On Wednesday, June 3, 2021, the Infectious Diseases Division gathered to celebrate two outstanding fellows, Drs. Mark Ridder and Clayton Mowrer. Both are graduating and moving on to amazing (and different) next steps. These fellows joined our division in July 2019, a mere 6 months before our world would change as a result of the COVID-19 pandemic. They adapted to zoom lectures and conferences, and underwent tremendous growth over the last two years. Thanks to vaccines, we were able to gather to celebrate their graduation in person together.
(best viewed in full screen mode!)
Dr. Ridder and Dr. Mowrer joined our fellowship as we had just gotten used to having 2 fellows per year, and the year after they joined, we expanded to 3 fellows per year. We were honored to help them both grow and develop their infectious diseases knowledge, leadership and team management skills, the art of medical education, and most importantly, to expand their skills in delivering compassionate patient care. We also enjoyed getting to know them as amazing people, share laughs with them, and celebrate milestones with them.
(left photo, Dr. Mark Ridder and Dr. Marcelin with GenID team on rounds; right photo, Dr. Clayton Mowrer and GenID team on rounds)
Dr. Mark Ridder (back 2nd from left) with Specialty Care Center clinic staff: (L-R back Jeremy Johnson, Precious Davis RN, Dan Cramer APRN; L-R front Sara Bares MD, Sheila Daniel Cobos RN, Genie Shumaker)Dr. Clayton Mowrer (middle, back) with clinic staff (L-R) Precious Davis RN, Rachelle Carr, Daniel Cobos RN
During fellowship, Dr. Clayton Mowrer published a manuscript describing an approach to using cycle threshold values for COVID-19 de-isolation. Dr. Mowrer is moving to our division of Pediatric Infectious Diseases, where he will complete his Pediatric ID fellowship at Children’s Hospital. We look forward to still having him around for conferences and collaboration!
Dr. Mark Ridder (Left) and Dr. Clayton Mowrer (Right) in the throes of the annual Specialty Care Center Annual Graduating Fellows’ Farewell Dance Day (this is a legitimate tradition started by our Nurse Case Manager Precious Davis RN, who always encourages our fellows to let loose and enjoy ‘shenanigans’ every once in a while. Every graduating fellow has to do a dance before they leave clinic for the last time)
We will certainly miss them both dearly, but wish them all the best in their journeys, and hope to keep sharing their news along the way!
Household contacts to active SARS-Cov2 to infectious cases has been identified as a significant risk factor for acquisition of infection since early in the pandemic. We identified this as one of our biggest risk factors for colleague acquisition of SARS-CoV2 to infection at Nebraska Medicine as well. This brief report written by a team from Nebraska Medicine/UNMC, shows our experience of our colleagues with household contacts post vaccination. This suggests several important points of the pandemic and fully healthcare providers. The vaccines are very effective (we are ready knew that) however breakthrough cases have been reported. Household contact remains a significant risk factor in these breakthrough cases. As the United States and other locations open up society, we need to keep in mind that all contacts to infections are not equal and consideration for household contacts and needing close monitoring and testing is still warranted. The single biggest thing healthcare providers can continue to do to protect themselves, their families, their colleagues and their patients is to not only get themselves immunized but to get their families immunized, especially their domestic partners. We have continued this program and more data will soon be available.
It took some time to find an a way to accurately summarize the last two years. I’ll start with one easy sentence:
This was a fantastic fellowship, and I would instantly choose it again.
I feel so fortunate that not only did we received such a breadth of training in all aspects of ID (ASP, SOT, ortho), but that we had the unique privilege to work with experts in public health, health security/biodefense, as well as some who were at the forefront of the COVID response.
It was a joy to work with a group of physicians who were such advocates for us fellows and who truly helped us not only become better ID clinicians/researchers but helped us grow as humans – the two of which, in my opinion, go hand-in-hand. I will defer to my colleague’s – Dr. Mark Ridder – elaboration on this in an earlier post, of which I am in full agreement; he is much more eloquent than I.
Regardless, I have lost count of how many of the faculty I consider mentors. And my co-fellows? Absolute Rockstars.
As for my next step: I’m not quite through with my training (cue eye roll for everyone who knows me). I’m headed to complete two years of pediatric ID fellowship next, along with pursuing an MPH here at UNMC. I have yet to determine my next steps following that, but I have developed a passion for emerging pathogens and health security and hope to dive deeper into that world throughout my career.
