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To treat severe injection-related infections in people with substance use disorder, collaborate

The UNMC OPAT-MAT team

Here’s a too-common infectious diseases consultation:

A 30-year-old man comes to the ER with two weeks of fevers, chills, and back pain, plus increasingly difficult breathing for the past two days. He has injected opioids for the past five years. He has abscesses in the left arm, tenderness in the low spine, and a new heart murmur. His doctors obtain blood cultures, start IV vancomycin, and bring him into the hospital. After a few hours, his blood cultures grow Staphylococcus aureus. An echocardiogram shows infective endocarditis of the mitral valve with destruction of the anterior leaflet and severe mitral regurgitation, a CT of the chest reveals multiple septic pulmonary emboli, and an MRI of the back shows lumbar vertebral osteomyelitis/discitis and psoas abscesses.
What to do?

Perhaps your first instinct is to focus solely on the staphylococci invading his body – to make treating him a matter of advising your hospitalist colleagues which antibiotics to give and for how long, of knowing where to ask the surgeons and interventional radiologists to put their scalpels and needles. This approach is incomplete, but unfortunately, the medical literature tells us it is also typical – patients often receive high-quality care for the treatment of their bloodstream infections while receiving little to no attention or care for the underlying substance use disorder (SUD) at the heart of their problem.

Why does care for patients with SUD hospitalized with serious infections so often come up deficient? In part, because we have socialized rather than medicalized SUD (e.g. cast SUD as an inherent character flaw or immutable condition rather than a treatable physiologic disorder, like infection). The use of stigmatizing language in the medical record – “drug abuser” and “addict” – elicits negative associations among healthcare professionals. As a result, patients with endocarditis related to injection drug use are likely to receive antibiotics but exceedingly unlikely to receive a comprehensive plan of care for their SUD, such as Addiction Medicine or Addiction Psychiatry consultation, medication-assisted treatment, rescue naloxone, or education about safe injection practices and services.

So what does usual care for our patient look like in the US? He will receive IV antibiotics and surgery. Several folks will describe him as an addict in the chart and eventually someone will do it to his face, which will reinforce that his doctors don’t think much of him. The beginning and end of the plan for his SUD will be to tell him that if he wants to live he needs to stop using drugs. Later, he’ll be told that he needs to stay in the hospital for 6 weeks of IV antibiotics (no one will mention the option of letting him finish his IV antibiotics at home with a PICC, because of anxiety that he might inject his drugs through the catheter). At some point, our patient will become so frustrated about languishing in the hospital with no treatment of his SUD that he will leave against medical advice. Perhaps his doctors will write a prescription for oral antibiotics that he may or may not hear about or go pick up, and perhaps he will come back with renewed infection in a week or two, and probably his treatment team will feel that they did their best and will absolve themselves of culpability, saying something like, well, at the end of the day we can’t stop people from making poor life choices.

As an ID physician, and also the medical director of UNMC’s OPAT (home IV antibiotic) program, I think we can do better. First, let’s address the anxiety about PICCs and home IV antibiotic in people who inject drugs (PID). Suzuki et al found that the available data indicates that PID have low (0-2%) rates of PICC misuse with no greater incidence of line infection or thromboembolism than non-PID and similar rates of treatment completion, rehospitalization, disease relapse, and mortality. While other data suggest that OPAT in PID may be labor-intensive on account of more frequent missed visits, line infections, and re-admissions, we must weight these adverse events against the unmeasured adverse events of prolonged hospitalizations: namely, treatment non-completion and failures due to patients leaving AMA, nosocomial infections, and uncontrolled costs. Fortunately, Eaton et al at the University of Alabama at Birmingham have validated a risk assessment tool identifying PID likely to do well with OPAT, and Fanucchi et al showed in a pilot randomized trial that combining OPAT with pharmacologic therapy for SUD in patients with severe injection-related infections resulted in similar infection and drug use outcomes to standard care while shortening hospitalizations by more than three weeks.

The key to success in treating severe injection-related infections in PID is to generate a comprehensive plan for both the patient’s infection and their SUD – and specifically, to offer the patient effective treatment for their SUD that results in harm reduction (i.e. helping these folks to either stop injecting drugs or inject less frequently or in a manner that reduces their risk of developing infections). While SUD treatment is not inherently beyond the scope of infectious disease specialists, here at UNMC we’re blessed with a dedicated Addiction Psychiatry service headed by Drs. Alëna Balasanova and VaKara Meyer Karre.

