the prevention, containment, mitigation, or treatment of erectile dysfunction treatment unless a statute is enacted expressly authorizing such a waiver with respect to such. Requires the President to allocate excess U.S. erectile dysfunction treatments in a specified order of priority, with certain exceptions, and to monitor the allocation of such to ensure assisted governments provide treatments to their peoples in a timely manner and do not otherwise withhold them. Requires such treatments provided to foreign countries to be marked as assistance from the American people or the U.S. Government and to include a depiction of the flag of the U.S. If appropriate.American Rescue Plan Act of 2021To provide for reconciliation pursuant to title II of S. Con. Res. 5.2/24/2021H.R. 1319Rep. John Yarmuth (D-KY-3)Became law (P.L. 117-2)erectile dysfunction treatment, Global FundSee KFF summary.American Values ActTo permanently enact certain appropriations Act restrictions on the use of funds for abortions and involuntary sterilizations, and for other purposes.2/4/2021S. 239Sen. James Risch (R-ID)Read twice and referred to SFRCAbortion, involuntary sterilization amendment, Siljander amendment, Kemp-Kasten amendment, Peace Corps provision, Helms amendment, Biden amendmentAmends the Foreign Assistance Act of 1961 to codify in permanent law the Siljander amendment, which prohibits the use of funds to lobby for or against abortion, and the Kemp-Kasten amendment, which prohibits funding any organization or program, as determined by the President, that supports or participates in the management of a program of coercive abortion or involuntary sterilization. Restates the Helms amendment, the Involuntary Sterilization amendment (which prohibits the use of funds to pay for involuntary sterilizations as a method of family planning or to coerce or provide a financial incentive to anyone to undergo sterilization), and the Biden amendment (which states that funds may not be used for biomedical research related to methods of or the performance of abortion or involuntary sterilization as a means of family planning) that are already in permanent law. Also amends the Peace Corps Act to codify in permanent law the Peace Corps provision, which prohibits Peace Corps funding from paying for an abortion for a Peace Corps volunteer or trainee, except in cases where the life of the woman is endangered by pregnancy or in cases of rape or incest. In the past these have been included only in annual State-Foreign Operations appropriations language. See also the KFF fact sheet on FP/RH statutory requirements and policies and the KFF explainer on UNFPA funding and Kemp-Kasten.Binational Health Strategies Act of 2021To amend the United States-Mexico Border Health Commission Act, with respect to preparedness for erectile dysfunction treatmentâ19 and other infectious diseases in the border region, and for other purposes.3/03/2021H.R. 1538Rep.. Veronica Escobar (D-TX-16)Referred to H. Energy and HFACMexicoAuthorizes and directs the President to seek to begin negotiations with Mexico to amend an existing agreement addressing infectious disease preparedness in the U.S.-Mexico Border Area, with respect to erectile dysfunction treatment and other infectious diseases, specifically requiring the U.S.-Mexico Border Health Commission to submit a report on the border areaâs response to erectile dysfunction treatment and requiring it to also develop and publicly publish a binational strategic plan that addresses how the area should strengthen its erectile dysfunction treatment response, sharing relevant health data, and how a erectile dysfunction treatment should be disbursed throughout the area, among other things. Requires the Commission to publish what actions federal agencies in the U.S. And Mexico will take to facilitate implementation of the strategic plan and then to submit a report on actions taken each year. Requires the Commission to develop and publish a plan to prepare and respond to infectious diseases (other than erectile dysfunction treatment) within the border area, to update the plan at least once every three years for as long as necessary, and to publish what actions federal agencies in the U.S. And Mexico will take to facilitate implementation of this plan, with a report on actions taken each year required to be submitted.BLUE Pacific ActTo establish a comprehensive, long-term United States strategy and policy for the Pacific Islands, and for other purposes.5/4/2021H.R. 2967Rep. Ed Case (D-HI-1)Referred to HFAC, H. Ways and Means, H. Natural ResourcesPublic health capacity building, erectile dysfunction treatment, gender-based violenceStates U.S. Policy is to develop and commit to a comprehensive, multifaceted, and principled U.S. Policy in the Pacific Islands that, among other things, assists the Pacific Islands in preventing and containing the spread of the erectile dysfunction treatment levitra. Requires the USAID Administrator, in coordination with the Secretary of States, to develop and implement a strategy to assist the Pacific Islands in improving public health outcomes and building public health capacity, including in response to the erectile dysfunction treatment levitra. Requires the strategy include programming to address maternal and child health, family planning and reproductive health, gender-based violence, food security and nutrition, NCDs, NTDs, tuberculosis, HIV/AIDS, STDs, and zoonotic and emerging infectious disease threats, clean water, sanitation, and hygiene (WASH), health system strengthening, and other activities. Requires a report not later than 180 days after enactment with strategy. Authorizes to be appropriated $20 million for each FY22-FY26 to carry out these efforts. Requires the Secretary of State and USAID Administrator to develop and implement an initiative to encourage and support efforts by the Pacific Island to reduce and combat gender-based violence.Climate Change Health Protection and Promotion Act of 2021To direct the Secretary of Health and Human Services to develop and implement a national strategic action plan and program to assist health professionals and systems in preparing for and responding to the public health effects of climate change, and for other purposes.5/17/2021H.R. 3271Rep. Matt Cartwright (D-PA-8)Referred to H. Energy and CommerceClimate change, global healthDirects Secretary of HHS to publish a strategic action plan and establish a climate change and health program (at CDC, in collaboration with other agencies, as appropriate) to ensure the public health and health care systems are prepared for and can respond to the impacts of climate change on health in the U.S. And other nations. Requires the action plan include an assessment of U.S. Capacity to address climate change including, among other things, providing technical assistance and support for preparedness and response plans for the health threats of climate change in developing countries, and developing or strengthening domestic and international disease surveillance systems and monitoring capacity to respond to health-related impacts of climate change. Describes priority health actions for the climate and health program, including with regard to global health aspects of climate change. Requires periodic updates of action plan. Establishes science advisory board and its functions, including with regarding to international impacts of climate change on health. And directs HHS Secretary to have National Academies prepare reports on topic, with the first due in one year and then every 4 years thereafter.Climate Change Health Protection and Promotion Act of 2021To direct the Secretary of Health and Human Services to develop and implement a national strategic action plan and program to assist health professionals and systems in preparing for and responding to the public health effects of climate change, and for other purposes.5/19/2021S. 1702Sen. Edward Markey (D-MA)Read twice and referred to S. HELPClimate change, global healthDirects Secretary of HHS to publish a strategic action plan and establish a climate change and health program (at CDC, in collaboration with other agencies, as appropriate) to ensure the public health and health care systems are prepared for and can respond to the impacts of climate change on health in the U.S. And other nations. Requires the action plan include an assessment of U.S. Capacity to address climate change including, among other things, providing technical assistance and support for preparedness and response plans for the health threats of climate change in developing countries, and developing or strengthening domestic and international disease surveillance systems and monitoring capacity to respond to health-related impacts of climate change. Describes priority health actions for the climate and health program, including with regard to global health aspects of climate change. Requires periodic updates of action plan. Establishes science advisory board and its functions, including with regarding to international impacts of climate change on health. And directs HHS Secretary to have National Academies prepare reports on topic, with the first due in one year and then every 4 years thereafter.Curbing Chinaâs treatment Diplomacy ActTo prioritize the international distribution of erectile dysfunction treatment doses, and for other purposes.7/6/2021H.R.4362Rep. Carlos Gimenez (R-FL-26)Referred to HFACerectile dysfunction treatment, treatmentsRequires the Secretary of States to prioritize, in carrying out the international distribution of erectile dysfunction treatment doses, distribution to Taiwan and crucial Latin American allies, subject first to Administration certification to Congress that it has determined all Americans have been afforded ample opportunity to be fully vaccinated against erectile dysfunction treatment. Requires the Secretary to ensure that not less than 25% of the total number of erectile dysfunction treatment doses intended for international distribution are reserved for and distributed to Taiwan and crucial Latin American allies and states the Secretary may not distribute any doses to other recipients or countries until the above have each received at least a first shipment of their reserved doses. States the Secretary may not distribute erectile dysfunction treatment doses to any country which has a government that has been determined to have engaged in systemic or widespread human rights abuses. Terminates five days after the date on which the Secretary determines the above have each achieved 40% vaccination rates of their respective populations.Department of State, Foreign Operations, and Related Programs Appropriations Act, 2022(State/Foreign Ops â SFOPS Approps)Making appropriations for the Department of State, foreign operations, and related programs for the fiscal year ending September 30, 2022, and for other purposes.7/6/2021H.R. 4373Rep. Barbara Lee (D-CA-13)Passed House, received in the SenateAppropriationsSee KFF summary. Includes the text of the Global Health, Empowerment, and Rights (Global HER) Act (H.R. 556), which codifies prohibition of the expanded Mexico City policy (rescinded by President Biden in Jan. 2021, see KFF explainer). Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2022(Labor/HHS â LHHS Approps)Making appropriations for the Departments of Labor, Health and Human Services, and Education, and related agencies for the fiscal year ending September 30, 2022, and for other purposes.7/19/2021H.R. 4502Rep. Rosa DeLauro (D-CT-3)Passed HouseAppropriationsSee KFF summary.Global Autism ActTo establish a Global Autism Assistance Program.6/24/2021H.R. 4160Rep. Christopher Smith (R-NJ-4)Referred to HFACAutismEstablishes a health and education grant program known as the Global Autism Assistance Program at USAID to support activities focused on autism spectrum disorder (ASD) in developing countries and to establish a program, known as Train the Trainers, to train health and education professionals working with children with ASD in developing countries. Outlines designation of eligible regions and selection of implementing NGO and activities it may carry out with the grant. Requires the implementing NGO to establish a Project Advisory Board to review local applications for content and appropriateness. To carry out this program, requires the USAID Administrator to allocate amounts that have been appropriated or otherwise made available to USAID. Requires an annual report on activities.Global Health, Empowerment and Rights Act(Global HER Act) To prohibit the application of certain restrictive eligibility requirements to foreign nongovernmental organizations with respect to the provision of assistance under part I of the Foreign Assistance Act of 1961.1/28/2021H.R. 556Rep. Barbara Lee (D-CA-13)Referred to HFACAbortion, Mexico City policyCodifies prohibition of the expanded Mexico City policy (rescinded by President Biden in Jan. 2021, see KFF explainer). States that notwithstanding any provision of law, regulation, or policy, foreign non-governmental organizations (NGOs) shall not be ineligible for certain foreign aid under the Foreign Assistance Act solely on the basis of health or medical services provided with non-U.S. Funds (insofar as legal in country where provided and under U.S. Law) and shall not be subject to requirements relating to their use of non-U.S. Funds for advocacy and lobbying activities.*Global Health, Empowerment and Rights Act(Global HER Act) To prohibit the application of certain restrictive eligibility requirements to foreign nongovernmental organizations with respect to the provision of assistance under part I of the Foreign Assistance Act of 1961.1/28/2021S. 142Sen. Jeanne Shaheen (D-NH)Read twice and referred to SFRCAbortion, Mexico City policyCodifies prohibition of the expanded Mexico City policy (rescinded by President Biden in Jan. 2021, see KFF explainer). States that notwithstanding any provision of law, regulation, or policy, foreign non-governmental organizations (NGOs) shall not be ineligible for certain foreign aid under the Foreign Assistance Act solely on the basis of health or medical services provided with non-U.S. Funds (insofar as legal in country where provided and under U.S. Law) and shall not be subject to requirements relating to their use of non-U.S. Funds for advocacy and lobbying activities.*Global Health Security Act of 2021To authorize a comprehensive, strategic approach for United States foreign assistance to developing countries to strengthen global health security, and for other purposes.1/21/2021H.R. 391Rep. Gerald Connolly (D-VA-11)Passed House, read twice and referred to SFRCGlobal health security, global health emergenciesStates it is U.S. Policy to promote and invest in global health security and levitra preparedness as a core national security interest. Establishes a Global Health Security Agenda Interagency Review Council, designates members, responsibilities, and frequency of meetings. Designates a U.S. Coordinator for Global Health Security responsible for coordination of the interagency process for responding to global health security emergencies. Express Sense of Congress that the President should consider appointing an individual with significant background and expertise in public health or emergency response management to such position. Requires a U.S. Global health security strategy, its implementation (including agency-specific plans), and an annual report on status of implementation. Directs the Secretary of State, Treasury Secretary, USAID Administrator, and HHS Secretary, among others, to seek to enter into negotiations with donors, relevant U.N. Agencies (including WHO), and other stakeholders to establish a fund for global health security and levitra preparedness as a multilateral, catalytic financing mechanism. Describes Fundâs Advisory Board, purpose, Executive Board and its makeup and duties. Creates a Coordinator of U.S. Government activities to advance global health security, who shall be appointed by the President to represent the U.S. On the Executive Board. Outlines eligible partner country definition and Fund program objectives, supported activities, administration, including appointment of an Administrator appointed by the Executive Board, and transparency and accountability requirements. Requires reports to Congress on the Fund including a 6 month status report and then annual reports after the Fundâs establishment. And authorizes U.S. Contributions to the Fund with a limit that the U.S. Share not exceed 33% of total contributions to the Fund cumulatively.Global Malnutrition Prevention and Treatment Act of 2021To advance targeted and evidence-based interventions for the prevention and treatment of global malnutrition and to improve the coordination of such programs, and for other purposes.07/26/2021H.R. 4693Rep. Michael McCaul (R-TX-10)Passed HFAC (Ordered to be Reported by Voice Vote)MalnutritionAuthorizes the USAID Administrator to support efforts to prevent and treat malnutrition globally, including by targeting resources and nutrition interventions to support the most vulnerable populations susceptible to severe malnutrition, including children under the age of 5 and pregnant and lactating women. Directs the Administrator and others to coordinate with bilateral and multilateral donors, governments of partner countries, U.N. Agencies, and others to prevent and treat malnutrition globally. Requires the Administrator and others to seek to leverage additional resources to this end by increasing interagency cooperation among relevant departments and agencies represented in the Global Nutrition Coordination Plan. Requires the selection of priority countries and outlines criteria. Express Sense of Congress that efforts to undertake nutrition interventions in countries not selected as priority countries should continue. Authorizes the establishment of the Nutrition Leadership Council within USAID and outlines its duties and membership. Requires the development of an implementation plan. Requires an annual progress report for five years.Global levitra Prevention and Biosecurity ActTo establish a global zoonotic disease task force, and for other purposes. 5/20/2021H.R. 3424Rep. Grace Meng (D-NY-6)Referred to HFAClevitra, zoonotic diseases, One Health, global health security, biosecurityRequires the Secretary of State and USAID Administrator to work with certain relevant agency heads to coordinate, work with, and engage governments, multilateral entities, and certain others to prevent zoonotic spillover events through various actions such as addressing the commercial trade in wildlife, strengthening global capacity for detection of zoonotic diseases with levitra potential, and supporting the development of One Health systems at the community level. Establishes the global zoonotic disease task force and outlines its membership and their terms, duties (including developing and publishing a plan for global biosecurity and zoonotic disease prevention and response and expanding the scope of the global health security strategy to more robustly support the prevention of zoonotic spillover and to respond to zoonotic disease investigations and outbreaks by establishing a 10 year strategy), required reports from agencies to the task force as well as from the task force to Congress, and its termination date 7 years after the date of enactment or a later date that is not later than two years after that.Global levitra Prevention and Biosecurity ActTo establish a global zoonotic disease task force, and for other purposes. 