– Dr. Clayton Mowrer, graduating ID Fellow, June 2021 – heading to Pediatric ID fellowship/MPH at UNMC
As my time draws to a close, I been asked to put forward some final words about fellowship. It is difficult to place in the words all the different things in which I have encountered, learned, and grown from in the past 2 years but I will make my best effort. It is well-known amongst the fellow’s office that I may be not the most succinct, nor the wittiest of our office, but I would like to say that I hope I am remembered for my earnestness. I mean the following words from the bottom of my heart.
The beginning of fellowship was certainly a rocky one. Having spent my time as an internist I was comforted by the degree with which I could feel certain of protocols, treatment modalities, diagnostics, that generally were expected by my peers. It was a challenge to start into a field with which the questions being asked are by their very nature controversial. With time however, I grew to learn and appreciate that these are the exact sort of questions which make medicine all the more enticing, and real. I have learned how to discern the best course of action amid at best mixed evidence, and in particular difficult situations for our patients. It has been exhausting, but with time rewarding and in the end of life giving. With time and growth, I found myself slowly talking the language of my attendings. Being able to speak to different ways in which my colleagues would approach situations, problems, etc. and being able to find for myself which of these was my own style. It was easy to believe that I had reached the pinnacle after completing internal medicine training where I had very clean endpoints within the realm of practice. However, training within infectious diseases I found myself with time becoming comfortable the controversy and individualize patient care based upon the best evidence that I had available.
I think in the end, I believe that training in infectious disease truly rounded out my education.
Furthermore, this training highlighted to me the significant gaps within American health care. Unfortunately, infectious diseases disproportionately affect the marginalized. This has been highlighted in the midst of a pandemic, racial injustices, and political uprising which were the hallmark of my senior year of fellowship. I have been inspired by my mentors and teachers with their foresight and decision making early on in this pandemic. Their tenacity throughout its course was powerful. I am hopeful that by at least being trained by these remarkable individuals that someday I too may be able to tackle these incredibly complex problems with half the degree of grace that they were able to carry on through the course this crisis. It has highlighted to me the requirement of incredible leadership mixed with empathy and recognition of the fear of both patients and clinicians, providing guidance when perhaps there is no clear evidence of the proper way forward.
I think above all else, my time here has underscored the importance of recognizing the humanity of both our patients and ourselves. I have had to come to grips with my own limitations and realize what I am able and unable at times to do, and when I truly need help. I have repeatedly seen time and time again that no matter the aptitude of the clinician, the ultimate requirement for excellent patient care is the ability to reach the individual. I personally experienced, from those who taught me the significance of this approach, and it is my hope that I have learned at least a partial bit of their skill, and I hope to continue to dedicate my life to this practice.
This training has changed me to the core. It has taught me the skills to treat my patients with confidence, using the most targeted strategies possible. It has taught me to be a scrupulous discerner of evidence-based medicine, to be able to apply the best data available while recognizing the limitations for applying my findings globally to my patients. And finally, it has taught me that I need to be an empathetic and available provider in order to access my patients and provide the best possible care. I have a great deal of gratitude for UNMC Infectious Diseases, and I am very privileged to have been able to train here. I thank you all for your time your expertise in your incredible patience.
Dr. Mark Ridder – graduating UNMC ID fellowship June 2021, headed to Marshfield Clinic in Wisconsin
To say that dealing with the COVID-19 pandemic has been challenging may be the understatement of the year. Yet despite COVID-19, our faculty and staff are continuing to publish impactful papers, engage with their communities, transform medical education, practice extraordinary medicine, and change people’s lives.
In this post, we want to highlight our division members who have been honored with local, regional, and national awards over the last several months. This is just a snapshot of the excellence you can find within the UNMC Division of Infectious Diseases, but rather than list all of the accolades, we wanted to SHOW you!
Our Division Chief, Dr. Mark Rupp said “The recent recognition and awards received by the UNMC ID Division is truly remarkable. Not only was the Division recognized for heroic efforts surrounding the COVID-19 pandemic, but while we were all working overtime on COVID, we also received accolades for our accomplishments in teaching, patient care, and research – a real testament to the dedication and passion of the ID faculty, APPs, fellows, and staff. I am incredibly proud of the ID Division and our commitment to excellence in all phases of our mission – delivering compassionate patient care, educating the next generation of healthcare providers, pushing the boundaries of our knowledge, and providing valuable service to our community and our profession”.