Starting in Fall 2019, the UNMC ID OPAT team and the Addiction Psychiatry service began working together to identify patients with opioid use disorder severe injection-related infections who, based on the work by Eaton and our own clinical experience, appear likely to do well with early hospital discharge and combination OPAT/MAT. We combine inpatient consultation by Addiction Psychiatry and ID with early (1-2 weeks) follow-up in both ID and psychiatry clinics to help these patients engage and remain in care for both their infection and substance use issues. We believe this approach helps UNMC provide some of our most stigmatized patients with extraordinary care.

Antibiotics At the End-of-Life: Helping or Harming?

UNMC 2nd Year ID Fellow, Clayton Mowrer, D.O., MBA.

Content written by Dr. Clayton Mowrer.

Early in my medical training, my father developed a rapidly-progressive type of cancer. Over the course of several months, his health declined quite quickly, and he was spending more time in the hospital than outside of it. It became uncomfortably clear that pushing forward with invasive and toxic interventions would cause him much more harm and discomfort than it would any benefit. Our family had many gut-wrenching discussions with my dad’s physicians, and we eventually decided that transitioning him to hospice care would be in his best interest in order to focus on keeping him comfortable in his final days of life. Though that time is mostly a blur to me, I do recall that we were able to discharge him from the hospital and he was able to die peacefully, surrounded by family, without the hassles, tests, and complications that come with being in the hospital.

The discussions surrounding end of life (generally defined as the final days or weeks of life) are incredibly difficult. While the goals of palliative and hospice care being that primarily of minimizing suffering and maximizing quality of life, it is not always a clear or easy decision as to which interventions fall under this definition. Most tend to agree that interventions such as CPR, intubation, or medications with high risk for side effects – e.g. chemotherapy – are not in line with the goals of comfort care and are therefore commonly avoided in end of life care; conversely, the approach to the treatment of infections and the use of antibiotics at the end of life is a much more polarizing topic.    

And the discussion of the use of antibiotics is particularly important, as many studies and observations have shown that many patients at the end of life have a high risk of infections due to a weakened immune system, comorbidities, very frequent exposure to healthcare facilities (where infections are easily spread), and adverse effects of medications such as chemotherapy. Consequently, antibiotics are often given in these final days or weeks of life.

However, here is not much known about the true prevalence of infection at the end of life, with research showing that antibiotics are commonly prescribed in terminally ill patients in the absence of clinical evidence of bacterial infection, due in part to the view that antibiotics are historically viewed as relatively benign. But, just as with the general population, antibiotics don’t come without their own risks, and it is important to thoroughly understand the risks and benefits of antibiotic therapy in order to have an informed conversation when the decision to move towards comfort care is made. 

Antibiotics, to be sure, can be quite beneficial if used in the appropriate clinical scenario. Particularly when there is a proven bacterial infection, an appropriate course of antibiotics can provide relief of pain associated with the infection, especially in infections such as urinary tract infections that can cause significant discomfort. Additionally, some patients may have certain events that are important to their quality of life – such as a wedding or graduation – which they would like to attend, and there is evidence that the treatment of a documented infection in terminally ill patients may prolong life just a little bit.

Yet, suspected infections are not often proven, leading to the frequent and long-term use of broad-spectrum antibiotics (known as empiric antibiotics). Such broad-spectrum antibiotics come with risks, including liver and kidney toxicities, as well as an increased risk for developing Clostridiodes difficile infection (C diff) – an infection that can lead to profound diarrhea, resulting in intensified distress. The administration of antibiotics itself can carry some risk if necessary to give intravenously: IV’s can cause irritation to the skin and soft tissue, occasionally leading to further/additional local or disseminated infections. In the setting of patients who may be exhibiting delirium or an altered mental status, restraints could be necessary. 

Patients, their families, and providers should also be aware and take into consideration what the evaluation of a suspected infection entails. Hospitalization, with many blood tests and imaging, is typically involved. In addition – though this is not always a concern for patients and their families, I do believe it is important to consider – there can be a financial burden that accompanies pursuit of infectious diagnostic workup and treatment. Workup of suspected infections are a frequent cause for hospitalizations in terminally ill patients and can lead to prolonged stays and numerous diagnostic tests, which can be costly. 

Finally, studies have shown that greater antibiotic use at the end-of-life is associated with the acquisition of multidrug-resistant organisms. Addressing these organisms has become a priority in the field of medicine worldwide and has been specifically targeted by organizations such as the CDC, who released a recent report regarding the threat of antibiotic-resistant organisms in the United States. 