5/20/2021S.1737Sen. Chris Coons (D-DE)Read twice and referred to SFRClevitra, zoonotic diseases, One Health, global health security,biosecurityRequires the Secretary of State and USAID Administrator to work with certain relevant agency heads to coordinate, work with, and engage governments, multilateral entities, and certain others to prevent zoonotic spillover events through various actions such as addressing the commercial trade in wildlife, strengthening global capacity for detection of zoonotic diseases with levitra potential, and supporting the development of One Health systems at the community level. Establishes the global zoonotic disease task force and outlines its membership and their terms, duties (including developing and publishing a plan for global biosecurity and zoonotic disease prevention and response and expanding the scope of the global health security strategy to more robustly support the prevention of zoonotic spillover and to respond to zoonotic disease investigations and outbreaks by establishing a 10 year strategy), required reports from agencies to the task force as well as from the task force to Congress, and its termination date 7 years after the date of enactment or a later date that is not later than two years after that.Greater Leadership Overseas for the Benefit of Equality Act of 2021(GLOBE Act of 2021)To protect human rights and enhance opportunities for LGBTQI people around the world, and for other purposes. 6/9/2021S. 1996Sen. Edward Markey (D-MA)Read twice and referred to SFRCLGBTQI health, HIV, Mexico City policyRequires equal access of all elements of the population to programs funded by U.S. Assistance, including global health programs.Also requires PEPFAR to. Be implemented in a way that equitably serves LGBTQI people, submit a report to Congress describing international prosecutions for sex work or consensual sexual activity based on commodities provided by PEPFAR or other U.S. Support, and submit a report to Congress on HIV/AIDS-related index testing. Requires GAO to submit a report to Congress that describes the impact of the implementation and enforcement of any iteration of the Mexico City Policy on the global LGBTQI community. And expresses Sense of Congress regarding the U.S. Engaging international organizations in efforts to eliminate LGBTQI discrimination.Greater Leadership Overseas for the Benefit of Equality Act of 2021(GLOBE Act of 2021)To protect human rights and enhance opportunities for LGBTQI people around the world, and for other purposes. 6/8/2021H.R. 3800Rep. Dina Titus (D-NV-1)Referred to HFAC, H. JudiciaryLGBTQI health, HIV, Mexico City policyRequires equal access of all elements of the population to programs funded by U.S. Assistance, including global health programs.Also requires PEPFAR to. Be implemented in a way that equitably serves LGBTQI people, submit a report to Congress describing international prosecutions for sex work or consensual sexual activity based on commodities provided by PEPFAR or other U.S. Support, and submit a report to Congress on HIV/AIDS-related index testing. Requires GAO to submit a report to Congress that describes the impact of the implementation and enforcement of any iteration of the Mexico City Policy on the global LGBTQI community. Expresses Sense of Congress regarding the U.S. Engaging international organizations in efforts to eliminate LGBTQI discrimination. And repeals the Mexico City policy by removing certain limitations on eligibility for foreign assistance.Honoring OCEANIA ActTo strengthen United States engagement in the Oceania region and enhance the security and resilience of allies and partners of the Oceania community, and for other purposes.5/20/2021H.R. 3373Rep. Ami Bera (D-CA-7)Referred to HFAC, H. Veteransâ Affairs, H. Natural Resources, H. Armed Services, H. Financial Services, H. Judiciary, H. Transportation and Infrastructure, H. Homeland SecurityPublic health capacity building, global health securityStates it is U.S. Policy to, among other things, improve the local capacity of the countries of Oceania to address public health challenges and improve global health security. Requires the Secretary of State, in consultation with the HHS Secretary, to establish a program to support building public health capacity and improving access to care and local health outcomes in Oceania related to maternal and child health, STDs, HIV/AIDS, tuberculosis, malaria, NTDs, NCDs, gender-based violence, substance use disorder, mortality due to epidemics, disasters, and the impacts from severe weather and environmental change, and other health issues. Requires a report on these efforts annually. Authorizes to be appropriated such sums as may be necessary to carry out the program. Requires amounts appropriated or made available to remain available under expended.Honoring OCEANIA ActTo strengthen United States engagement in the Oceania region and enhance the security and resilience of allies and partners of the Oceania community, and for other purposes.5/20/2021S. 1774Sen. Brian Schatz (D-HI)Read twice and referred to SFRCPublic health capacity building, global health securityStates it is U.S. Policy to, among other things, improve the local capacity of the countries of Oceania to address public health challenges and improve global health security. Requires the Secretary of State, in consultation with the HHS Secretary, to establish a program to support building public health capacity and improving access to care and local health outcomes in Oceania related to maternal and child health, STDs, HIV/AIDS, tuberculosis, malaria, NTDs, NCDs, gender-based violence, substance use disorder, mortality due to epidemics, disasters, and the impacts from severe weather and environmental change, and other health issues. Requires a report on these efforts annually. Authorizes to be appropriated such sums as may be necessary to carry out the program. Requires amounts appropriated or made available to remain available under expended.International Human Rights Defense Act of 2021To establish in the Bureau of Democracy, Human Rights, and Labor of the Department of State a Special Envoy for the Human Rights of LGBTI Peoples, and for other purposes.2/22/2021H.R. 1201Rep. Alan Lowenthal (D-CA-47)Referred to HFACLGBTI health, HIVIncludes statement of U.S. Policy regarding LGBTI issues globally, including employing a multisectoral approach to preventing and responding to criminalization, discrimination, and violence against LGBTI people internationally, including activities in the health sector. Authorizes the provision of U.S. Assistance to prevent and respond to these issues internationally, including enhancement of health sector capacity related to violence against LGBTI people and communities and to combat HIV.International Human Rights Defense Act of 2021To establish in the Bureau of Democracy, Human Rights, and Labor of the Department of State a Special Envoy for the Human Rights of LGBTI Peoples, and for other purposes.2/24/2021S. 424Sen. Edward Markey (D-MA)Read twice and referred to SFRCLGBTI health, HIVIncludes statement of U.S. Policy regarding LGBTI issues globally, including employing a multisectoral approach to preventing and responding to criminalization, discrimination, and violence against LGBTI people internationally, including activities in the health sector. Authorizes the provision of U.S. Assistance to prevent and respond to these issues internationally, including enhancement of health sector capacity related to violence against LGBTI people and communities and to combat HIV.International levitra Preparedness and erectile dysfunction treatment Response Act of 2021To improve global health, and for other purposes.6/24/2021S. 2297Sen. James Risch (R-ID)Placed on Senate Legislative Calendar under General Orderslevitra preparedness, erectile dysfunction treatment, treatments, WHO, health systems strengthening, CEPI, global health security, Global Fund to Fight AIDS, Tuberculosis and malariaRequires a report describing certain foreign assistance obligated/expended under the American Rescue Plan Act of 2021 and a plan for certain remaining funds. Requires development of a strategy to expand access to, and accelerate the global distribution of, erectile dysfunction treatments to other countries. Requires a report that assesses the global humanitarian response to erectile dysfunction treatment and outlines specific elements of the U.S. Governmentâs country-level response to the erectile dysfunction treatment levitra. In the event of an infectious disease outbreak outside the U.S. With levitra potential, states the President should designate the Department of State to serve as the lead for diplomatic engagement and related foreign policy efforts, USAID to serve as the key lead agency for design and implementation of the U.S. International response, relief, and recovery assistance, and the CDC to serve as the public health lead for the international response such as building up (in coordination with USAID) emergency operation centers. Allows certain foreign assistance funding to be used to support USAID disaster surge capacity. Requires a U.S. Global health security strategy and report. Authorizes to be established a committee on global health security and levitra and biological threats within the National Security Council (NSC) led by the Special Advisor for Global Health Security of the NSC. Within the Department of State, establishes a Special Representative for U.S. International activities to advance global health security and diplomacy overseas, to be appointed by the President and report to the Secretary of State and to lead in developing a global levitra prevention, preparedness and response framework. Authorizes the Representative to transfer and allocate certain U.S. Foreign assistance funding to the relevant departments and agencies implementing the U.S. Global health security strategy. Authorizes to be appropriated $3 billion for the five-year period beginning Oct. 1, 2022, to support enhancing preparedness in partner countries, replenishing the USAID Emergency Reserve Fund, U.S. Contributions to the World Bank Health Emergency Preparedness and Response Multi-Donor Fund, and U.S. Contributions to a new multilateral, catalytic financing mechanism