We are very proud of the work that our UNMC ID family has been doing over the last year and they deserve all of the awards and recognition. Congratulations to everyone, and we look forward to seeing what we can accomplish in 2021!
Sudan emerged from a 30-year dictatorship in 2019 to face the COVID-19 pandemic with a fragile health system and a half-finished transitional government structure. During the dictatorship, the majority of GDP was spent on military and security forces and very little was spent on health. This led to privatization of healthcare and a near complete collapse of the previously well-structured public health sector. In the beginning of the pandemic, the country did not have any infrastructure or funding for public health services which made it difficult to conduct proper testing and contact tracing. Transitional government officials elected to enter a state or lockdown which was poorly received by the public due to the economic hardships the country was going through. In addition, conspiracy theories from the previous regime allies spread rapidly promoting the myth that COVID-19 does not exist and that the transitional government is using it as an excuse to suppress protestors. In our recently published article, “Re-opening Sudan: the Balance Between Maintaining Daily Living and Avoiding the Next Peak of COVID-19”, we emphasize the role that the community (including religious leaders, youth neighborhood committees and diaspora organizations) played and continue to play in the fight against COVID-19 and we urge the government to develop a formal mechanism to channel these efforts so that their outcomes can be tracked and documented.
Content written by Drs. Van Schooneveld and Stohs.
Antimicrobial stewardship programs improve patient outcomes, efficiency of care, and are a key tool in combating antimicrobial resistance. The field of antimicrobial stewardship is rapidly expanding and while ID fellows have the foundation for leading antimicrobial stewardship efforts, leading such programs require unique skills and knowledge. To meet this need, in 2016 the Infectious Diseases Society of America began to develop a curriculum designed to prepare fellows to lead antimicrobial stewardship programs. UNMC faculty and fellows have been involved in the development and evaluation of this curriculum with a description of the content development and purpose recently published in Clinical Infectious Diseases. The curriculum was created in two parts, a core and an advanced program. Both programs are designed to be integrated into ID fellowship and interactive online learning coupled with application exercises designed to be completed with local stewardship experts.
The core program lays the foundation for understanding antimicrobial stewardship exploring topics like the role of the microbiology lab in stewardship, how to apply stewardship principles to clinical situations, communication of stewardship recommendations, and program logistics. The UNMC fellowship program participated in the initial trial of the curriculum with local faculty with Jasmine Marcelin MD, Scott Bergman PharmD, and Trevor Van Schooneveld MD facilitating the training which included case-based learning, communications training, and role-playing of interactions with clinicians. Fellows found these communication training sessions particularly useful. The core curriculum is currently being updated and Dr. Trevor Van Schooneveld and Dr. Erica Stohs are assisting in this revision.
In addition to the core program, an advanced curriculum was developed targeted at fellows pursuing a career track in antimicrobial stewardship. This program focused on program logistics in much greater detail along with helping fellows understand the role of the stewardship program within the hospital leadership structure. Training was provided on how to “pitch” a program expansion to hospital executives along with advanced communication skills. Fellows were trained in how to go about implementing stewardship in specialized populations such as immunocompromised patients and unique settings such as long-term care, the emergency department, and ambulatory areas. Finally, career development resources were also provided. Dr. Van Schooneveld was part of the team which created the content on stewardship in specialized settings and populations and UNMC fellows have been piloting the advanced curriculum with Dr. Van Schooneveld and Dr. Stohs. IDSA reports that both the revised core curriculum and the advanced curriculum will be available this fall.
Ventilator-Associated Events (VAEs) were adopted by the National Health Safety Network (NHSN) in 2013, and have subsequently been associated with worse patient outcomes. However, the shift to VAE has left controversy as to both its value, and how best to prevent it.
Recently, Zhu et al published a large study focused on risk factors and outcomes from VAEs. This study again demonstrated worse outcomes for those with VAEs. Yet, again despite a large cohort of patients, we lack the causality needed to understand how to improve VAEs, and subsequent patient-centered outcomes, beyond simply avoiding mechanical ventilation.