Patients in end-of-life care and their families, with their medical providers, should include antibiotic use in discussions of goals of care, as, though it can have some benefits, it also carries distinct risk for harms and should be considered in a similar manner as other treatment interventions. In this way, the comfort of the patient can remain the ultimate focus.

I encourage the reader to  read the writings of Timothy Sullivan and Manisha Juthani-Mehta MD (below), on this topic, as they are much more eloquent than I. 

  1. HIV and ID Observations, by Paul Sax, MD 
  2. Antibiotics Are Often Used at the End of Life, But At What Cost? By Timothy Sullivan
  3. Why Infection May Be a Good Way to Die
  4. Infect Dis Clin N Am. 2017 Dec; 31(4): 639–647. https://doi.org/10.1016/j.idc.2017.07.009
  1. JAMA. 2015 Nov 17; 314(19): 2017–2018. https://doi:10.1001/jama.2015.13080
  2. Cancers (Basel). 2016 Sep; 8(9): 84.
  3. Chest. 2010 Sep; 138(3): 588-594.  https://doi.org/10.1378/chest.09-2757
  4. Journal of Pain and Symptom Management. 2003 May; 25(5): 438-443.https://doi.org/10.1016/S0885-3924(03)00040-X
  5. Journal of Pain and Symptom Management. 2000 Nov; 20(5): 326-334. https://doi.org/10.1016/S0885-3924(00)00189-5
  6. Journal of Pain and Symptom Management. 2013 Oct: 46(4): 483-490. https://doi.org/10.1016/j.jpainsymman.2012.09.010

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Physical Barriers for Prevention Amidst a Pandemic – The Roles of Distancing, Masks and Eye Protection

The following content was originally written for the IDSA Journal Club by Dr. Kelly Cawcutt.

As we continue forward in a global pandemic of unprecedented proportions, prevention of continued transmission of SARS-CoV-2 remains critically important. There has been ongoing debate regarding the highest risk factors for transmission, including the risk of potential aerosolized virus versus primary droplet spread. Based on this debate, the appropriate levels of personal protective equipment for both frontline healthcare workers and the general public have also remained somewhat controversial.

In an attempt to answer this question Chu et al recently published a systematic review and meta-analysis assessing physical distancing, face masks of varying types and eye protection within healthcare and non-healthcare settings, to determine if there is evidence for benefit to support ongoing recommendations of their use.

The systematic review included published research related to SARS, MERS and COVID-19. It is of note, that all studies were observational with no randomized controlled trials regarding these 3 infections. Results demonstrated that transmission of infection decreased with physical distancing of at least 1 m (adjusted OR 0.18; 95% CI 0.09-0.38) with a risk reduction of approximately 10% and increasing protection if the distance was extended to 2 m or greater. Additionally, the use of face masks in all settings was associated with decreased transmission of infection (adjusted OR 0.15, 95% CI 0.07-0.34) with a risk reduction of approximately 14%. There were some potential differences in mask type, with decreased transmission with respirators (N95) as compared to surgical or cloth masks. Finally, eye protection (including goggles, faceshields) also demonstrated decreased risk of transmissions with use (adjusted OR 0.22; 95% CI 0.12 -0.39) with the risk reduction of approximately 10%.

This study provides early evidence of the efficacy of continued PPE use to prevent transmission of COVID-19, both in the community and in the healthcare setting, including continued physical distancing, facemask use and eye protection. It should be noted that the impact as facemask and eye protection utilization is not adjusted for duration of time spent with an actively infected person nor the impact of physical distancing in the absence of the masks or eye protection. The variation of impact in different types of masks, including N95s, is difficult at best to interpret due to lack of randomized controlled trials, lack of information on aerosol generating procedures within studies, and potential variations both in mask quality, appropriate fit of masks, donning and doffing and hand hygiene.

Further research is clearly needed to optimize PPE utilization in the setting of existing shortages faced during this pandemic and for ongoing public health and infection control policy on healthcare based PPE recommendations.

Indeed, this is not over yet.

Fighting Fear in COVID-19

“Fear is a reaction. Courage is a decision”
Sir Winston Churchill

COVID-19 has delivered profound impact on each of us, the healthcare system and world. Events like this carry the impact of an earthquake – the life-altering natural disaster from which we simply cannot be the same thereafter. Yet, for COVID-19, the tremors have not yet stopped.

As we have lived through this pandemic as Infectious Diseases physicians and leaders in Infection Control and Employee Health, we also have encountered nearly unprecedented fear within our workplace.