for global health security and levitra prevention and preparedness (see âthe Fundâ below). Requires U.S. Global health program leadership identify areas of collaboration and coordination to ensure that such activities contribute to health systems strengthening. Directs the Secretary of State, with the USAID Administrator, to work with the Global Fund to Fight AIDS, Tuberculosis and Malaria, Gavi, the treatment Alliance, bilateral donors, and others to develop shared core indicators for strengthened health systems. Authorizes the U.S. To participate in the Coalition for Epidemic Preparedness Innovations (CEPI). Expresses Sense of Congress that the President should make an immediate contribution to CEPI of $300 million to expand research and development of treatments to combat the spread of erectile dysfunction treatment variants. Requires an annual National Intelligence Estimate (for five years) regarding the risks posed to the national security interests of the U.S. By the emergence, reemergence, and overseas transmission of pathogens with levitra potential. Requires the Secretary of State and others to work with WHO and other key stakeholders to establish or strengthen effective early warning systems for infectious disease threats with epidemic and levitra potential. Directs the Secretary of State, with the HHS Secretary, to work with WHO and like-minded member states to adopt an approach toward assessing infectious disease threats under the International Health Regulations (2005) for the WHO to identify and transparently communicate on an ongoing basis varying levels of risk leading up to, and during and after, a public health emergency of international concern (PHEIC) declaration. Directs the Secretary of State and others to seek to enter into negotiations to establish âthe Fund;â authorizes the President to make available for U.S. Contributions to the Fund such funds as may be appropriated or otherwise made available for such purpose. Limits the U.S. Contribution to the Fund to not exceed 33% of the total contributions from all sources.Mental Health in International Development and Humanitarian Settings Act(MINDS Act)To enhance mental health and psychosocial support within United States foreign assistance programs.6/17/2021H.R. 3988Rep. Theodore Deutch (D-FL-22)Referred to HFACMental health, children in adversity, erectile dysfunction treatmentExpresses Sense of Congress that mental health is integral and essential to overall health outcomes and other development objectives. Codifies the position of USAID coordinator for mental health and psychosocial support and describes the positionâs duties, including establishing a Mental Health and Psychosocial Support Working Group. Describes the Groupâs duties and members. States U.S. Policy is to integrate mental health and psychosocial support across all foreign assistance programs funded by the U.S.. Requires USAID and the Department of State regional bureaus and missions to utilize such policy for local capacity building, as appropriate and that such programming be evidence-based and culturally competent and respond to the specific needs of children in adversity. Requires USAID to brief Congress on progress and challenges to implementation, including programming in conflict and humanitarian settings, as well as the impact of erectile dysfunction treatment on programming. Requires the USAID Administrator in consultation with the OMB Director to brief Congress annually for five years (FY22 â FY26) on spending for this programming in U.S. Foreign assistance.Mental Health in International Development and Humanitarian Settings Act(MINDS Act)To enhance mental health and psychosocial support within United States foreign assistance programs.6/17/2021S. 2105Sen. Robert Casey (D-PA)Read twice and referred to SFRCMental health, children in adversity, erectile dysfunction treatmentExpresses Sense of Congress that mental health is integral and essential to overall health outcomes and other development objectives. Codifies the position of USAID coordinator for mental health and psychosocial support and describes the positionâs duties, including establishing a Mental Health and Psychosocial Support Working Group. Describes the Groupâs duties and members. States U.S. Policy is to integrate mental health and psychosocial support across all foreign assistance programs funded by the U.S.. Requires USAID and the Department of State regional bureaus and missions to utilize such policy for local capacity building, as appropriate and that such programming be evidence-based and culturally competent and respond to the specific needs of children in adversity. Requires USAID to brief Congress on progress and challenges to implementation, including programming in conflict and humanitarian settings, as well as the impact of erectile dysfunction treatment on programming. Requires the USAID Administrator in consultation with the OMB Director to brief Congress annually for five years (FY22 â FY26) on spending for this programming in U.S. Foreign assistance.Nullifying Opportunities for Variants to Infect and Decimate Act(NOVID Act)To establish a program to oversee the global erectile dysfunction treatment response and prepare for future levitras, and for other purposes.6/8/2021H.R. 3778Rep. Raja Krishnamoorthi (D-IL-8)Referred to HFAC and H. Energy and Commerceerectile dysfunction treatment, global health security, levitra preparedness and responseEstablishes the levitra preparedness and response program to be responsible for and provide oversight over the U.S. Global health response to the erectile dysfunction treatment levitra and protect Americans from the emergence of erectile dysfunction treatment variants and other pathogens with levitra potential. Require President to appoint program director who will coordinate the work of identified agencies, including USAID, CDC, and the Department of State, among others. Requires development of a comprehensive strategy to end the erectile dysfunction treatment levitra worldwide as well as a long-term strategy for preventing future levitras. Authorizes to be appropriated $34 billion for these efforts, and expresses Sense of Congress that $25 billion be made available to scale treatment manufacturing capacity and produce treatments, $8.5 billion to cover the cost of end-to-end delivery and administration of treatments in target countries, and $500 million to establish a global disease surveillance network to protect against future levitras. Describes implementation of comprehensive strategy, including requiring director to ensure immediate release of 80 million treatment doses that the U.S. Has already committed to send abroad and to reassess the U.S. treatment stockpile to determine whether further treatments can be sent abroad and to coordinate with BARDA to rapidly scale manufacturing capacity around the world to produce 8 billion treatment doses as soon as possible. Also requires director to ensure equitable access to treatments in collaboration with COVAX and to work with international partners to provide enough treatments to lower- and middle-income countries to fully vaccinate at least 60% of their respective populations, especially 92 countries identified by COVAX as being most in need of assistance. Requires the program to, among other things, build on PEPFAR and other existing U.S. Programs and relationships bilaterally and multilaterally. Express Sense of Congress that in the face of a global health emergency, the U.S. Government has broad authority, including under the Defense Production Act and the âBayh-Dole Actâ, to ensure adequate supply of treatments, necessary components, and raw materials through technology sharing and direct collaboration with manufacturers around the world.Nullifying Opportunities for Variants to Infect and Decimate Act(NOVID Act) To establish a program to oversee the global erectile dysfunction treatment response and prepare for future levitras, and for other purposes.6/8/2021S. 1976Sen. Jeff Merkley (D-OR)Read twice and referred to SFRCerectile dysfunction treatment, global health security, levitra preparedness and responseEstablishes the levitra preparedness and response program to be responsible for and provide oversight over the U.S. Global health response to the erectile dysfunction treatment levitra and protect Americans from the emergence of erectile dysfunction treatment variants and other pathogens with levitra potential. Require President to appoint program director who will coordinate the work of identified agencies, including USAID, CDC, and the Department of State, among others. Requires development of a comprehensive strategy to end the erectile dysfunction treatment levitra worldwide as well as a long-term strategy for preventing future levitras. Authorizes to be appropriated $34 billion for these efforts, and expresses Sense of Congress that $25 billion be made available to scale treatment manufacturing capacity and produce treatments, $8.5 billion to cover the cost of end-to-end delivery and administration of treatments in target countries, and $500 million to establish a global disease surveillance network to protect against future levitras. Describes implementation of comprehensive strategy, including requiring director to ensure immediate release of 80 million treatment doses that the U.S. Has already committed to send abroad and to reassess the U.S. treatment stockpile to determine whether further treatments can be sent abroad and to coordinate with BARDA to rapidly scale manufacturing capacity around the world to produce 8 billion treatment doses as soon as possible. Also requires director to ensure equitable access to treatments in collaboration with COVAX and to work with international partners to provide enough treatments to lower- and middle-income countries to fully vaccinate at least 60% of their respective populations, especially 92 countries identified by COVAX as being most in need of