Drs. Cawcutt and Van Schooneveld published a related commentary in Infection Control and Hospital Epidemiology entitled Caution, Not Causality: The Limitations of Risk Factor & Outcome Research on Ventilator-Associated Events, highlighting many of the issues that plague research on VAEs – from the limited data on VAE-related outcomes, to the multifactorial etiologies of VAE (not all VAE’s are related to pneumonia), and finally, the limitations of retrospective research providing associations, but not causality, for VAE’s amongst adult patients on mechanical ventilation.
VAE’s do seem to matter for patient outcomes, justifying the surveillance and metrics. But, we lack adequate understanding on most effective preventative strategies. With the recognition that VAEs may not be infectious, evidence-based, holistic approaches to best practices for mechanically ventilated patients are needed.
Drs. Ridder (left) & Rupp(right) as co-authors on this important manuscript regarding the innovative use of UVGI N95 decontamination during the COVID-19 pandemic.
Outbreaks due to respiratory viruses pose a unique threat to health care as they require often significant amounts of personal protective equipment. Based upon previous modeling of severe influenza pandemics, the need for N95 filtering face piece respirators (FFRs) would range between 1.7 and 7.3 billion FFR’s, however there were only an estimated 60 million FFRs available at the time of the onset of the COVID-19 pandemic [1].
Given this known threat and likely shortfall of FFRs, work has been done to evaluate the efficacy and safety of maximizing the use of FFRs in the context of pandemic situations. Strategies have included prolonged use, as well as decontamination and reuse which may be employed in the context of FDA issued emergency use authorization. This paper is an overview of decontamination strategies as well as the particular data supporting the evidence for decontamination and reuse at the Nebraska Medical Center with the use of ultraviolet light germicidal irradiation (UVGI).
Findings of this review include that multiple strategies may be employed dependent upon resources and requirement for facilities, and that UVGI is a feasible and effective strategy for large-scale decontamination and reuse of FFRs with recognition of certain limitations. Advantages of UVGI include a generally low resource requirement with high output for reuse of FFRs with evidence for efficacious decontamination for many target pathogens (including many respiratory viruses), and evidence for efficacy in particular for 3M 1860, 1870, and 1870+ N95 respirators. However, limitations include strap integrity reduction over multiple irradiation cycles and the use, thus limiting the total number of cycles for FFR decontamination and reuse and the inability to apply UVGI to all N95 respirators.
UVGI decontamination can safely be used in times of emergency to extend the supply of N95 respirators. However, each N95 respirator model is different and the efficacy of UVGI decontamination should be confirmed for each model before broad application. In addition, manufacturer’s recommendations for single use should be reinstituted when adequate supplies of FFRs are available. A more sustainable approach to respiratory protection with the use of elastomeric respirators or powered air purifying respirators (PAPRs) should also be considered. Finally, it is important to recognize that PPE is but one intervention in a fully functional respiratory protection plan that includes engineering and administrative controls.
For more information, click here for the article.
1) MillsD,Harnish DA, Lawrence C, Sandoval-PowersM, Heimbuch BK. Ultraviolet germicidal irradiation of influenza-contaminated N95 filtering facepiece respirators. Am J Infect Control. 2018;46(7):e49–55. https://doi.org/10.1016/j.ajic.2018.02.018.
The University of Nebraska Medical Center and Nebraska Medicine are participating in an international clinical trial to evaluate the safety and effectiveness of Novavax COVID-19 vaccine for adults.
Novavax vaccine is a protein-based vaccine from the coronavirus spike protein and is adjuvanted with saponin-based Matrix-M™ to enhance the immune response and stimulate high levels of neutralizing antibodies. It does not contain live virus, it cannot replicate, nor cause COVID-19.
Initially in the trial, two of three participants received vaccine and one of three received placebo. At this point, participants who first received the vaccine will receive placebo, and participants who received placebo first will now receive the vaccine. This crossover design ensures the administration of active vaccine to all participants in the trial. Crossover participants will remain blinded to their courses of treatment to preserve the ability to assess efficacy of the Novavax vaccine. All participants will be followed for up to two years to monitor the safety and durability of the protection from the vaccine.
The company is now expanding the vaccine trial to include adolescents. If you would like to be notified about the opportunity to participate in the adolescent trial, you can email us at unmcvaccine@unmc.edu
Dr. Diana Florescu is leading the UNMC Novavax trials
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