Fear about how many will become ill, and die of COVID-19.

Fear about inadequate testing.

Fear about not having enough PPE or that it will fail.

Fear that frontline healthcare workers will bring COVID-19 home to families.

Fear has overcome us like a tsunami after the earthquake.

Unfortunately, fear itself has a secondary impact in healthcare. It can influence our actions, including maladaptive behaviors such as hoarding PPE, overuse and misuse of PPE or other scarce resources and avoidance of appropriate cares for our patients.

The potential influence of fear in this pandemic has to be discussed. Here are a few of our thoughts:

“Unfortunately, fear and misinformation has spread as fast as the virus.  Ambiguity breeds anxiety and, as this is a novel infection, there are plenty of unknowns and ambiguities.  We’ve tried to be as transparent and honest as possible, shared information as it became available, and admitted when something was unknown.  We’ve really stressed PPE availability and appropriate use as well as administrative and engineering infection prevention interventions. Hopefully, to some degree, this has lessened anxiety and fear for our healthcare providers.”    – Dr. Mark Rupp

“Fear is a normal human reaction. Fear about COVID-19 can take a significant emotional and physical toll. Fear can be exacerbated by misleading or false information. Recognizing and accepting that fear of this virus is widespread is an important step in process. Providing consistent information and education of the facts on COVID-19 is vital to controlling fear. Hopefully these efforts will prove valuable and protect our most valuable resource- our healthcare workers” – Dr. Rick Starlin

“The impact of fear has been significant in our day-to-day lives. Fear introduces bias to our beliefs that may be unfounded, creates a significant burden to carry, and if not understood and addressed, can inadvertently cause further harm. Creating a safe place to ask questions, provide education and training, and to simply process through these emotions is critical during this pandemic. We cannot afford to underestimate the power of fear.” – Dr. Kelly Cawcutt

Please read our full perspective linked below.

https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/fighting-fear-in-healthcare-workers-during-the-covid19-pandemic/B98F7E283611FCF4F2E3CF5B7BCD192E

Learning from Tuskegee in 2020: Reflections from Dr. Tatia Hardy

This guest blog post is written by Dr. Tatia Hardy, a graduating PGY4 Internal Medicine/Pediatrics resident at UNMC. Dr. Hardy wanted to share her reflections on racism as a public health crisis, looking through the historical lens of the Tuskegee syphilis experiment.

Dr. Tatia Hardy

A tradition in many medical schools in the United States is a ceremony where incoming students recite the Hippocratic Oath. Within that creed are words that are habitually considered and sometimes recited when making decisions regarding patients’ care: “first, do no harm.” Contrary to our oath, the realm of medicine has played an active role in the long history of harm and oppression of Black people in the United States.

In 1932, the United States Public Health Service (PHS) embarked on what would become one of the most famous examples of the country’s medical maltreatment of the Black community. Lured by the promise of free medical care, six hundred Black men in Macon County, Alabama, initially enrolled in the Tuskegee syphilis study. The men were told they would be treated for “bad blood,” a term used in the South that encompassed a number of ailments, including syphilis and anemia. The 399 enrolled men found to have syphilis were not told of their diagnosis, despite the risk of spread to others. Syphilis was known to be associated with significant morbidity and mortality at the start of the study.

Photo Credit: Centers for Disease Control and Prevention https://www.cdc.gov/tuskegee/index.html

In the first half of the 20th century, physicians attempted to treat syphilis with various agents because of the known dangers of the disease. The therapies used were risky and not always effective. A window in a basement lab had been left open years prior to the start of the Tuskegee study, giving Sir Alexander Fleming the opportunity to introduce the world to a new drug called penicillin. This new drug could not be produced in large quantities until the mid-1940s and would not become standard treatment of syphilis until 1947.

When the United States entered World War II, 250 of the men involved in the study registered for the draft. As part of the physicals done prior to entry into the armed forces, the men were diagnosed with syphilis and ordered to get treatment. Researchers from the PHS intervened and prevented the men from getting treated. The study was originally intended to last six months but was still going on when penicillin was recommended for the treatment of syphilis in 1947. Despite the availability of a medication to cure the disease, the men in the study were not offered treatment. In fact, they had been misled to believe they had been treated in the course of the study; they were given placebos and subjected to non-therapeutic procedures such as lumbar punctures.