assistance. Requires the program to, among other things, build on PEPFAR and other existing U.S. Programs and relationships bilaterally and multilaterally. Express Sense of Congress that in the face of a global health emergency, the U.S. Government has broad authority, including under the Defense Production Act and the âBayh-Dole Actâ, to ensure adequate supply of treatments, necessary components, and raw materials through technology sharing and direct collaboration with manufacturers around the world.Preventing Foreign Attempts To Erode Healthcare Innovation ActTo prohibit the use of funds to support a measure at the World Trade Organization waiving intellectual property rights, and for other purposes.5/18/2021S. 1683Sen. Tim Scott (R-SC)Read twice and referred to S. FinanceTRIPS, WTO, intellectual property rights, erectile dysfunction treatmentsExpresses Sense of Congress that U.S. Should continue to promote strong international [sic] property rights internationally and that it is in the national interest of the U.S. To oppose efforts to transfer U.S. Intellectual property and technology to China or other countries seeking to profit off U.S. Investments. Prohibits use of funds to support, allow, or facilitate the negotiation or approval of the TRIPS waiver for the prevention, containment, and treatment of erectile dysfunction treatment proposed by India and South Africa or any other measure at the WTO to waive intellectual property rights.Preventing Future levitras Act of 2021To address the public health risks posed by wildlife markets, and for other purposes.1/4/2021H.R. 151Rep. Mike Quigley (D-IL-5)Referred to HFAC, H. Energy and Commerce, H. Judiciary, H. Ways and Means, H. Financial Services, H. Natural ResourcesGlobal health security, One Health, zoonotic diseasesRequires the HHS Secretary to enter into an agreement with the National Academies of Sciences, Engineering, and Medicine for it to conduct a study on the risk of wildlife markets on the emergency of novel viral pathogens, to be submitted not later than one year after the date of agreement. Expresses Sense of Congress that global institutions, including WHO, and others including USAID should promote the paradigm of One Health. States U.S. Policy is to facilitate international cooperation to close high risk wildlife markets around that world and to work to develop agreements and protocols to close these markets. Allows the President to impose sanctions on any country (or nationals of a country) continuing to license or enable commercial wildlife markets or engaged in certain activities. Authorizes FY 2021 â FY 2030 funding for USAID activities related to sustainable food systems. Requires the USAID administrator to increase activities related to biodiversity, global health, and resilience, among other things, in order to address the threats and causes of zoonotic disease outbreaks.. Requires reporting from the Department of State and USAID describing these efforts.Preventing Future levitras Act of 2021To address the public health risks posed by wildlife markets, and for other purposes.1/25/2021S. 37Sen. John Cornyn (R-TX)Read twice and referred to SFRCGlobal health security, One Health, zoonotic diseasesRequires the HHS Secretary to enter into an agreement with the National Academies of Sciences, Engineering, and Medicine for it to conduct a study on the risk of wildlife markets on the emergency of novel viral pathogens, to be submitted not later than one year after the date of agreement. Expresses Sense of Congress that global institutions, including WHO, and others including USAID should promote the paradigm of One Health. States U.S. Policy is to facilitate international cooperation to close high risk wildlife markets around that world and to work to develop agreements and protocols to close these markets. Allows the President to impose sanctions on any country (or nationals of a country) continuing to license or enable commercial wildlife markets or engaged in certain activities. Authorizes FY 2021 â FY 2030 funding for USAID activities related to sustainable food systems. Requires the USAID administrator to increase activities related to biodiversity, global health, and resilience, among other things, in order to address the threats and causes of zoonotic disease outbreaks.. Requires reporting from the Department of State and USAID describing these efforts.Protecting Life in Foreign Assistance ActTo restrict the availability of Federal funds to organizations associated with the abortion industry.1/28/2021H.R. 534Rep. Virginia Foxx (R-NC-5)Referred to HFACAbortion, Mexico City policyCodifies the expanded Mexico City policy (rescinded by President Biden in Jan. 2021. See KFF explainer) and expands it to apply more broadly to federal funding made available for purposes outside of the U.S. To 1) any foreign nonprofit organization, foreign nongovernmental organization, foreign multilateral organization, or foreign quasi-autonomous nongovernmental organization that carries out certain activities, and 2) any domestic nonprofit organization or domestic nongovernmental organization that carries out certain activities.Protecting Life in Foreign Assistance ActTo restrict the availability of Federal funds to organizations associated with the abortion industry.1/28/2021S. 137Sen. Mike Lee (R-UT)Read twice and referred to SFRCAbortion, Mexico City policyCodifies the expanded Mexico City policy (rescinded by President Biden in Jan. 2021. See KFF explainer) and expands it to apply more broadly to federal funding made available for purposes outside of the U.S. To 1) any foreign nonprofit organization, foreign nongovernmental organization, foreign multilateral organization, or foreign quasi-autonomous nongovernmental organization that carries out certain activities, and 2) any domestic nonprofit organization or domestic nongovernmental organization that carries out certain activities.Reach Every Mother and Child ActTo amend the Foreign Assistance Act of 1961 to implement policies to end preventable maternal, newborn, and child deaths globally.4/29/2021S. 1451Sen. Susan Collins (R-ME)Read twice and referred to SFRCMaternal health, child healthIncludes statement of U.S. Policy to establish and implement a coordinated, integrated, and comprehensive strategy to end preventable child and maternal deaths and ensure healthy and productive lives. Requires the establishment and implementation of a five-year comprehensive strategy to contribute toward the global goal of ending preventable child and maternal deaths by 2030. States the President should designate a Child and Maternal Survival Coordinator and describes their duties. Requires an annual report on progress.Reproductive Rights are Human Rights Act of 2021To amend the Foreign Assistance Act of 1961 to require a section on reproductive rights in the Annual Country Reports on Human Rights Practices.5/28/2021H.R. 3576Rep. Katherine Clark (D-MA-5)Referred to HFACState Dept. Annual human rights report, family planning/reproductive health (FP/RH), maternal mortality, abortion, violence against womenAmends existing law to require annual reporting by the Department of State on human rights to include, among other things. The status of reproductive rights in each country. Description of the rates and causes of pregnancy-related injuries and deaths (including deaths due to unsafe abortions), violence against women, and access to family planning. Requires that civil society and multilateral organizationsâ representatives in the U.S. And countries included in such reporting be consulted with during the preparation of annual reporting.Reproductive Rights are Human Rights Act of 2021To amend the Foreign Assistance Act of 1961 to require a section on reproductive rights in the Annual Country Reports on Human Rights Practices.5/26/2021S. 1864Sen. Robert Menendez (D-NJ)Read twice and referred to SFRCState Dept. Annual human rights report, family planning/reproductive health (FP/RH), maternal mortality, abortion, violence against womenAmends existing law to require annual reporting by the Department of State on human rights to include, among other things. The status of reproductive rights in each country. Description of the rates and causes of pregnancy-related injuries and deaths (including deaths due to unsafe abortions), violence against women, and access to family planning. Requires that civil society and multilateral organizationsâ representatives in the U.S. And countries included in such reporting be consulted with during the preparation of annual reporting.Robust International Response to levitra ActTo provide support for a robust global response to the erectile dysfunction treatment levitra.2/11/2021H.R. 986Rep. Jesus âChuyâ Garcia (D-IL-4)Referred to H. Financial Serviceserectile dysfunction treatmentDirects the Secretary of the Treasury to instruct U.S. Executive Directors at international financial institutions to ensure international financial institution support for a robust international response to the global erectile dysfunction treatment levitra, including to oppose the approval or endorsement of any loan, grant, document, or strategy that would lead to a decrease in health care spending or in any other spending that would impede the ability of any country to prevent or contain the spread of, or treat persons who are or may be infected with, the erectile dysfunction treatment levitra.Securing America From Epidemics Act(SAFE Act) To authorize United States participation in the Coalition for Epidemic Preparedness Innovations, and for other purposes.3/23/2021H.R. 2118Rep. Ami Bera (D-CA-7)Passed House, read twice and referred to SFRCResearch &. Development (R&D), global health security, levitra, epidemicAuthorizes U.S. Participation in the Coalition for Epidemic Preparedness Innovation (CEPI). Reports to Congress required to be submitted by the President not later than 180 days after enactment of the Act and to outline planned U.S. Contributions to CEPI, the manner and extent to which the U.S. Will participate in the governance of CEPI, and how participation in CEPI supports relevant U.S. Strategies and programs in health security and biodefense, among other things. Authorizes certain appropriated funding to be made available for U.S. Contributions to CEPI.Strategic Competition Act of 2021To address issues involving the Peopleâs Republic of China. 