Objections to the study were raised in the 1950s and 1960s by individuals concerned about the ethics of the study. Action wasn’t taken until 1972 when a PHS researcher got information to a reporter with the Associated Press. Public outcry from the nationally published article prompted swift action to stop the study and investigate. By that time, only 74 of the original 399 men with syphilis were still alive; 28 had died of syphilis and 100 died of complications related to syphilis. Forty wives of the study participants were infected, and 19 infants were born with congenital syphilis.

Healthcare professionals at a #WhiteCoats4BlackLives demonstration at UNMC/Nebraska Medicine on 6.5.20
Photo credit: UNMC/Nebraska Medicine

When learning about historical events, particularly those that are tragic and preventable, there is a tendency for introspection: “what would I have done? Would I have been brave enough to do the right thing?” Physicians involved in the Tuskegee study stood by as their research subjects suffered from the devastating effects of syphilis. As physicians in 2020, we must recognize that we are still in the midst of a public health crisis. Racism has broad consequences and adversely affects the health and well-being of Black men, women, and children.

For me personally, my interests in medicine, public health, and social justice intersect in the domain of prison medicine. Having privilege meant that I didn’t ever have to think or worry about being arrested in school, no matter how disruptive I was. I plan to continue learning about how to dismantle the school-to-prison pipeline and advocate for better resources for justice-involved youth and their families. I plan to use my knowledge of the studies regarding adverse childhood experiences to advance legislation aimed at community improvement – providing funding and resources to areas of need.

On a smaller scale, I want to listen to and support my Black colleagues in medicine: physicians, nurses, students, and ancillary staff. I plan to engage medical students and residents in more frank discussions about racism and how it contributes to health disparities. I will encourage my co-residents in Internal Medicine and Pediatrics to consider taking a course called “Institutional Oppression” from the University of Nebraska Omaha. I will vote, and as the leader of my medical team, I will do everything possible to make sure those around me have an opportunity to leave the hospital or clinic to vote.

When this chapter of history is studied in the future, will we be proud of what we’ve done? Are we brave enough to do the right thing? We must uphold our Hippocratic oath to first do no harm. But we also have an opportunity and a responsibility to be active in ending systemic racism.

References:
Centers for Disease Control and Prevention. (2020). “U.S. Public Health Service Syphilis Study at Tuskegee.”
Gamble, VN. (1997). “Under the shadow of Tuskegee: African Americans and health care.” American Journal of Public Health. 87(11): 1773-1778.
Heller, J. (1972). “Syphilis victims in U.S. study went untreated for 40 years.” New York Times.
Nix, E. (2017). “Tuskegee experiment: The infamous syphilis study.” History Channel

Farewell and new beginnings for our graduating fellows

On Wednesday, June 10, 2020, the Infectious Diseases Division gathered to celebrate two outstanding fellows, Drs. Lindsey Rearigh and Randy McCreery. Both are graduating and moving on to amazing next steps. This year’s graduation was unprecedented for our program (and every other training program) due to the COVID-19 pandemic. But even though these graduating fellows capped off their year with zoom lectures and conferences, and we had to celebrate their graduation in a physically distant manner, we were grateful to be able to celebrate them nonetheless.

Physically distanced graduation dinner for our fellows and select faculty (Photo credit: Dr. Andrea Zimmer)

In 2018, our ID fellowship program was expanded to 4 fellows per year and both Dr. Rearigh and Dr. McCreery welcomed the opportunity to experience the program growth in live action. As a division, we were honored to help Drs. Rearigh and McCreery grow and develop their infectious diseases knowledge, leadership and team management skills, 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.

UNMC ID Fellowship alumni dinner selfie at IDWeek2018 (Photo Credit: Dr. Jasmine Marcelin)

During her fellowship, Dr. Lindsey Rearigh received the Internal Medicine resident/fellow poster competition Top Poster presentation award (May 2020) and the Internal Medicine Department 2020 Fellow Research Award. She presented a poster at IDWeek2019, and also published two manuscripts (De-escalation of empiric broad spectrum antibiotics in hematopoietic stem cell transplant recipients with febrile neutropenia, and Uveomeningeal syndrome in a healthy, young male: an unusual presentation of West Nile virus). Two additional manuscripts are still in under review. Dr. Rearigh is moving on to private practice at the McFarland Clinic in Ames, IA.