4/15/2021S. 1169Sen. Robert Menendez (D-NJ)Placed on Senate Legislative Calendar under General Orderserectile dysfunction treatment, health cooperation, WHO, global health security, abortion, forced sterilization, debt reliefExpresses sense of Congress that the U.S. Government should encourage other foreign governments to use the official and scientific names for the erectile dysfunction treatment levitra. States U.S. Policy is to deepen cooperation between and among the U.S., Japan, South Korea, the Philippines, Thailand, and Australia, including through scientific and health partnerships. Expresses sense of Congress that recent pledge from the first-ever Quad (Australia, India, Japan, U.S.) leaders meeting on March 12, 2021, to respond to the economic and health impacts of erectile dysfunction treatment, including expanding treatment production and equitable access, further advances cooperation among Quad nations. States it is U.S. Policy to stand with the nations of ASEAN as they respond to erectile dysfunction treatment and support greater cooperation in building capacity to prepare for and respond to levitras and other public health challenges. States it is U.S. Policy to advocate and actively advance Taiwanâs meaningful participation in the World Health Assembly, among other bodies. Requires report on the origins of the erectile dysfunction treatment levitra to be submitted by the Director of National Intelligence, in coordination with the Secretary of State, HHS Secretary, and others, not later than 180 days after enactment. Requires strategies that describe how the U.S. Will enhance cooperation with Canada, the European Union, NATO, and European partner countries in managing relations with China, including detailing diplomatic efforts to work with them to track and counter Chinese attempts to exert influence across the multilateral system, including at WHO. Requires a strategy for countering and limiting Chinese influence in, and access to, the Middle East and North Africa, including efforts to encourage U.S. Private sector and public-private partnerships in healthcare technology, among other things. States it is U.S. Policy to work with Australia, New Zealand, and Japan to advance shared alliance goals of the Oceania region concerning health, among other things, and to improve the local capacity of the countries of Oceania to address public health challenges and improve global health security. Address the imposition of sanctions with respect to systematic rape, coercive abortion, forced sterilization, or involuntary contraceptive implantation in the Xinjiang Uyghur Autonomous Region. Addresses reporting related to debt relief via the International Development Association (IDA) for certain countries to respond to the erectile dysfunction treatment levitra.Support for Global Financial Institution levitra Response Act of 2021To support efforts by international financial institutions to provide a robust global response to the erectile dysfunction treatmentâ19 levitra.1/27/2021S. 67Sen. Richard Durbin (D-IL)Read twice and referred to SFRCerectile dysfunction treatmentDirects the Secretary of the Treasury to instruct U.S. Executive Directors at international financial institutions to ensure international financial institution support for a robust international response to the global erectile dysfunction treatment levitra, including to oppose the approval or endorsement of any loan, grant, document, or strategy that would lead to a decrease in health care spending or in any other spending that would impede the ability of any country to prevent or contain the spread of, or treat persons who are or may be infected with, the erectile dysfunction treatment levitra.Support UNFPA Funding ActTo authorize contributions to the United Nations Population Fund, and for other purposes.6/16/2021H.R. 3938Rep. Chrissy Houlahan (D-PA-6)Referred to HFACUNFPA, family planning/reproductive health (FP/RH)Includes statement of U.S. Policy regarding financial support for UNFPA as a crucial part of U.S. Global health commitment. Authorizes appropriations for five years for an annual contribution to UNFPA to support core functions and programs.To amend the National Security Act of 1947 to require the President to designate an employee of the National Security Council to be responsible for levitra prevention and response, and for other purposes.2/8/2021S. 290Sen. Edward Markey (D-MA)Read twice and referred to HSGAClevitraRequires the President to designate an employee of the National Security Council to be the permanent coordinator for levitra prevention and response for the federal government, outlines duties, and grants them authority to represent the U.S. In bilateral and multilateral discussions and agreements on relevant matters.To direct the Secretary of State to develop a strategy to regain observer status for Taiwan in the World Health Organization, and for other purposes.2/18/2021H.R. 1145Rep. Young Kim (R-CA-39)Passed HFAC (Ordered to be Reported in the Nature of a Substitute by Voice Vote)WHO, TaiwanDirects the Department of State to include additional information in its annual reports concerning Taiwanâs participation at WHOâs World Health Assembly as an observer.To direct the Secretary of State to develop a strategy to regain observer status for Taiwan in the World Health Organization, and for other purposes.3/17/2021S. 812Sen. Robert Menendez (D-NJ)Placed on Senate Legislative Calendar Under General OrdersWHO, TaiwanDirects the Department of State to include additional information in its annual reports concerning Taiwanâs participation at WHOâs World Health Assembly as an observer.To prohibit the use of funds to seek membership in the World Health Organization or to provide assessed or voluntary contributions to the World Health Organization.1/28/2021H.R. 497Rep. Jodey Arrington (R-TX-19)Referred to HFACWHOProhibits the use of federal funds to seek membership by the U.S. In WHO or to provide assessed or voluntary U.S. Contributions to WHO until such time as the President certifies that WHO meets certain conditions, including. WHO has adopted meaningful reforms to ensure that humanitarian assistance is not politicized and is to be provided to those with the most need, WHO is not under the control or significant malign influence of the Chinese Communist party, WHO is not involved in a coverup of the Chinese Communist Partyâs response to the erectile dysfunction treatment levitra, WHO grants observer status to Taiwan, WHO does not divert humanitarian or medical supplies to Iran, North Korea, or Syria, and WHO has put in place mechanisms to increase transparency and accountability in its operations and eliminate waste, fraud, and abuse.United States Climate Leadership in International Mitigation, Adaptation, and Technology Enhancement Act of 2021(U.S. CLIMATE Act) To restore the United States international leadership on climate change and clean energy, and for other purposes. 4/19/2021S. 1201Sen. Robert Menendez (D-NJ)Read twice and referred to SFRCClimate change, global healthRequires the Secretary of State, in consultation with other relevant agencies, to conduct biennial comprehensive evaluations of present and ongoing disruptions to the global climate system, including the scarcity of global natural resources including fresh water, global food, health, and energy insecurities and conditions that contribute to gender-based violence, among other things. Requires these evaluations to be used by the Secretary of State to inform the development and implementation of a climate security strategy, and to develop and implement plans to account for the impacts of climate change on global human health, fresh water, and marginalized groups. States U.S. Policy is to ensure that the International Climate Change Adaptation, Mitigation, and Security Program (required to be established under the act by the Secretary of State, in coordination with the Secretary of the Treasury and the Administrator of USAID) provide resources to developing countries to support efforts that reduce the vulnerability and increase the resilience capacities of communities to the effects of climate change, including effects on water availability and health and diseases. Directs the Secretary of the Treasury to use the influence of the U.S. To ensure that the Green Climate Fund requires country recipients to submit investment plan that describes how adaptation projects will advance public health outcomes, among other things. Incorporates the Women and Climate Change Act.Uyghur Stop Oppressive Sterilizations Act(Uyghur SOS Act) To address state-sanctioned violence against women in the Peopleâs Republic of China, including rape and torture in detention and forced sterilizations, forced abortions, and other coercive birth restriction policies, particularly in the Xinjiang Uyghur Autonomous Region, and for other purposes.5/18/2021H.R. 3306Rep. Vicky HartzlerReferred to HFAC and H. JudiciaryForced sterilization, abortionStates U.S. Policy is to regard the prevention of genocide and other atrocity crimes as a national interest particularly when those actions target certain groups in the Xinjiang Uyghur Autonomous Region through, among other things, forced sterilizations, forced abortions and other coercive birth restrictions policies, and sexual violence and other torture in detention, to raise the issue of state-sanctioned violence against women, including rape, torture, and coercively enforced population control policies in China in all multilateral organizations where the U.S. And China are members, including at the U.N. Security Council, and to consider state-sanctioned violence against women, including forced sterilizations and forced abortions and the systematic use of rape and torture in mass internment camps in the Region as a gross violation of internationally-recognized human rights. Expresses the Sense of Congress that all governments, including the U.S., and international organizations, such as the U.N., should call the atrocities perpetuated by the government of China, including forced sterilizations and forced abortions and other sexual violence, as genocide and crimes against humanity and that the U.S. Should strongly condemn the intimidation and threats targeting Uyghur and Kazakh women who provide public evidence of sexual violence and forced sterilizations and forced abortions in mass internment camps and the journalist who report these stories. Also expresses Sense of Congress that U.N. Member states should condemn such atrocities by demanding that China end all forced sterilization, forced abortions, and other state-sanctioned violence against women, among other things. Requires the president to submit a strategy for ending atrocity crimes in the Region. Requires the Secretary of State to provide all appropriate assistance to women who belong to certain groups and who experienced sexual violence, torture, forced sterilizations and forced abortions in China in order for them to receive needed medical care and psychological support. Requires all existing authorities to be used to allow such women to at least temporarily enter the U.S.Women and Climate Change Act of 2021To address the disparate impact of climate change on women and support the efforts of women globally to address climate change, and for other purposes.1/11/2021H.R. 260Rep. Barbara Lee (D-CA-13)Referred to HFAC, H. Energy &. CommerceClimate change, global health, reproductive healthAddresses climate change and its effects on women and girls. Establishes the Federal Interagency Working Group on Women and Climate Change within the Department of State and outlines its functions, such as identifying best practices for collecting data on the disparate impact of climate change on women â including in access to comprehensive health care, including reproductive health and rights. Requires the Department of Stateâs Office of Global Womenâs Issues (GWI) to submit a strategy (and shortly thereafter an implementation plan and budget) to prevent and respond to the effects of climate change on women, including effective action to promote public health. Requires the Ambassador-at-Large of GWI to designate a Senior Coordinator for Women and Climate Change. Requires the GWI Ambassador and the Senior Coordinator to submit to the appropriate congressional committees an assessment of the human and financial resources necessary to carry out the Act.World Health Organization Accountability ActTo prohibit the availability of United States contributions to the World Health Organization until Congress receives a full report on China and the erectile dysfunction treatmentâ19 levitra, and for other purposes.1/21/2021H.R. 374Rep. Lauren Boebert (R-CO-3)Referred to HFACWHO, erectile dysfunction treatmentProhibits the use of federal funds for U.S. Contributions to WHO or U.S. Participation in any of the activities of WHO until the Secretary of State and HHS Secretary jointly submit a report to Congress describing the manner and extent to which the handling of the erectile dysfunction treatment outbreak prior to March 11, 2020, by WHO and China contributed to the emergency of the levitra.NOTES. SFRC means Senate Committee on Foreign Relations. HFAC means the House Committee on Foreign Affairs. H. Means House. S. Means Senate. SFOPS means Department of State, foreign operations, and related programs. LGBTI means lesbian, gay, bisexual, transgender, or intersex. WHO is the World Health Organization. ASEAN is the Association of Southeast Asian Nations. * Other than those that apply to U.S. NGOs receiving certain foreign aid under the Foreign Assistance Act.. Buy vardenafil levitra18 November 2021 A look at how some of our members marked National Cost of zithromax 500mg Pathology Week from 1-7 buy vardenafil levitra November, 2021. Swansea Bay University Health Board Pathology staff at Morriston Hospital, Singleton Hospital, Neath Porth Talbot Hospital and Princess of Wales Hospital promoted pathology services and biomedical science at their respected hospitals throughout the week with a series of engagement events â all under the weekâs theme, #AllTogetherNow. #NationalPathologyWeek @princess of Wales Hospital buy vardenafil levitra. @IBMScience @RCPath @SBUPathology pic.twitter.com/YzTugwZ3Pw â Kim Lewis (@KimChrisLewis) November 2, 2021 Display stands were put up in front of pathology services, where staff were able to answer any questions from other Hospital staff as well as patients. The stands were visited by lots of different groups, including- medical students studying at Cardiff University, parents who were curious about career journeys in pathology on behalf of their children, and visitors wanting to understand what we do with their bloods after collection. Day buy vardenafil levitra 4 of #nationalpathologyweek2021. Some of our Pathology staff came out to support Harvey's Gang and Blood bike Wales @Princess of Wales Hospital. @IBMScience @GangHarveys @SBUPathology @RCPath pic.twitter.com/qst5T9VTgz â Kim Lewis (@KimChrisLewis) November 4, 2021 today our staff went on a walk round our hospital sites to raise funds for @Laird_Admiral and @BloodBikesWales pic.twitter.com/5NlZLi2f1r â Swansea Bay UHB Pathology (@SBUPathology) November 4, 2021 Pathology staff also held a Harveyâs Gang tour, where a young boy was taken around the laboratory and shown his blood films and other laboratory tests. After the tour, Pathology staff across all sites wore plastic aprons and marched around the Hospital in buy vardenafil levitra support of Harveyâs Gang and Blood Bike. With this hospital march, the department was able to raise money to support and promote Harveyâs Gang and Blood Bike Wales. âAfter the event there was a huge boost of morale in each department. Staff particularly liked the walk buy vardenafil levitra around the hospital and the departmental Kahoot!. quiz. In effort to promote staff well-being, the management have agreed to routine departmental engagement such as these to further support staff well-being. Overall, this was a successful buy vardenafil levitra event with positive outcomes.â Kimberly Lewis, Specialist Biomedical Scientist in Clinical Biochemistry at Princess of Wales Hospital To finish off the week, Swansea Bay UHB held a departmental quiz. Staff formed teams within their department (i.e. Biochemistry, haematology, microbiology and cellular pathology). Biochemistry took the win! buy vardenafil levitra. And the winners are â¦. Biochemistry at buy vardenafil levitra POW!. Trophy and prizes to be delivered next week. Thank you to all who have supported us this week #NationalPathologyWeek2021 #AllTogetherNow @RCPath @IBMScience @Rutharoo15 @RhodDavies1 @ChrissieMoz @maggsheidi pic.twitter.com/GnxXxntGVL â Swansea Bay UHB Pathology (@SBUPathology) November 5, 2021 Christie Pathology Partnership To mark National Pathology Week, IBMS Council Member Tahmina Hussain organised a week of lunchtime pathology featuring staff at The Christie Pathology Partners (Manchester). Each day they delivered a lunchtime session on a different discipline in Pathology - covering Blood Sciences Specimen Reception, a Histology buy vardenafil levitra lab tour, Cytogenetics, Mortuary and Bereavement Suite and the Blood Transfusion laboratory. âThese sessions gave a really interesting insight into Pathology and the roles each and every one of us plays in the patient care pathway. Often, we are so busy working in our own departments, we are not aware of what the role of our team members are in different departments so this was a really good way of getting âAll together nowâ, meeting other team members and learning something new!. Due to the success of these sessions, many of the staff members who were not able to attend have requested buy vardenafil levitra a repeat!.  Tahmina Hussain Specialist Biomedical Scientist in Haematology &. Blood Transfusion at The Christie Pathology Partnership Support from IBMS Chief Executive David Wells As IBMS Chief Executive and former Head of Pathology at NHS England, David Wells shared a message of support for National Pathology Week on social media. Whatever you have buy vardenafil levitra done to celebrate #nationalpathologyweek thank you!. @IBMScience @RCPath pic.twitter.com/uxGEQCfl7e â David Wells (@DavidRWells) November 5, 2021 Thank you to everyone across the profession who came together to raise awareness and celebrate National Pathology Week 2021!. 11 November 2021 The Association of British HealthTech Industries (ABHI) and the British In Vitro Diagnostics Association (BIVDA) write to Dr Jenny Harries OBE, Chief Executive Officer for UK Health Security Agency The letter raises concerns over validation processes and the quality of some erectile dysfunction treatment tests available on the market. They argue that implementation of the erectile dysfunction Test Device Approvals (CTDA) process has damaged the UK diagnostics industry and led to the needless withdrawal of erectile dysfunction treatment tests with buy vardenafil levitra no identified deficiency which has weakened supply resilience in the UK and could disrupt testing capacity and capability. The letter was shared with David Wells, IBMS Chief Executive and Professor Allan Wilson, IBMS President, as well as politicians and representatives from the diagnostics industry. David Wells, IBMS Chief Executive said. "The IBMS welcomes legislation that supports the supply of high-quality diagnostic tests for our patients and the general public. In enacting this legislation, the Government must ensure that existing capacity and capability is maintained to support the NHS over the coming months. Therefore, industry concerns, together with those of laboratory experts should be taken into consideration, to ensure the supply chain and resilience of the availability of tests is maintained to meet the needs of the country.â Read the letter in full>>. 18 November 2021 A look at how some of our members marked National Pathology Cost of zithromax 500mg Week from 1-7 cheapest levitra November, 2021. Swansea Bay University Health Board Pathology staff at Morriston Hospital, Singleton Hospital, Neath Porth Talbot Hospital and Princess of Wales Hospital promoted pathology services and biomedical science at their respected hospitals throughout the week with a series of engagement events â all under the weekâs theme, #AllTogetherNow. #NationalPathologyWeek cheapest levitra @princess of Wales Hospital. @IBMScience @RCPath @SBUPathology pic.twitter.com/YzTugwZ3Pw â Kim Lewis (@KimChrisLewis) November 2, 2021 Display stands were put up in front of pathology services, where staff were able to answer any questions from other Hospital staff as well as patients. The stands were visited by lots of different groups, including- medical students studying at Cardiff University, parents who were curious about career journeys in pathology on behalf of their children, and visitors wanting to understand what we do with their bloods after collection. Day cheapest levitra 4 of #nationalpathologyweek2021. Some of our Pathology staff came out to support Harvey's Gang and Blood bike Wales @Princess of Wales Hospital. @IBMScience @GangHarveys @SBUPathology @RCPath pic.twitter.com/qst5T9VTgz â Kim Lewis (@KimChrisLewis) November 4, 2021 today our staff went on a walk round our hospital sites to raise funds for @Laird_Admiral and @BloodBikesWales pic.twitter.com/5NlZLi2f1r â Swansea Bay UHB Pathology (@SBUPathology) November 4, 2021 Pathology staff also held a Harveyâs Gang tour, where a young boy was taken around the laboratory and shown his blood films and other laboratory tests. After the cheapest levitra tour, Pathology staff across all sites wore plastic aprons and marched around the Hospital in support of Harveyâs Gang and Blood Bike. With this hospital march, the department was able to raise money to support and promote Harveyâs Gang and Blood Bike Wales. âAfter the event there was a huge boost of morale in each department. Staff particularly liked the walk around cheapest levitra the hospital and the departmental Kahoot!. quiz. In effort to promote staff well-being, the management have agreed to routine departmental engagement such as these to further support staff well-being. Overall, this was a successful event with positive outcomes.â Kimberly Lewis, Specialist Biomedical Scientist in cheapest levitra Clinical Biochemistry at Princess of Wales Hospital To finish off the week, Swansea Bay UHB held a departmental quiz. Staff formed teams within their department (i.e. Biochemistry, haematology, microbiology and cellular pathology). Biochemistry took cheapest levitra the win!. And the winners are â¦. Biochemistry at cheapest levitra POW!. Trophy and prizes to be delivered next week. Thank you to all who have supported us this week #NationalPathologyWeek2021 #AllTogetherNow @RCPath @IBMScience @Rutharoo15 @RhodDavies1 @ChrissieMoz @maggsheidi pic.twitter.com/GnxXxntGVL â Swansea Bay UHB Pathology (@SBUPathology) November 5, 2021 Christie Pathology Partnership To mark National Pathology Week, IBMS Council Member Tahmina Hussain organised a week of lunchtime pathology featuring staff at The Christie Pathology Partners (Manchester). Each day they delivered a lunchtime session on a different discipline in Pathology - covering Blood Sciences Specimen Reception, a Histology lab tour, Cytogenetics, cheapest levitra Mortuary and Bereavement Suite and the Blood Transfusion laboratory. âThese sessions gave a really interesting insight into Pathology and the roles each and every one of us plays in the patient care pathway. Often, we are so busy working in our own departments, we are not aware of what the role of our team members are in different departments so this was a really good way of getting âAll together nowâ, meeting other team members and learning something new!. Due to the cheapest levitra success of these sessions, many of the staff members who were not able to attend have requested a repeat!.  Tahmina Hussain Specialist Biomedical Scientist in Haematology &. Blood Transfusion at The Christie Pathology Partnership Support from IBMS Chief Executive David Wells As IBMS Chief Executive and former Head of Pathology at NHS England, David Wells shared a message of support for National Pathology Week on social media. Whatever you have done to celebrate #nationalpathologyweek cheapest levitra thank you!. @IBMScience @RCPath pic.twitter.com/uxGEQCfl7e â David Wells (@DavidRWells) November 5, 2021 Thank you to everyone across the profession who came together to raise awareness and celebrate National Pathology Week 2021!. 11 November 2021 The Association of British HealthTech Industries (ABHI) and the British In Vitro Diagnostics Association (BIVDA) write to Dr Jenny Harries OBE, Chief Executive Officer for UK Health Security Agency The letter raises concerns over validation processes and the quality of some erectile dysfunction treatment tests available on the market. They argue that implementation of the erectile dysfunction Test Device Approvals (CTDA) process has damaged the UK diagnostics industry and led to the needless withdrawal of erectile dysfunction treatment tests with no identified deficiency which has weakened supply resilience in the UK and could disrupt testing capacity and capability cheapest levitra. The letter was shared with David Wells, IBMS Chief Executive and Professor Allan Wilson, IBMS President, as well as politicians and representatives from the diagnostics industry. David Wells, IBMS Chief Executive said. "The IBMS welcomes legislation that supports the supply of high-quality diagnostic tests for our patients and the general public. In enacting this legislation, the Government must ensure that existing capacity and capability is maintained to support the NHS over the coming months. Therefore, industry concerns, together with those of laboratory experts should be taken into consideration, to ensure the supply chain and resilience of the availability of tests is maintained to meet the needs of the country.â Read the letter in full>>. /" class="ctc-tag tag-link-9" title="106 topics" rel="tag" style="font-size: 18.243902439024pt;">boozeCompare viagra cialis levitra side effects |
Compare viagra cialis levitra side effectsCompare viagra cialis levitra side effectsObviously I haven’t updated in a long time. For the most part, that’s because my brewing equipment is packed up in expectation of moving somewhere or other. Pretty much all I’m doing these days is running in the mornings and trying to avoid heat in the afternoons. Anyway, I ran 10 km this morning. Probably […] Compare viagra cialis levitra side effectsIt’s only been spring here for about a month, but I’m starting to get back into a groove. I’m sure I’m positively dogging it by most people’s standards, but it’s gratifying to be seeing improvement almost daily. Name: Track 096 Date: Jun 5, 2013 9:41 am Map: View on Map Distance: 1.51 miles Elapsed Time: […] Compare viagra cialis levitra side effectsBrewing test batches isn’t necessarily a whole lot of fun, but it does lend itself to some potentially useful experimentation. Throughout my (home) brewing career, I’ve bounced more or less randomly from one Belgian strain to another, in the process collecting most of the common strains, but without really settling on a “house” yeast. For […] Compare viagra cialis levitra side effectsIt is exactly as dangerous as it looks. Heat sticks are becoming popular among home brewers, and for good reason. Having two heated vessels really streamlines a brew day, and makes double brew days significantly less painful. And the economics of electric heat are compelling (in fact, that’s the way I’ve decided to […] Compare viagra cialis levitra side effectsShaved Parmesan doesn’t work quite as well as shredded. A recipe that doesn’t involve beer?! I know, I’m in danger of becoming a well-rounded person. These are delicious, though, and very easy to make, and quickly becoming my go-to appetizer for guests. If you have access to Trader Joe’s, they sell a can of […] Compare viagra cialis levitra side effectsJust a quick note. While I was doing some calculations for Two Mile, I decided to expand on a year-old post on draft system balancing, primarily just to include the relevant results for longer draft systems. Enjoy. Or not. It doesn’t really affect me either way. […] Compare viagra cialis levitra side effectsI haven’t posted in… let’s see… six months. Yikes. Here’s a quartet of beer recipes, though, so that’s basically the same as posting almost once per month. 10.2 Mk2: I’m still struggling to get the attenuation I need out of my Belgian-style “Blond” (I use quotation marks because BJCP-wise, it would be a Belgian Specialty […] Compare viagra cialis levitra side effectsI’m not wild about the idea of driving somewhere for the sole purpose of running somewhere else, but I suppose allowances can be made. Name: Track 023 Date: Apr 26, 2012 11:35 am Map: View on Map Distance: 3.01 miles Elapsed Time: 29:41.2 Avg Speed: 6.1 mph Max Speed: 8.3 mph Avg Pace: 9′ […] Compare viagra cialis levitra side effectsWell, maybe “hate”‘s a strong word. I’ve just never had a wine that I’d prefer over a good beer. I’ll keep trying though. You know, for science. What I do hate is the wine industry. Bunch of namby-pamby grape gropers whose bottles collect dust and who spit instead of swallow. Which is why my interest […] |
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