UNMC ID Fellowship Program Director Dr. Trevor Van Schooneveld with graduate Dr. Lindsey Rearigh (Inset: we did wear masks!) (Photo Credit: Dr. Andrea Zimmer)

During fellowship, Dr. Randy McCreery won the 1st Place Research Award at the 2018 Graduate Medical Education Research Symposium. He also presented an oral presentation at IDWeek2019, and published a manuscript (Oral Vancomycin Prophylaxis for Clostridioides difficile in High-Risk Patients Receiving Systemic Antibiotics: What Exactly Are We Preventing?) with three additional manuscripts in progress. Dr. McCreery will be moving back to CA where he grew up. He will be practicing at Mercy Medical Group in Sacramento, CA.

UNMC ID Fellowship Program Director Dr. Trevor Van Schooneveld with graduate Dr. Randy McCreery (Inset: we did wear masks!) (Photo Credit: Dr. Andrea Zimmer)

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!

*Thanks to Megan Hoesing for contributing some of the content for this post

After you Kneel, Stand up and be Loudly Antiracist

*Disclaimer: the following represents my personal opinions only and do not represent the opinions of my employers*

Followers of the UNMC ID blog and Twitter accounts may have noticed that our accounts have not been very active lately. This is because as a Director of our Digital Innovation & Social Media Strategy, I have not been okay. Black men and women around our country have been killed as a result of racism in our country, at the hands of law enforcement and civilians alike. Here in Omaha, a young Black man named James Scurlock was killed last weekend during demonstrations about police brutality. It has been pretty overwhelming to watch all of this happening while having to presumably “go about life as normal”. So with this emotional exhaustion, I retreated; I stopped responding to emails, I rarely logged on to twitter on my personal account, and definitely did not log on to the blog or our divisional twitter account. The truth is, I have felt everything so deeply and personally, and while I have been speaking in an authentic voice on our divisional social media, I have never allowed myself to be this vulnerable.

Almost as soon as I knelt during the UNMC #WhiteCoats4BlackLives demonstration, I cried as I mourned George Floyd, Breonna Taylor, Ahmaud Arbery, James Scurlock, Sandra Bland, Tamir Rice, Trayvon Martin, and countless others whose lives were taken.

I wanted to share excerpts from a letter I wrote to my Department of Medicine last week about what all of this has been like.
“Dear colleagues,
I’m not sure how this message will be received, but I feel it needs to be said. I’ve been silent, even withdrawn, this past week. I lost a dear cousin to COVID-19 in Alabama. Then after reeling from shock of the devastating news of his death, I started seeing videos of a Black man [his name was George Floyd] being murdered by police in Minneapolis, only 90 minutes from where I used to live with my Black husband and my two Black sons…I have had feelings of despair, hopelessness, and wonder how it is that no matter what we do to overcome obstacles, this world, this country seems rigged against people that look like me. I am afraid for my family, and for my friends, and for the countless nameless people out there who live in fear too.
…I want you all to know that for many of your colleagues and friends, it is very difficult to operate in the “business as usual” mode. We are in the midst of a pandemic that is disproportionately killing Black people, but that is not the only danger we fear. Almost on a daily basis, racism in this country results in reports of Black people being harassed, threatened, or killed, simply for existing.
…If you are not Black, but these things bother you, you may also be struggling to process your own emotions and how to respond at a time like this. If you have a friend or a colleague who is Black, reach out to them and let them know that you care, that you are thinking about how they are doing and that you want to be there for them in whatever way they need from you. Try to just listen, and learn.
It wasn’t until I randomly decided to pick up the phone and call a girlfriend yesterday to just talk about our shared distress, that I realized that keeping it in is not good for me, even though it hurts when I try to articulate the unbearable grief from it all. So I’m reaching out to let you know that you can reach out to me whenever you need if you just want to process this….

UNMC ID multidisciplinary team members participating in the demonstration

As the disease detectives of medicine who have dealt with countless epidemics riddled with healthcare inequities, Infectious Diseases experts should be busying themselves with the business of dismantling systemic racism and advocating for justice. I personally view that as part of my mission. I am having the hard conversations with those around me with privilege, and extending everyone around me an invitation to step into the discomfort of talking about racism. We need to have more of these conversations in public spaces, pledge to speak up despite the discomfort, but it cannot be the burden of Black people to always lead these conversations, because we are exhausted. I was glad to see over 300 UNMC/Nebraska Medicine employees turn out for a #WhiteCoats4BlackLives demonstration, including many of my colleagues from the division of Infectious Diseases. Keep the support going, and remember it must be multifaceted. The hashtags, demonstrations, and words of support are great for the movement and welcomed, but more important are the actions.

Almost 300 healthcare workers gathered at UNMC in solidarity of #BlackLivesMatter and in remembrance of George Floyd on 6.5.20

After you kneel, stand up, and be loudly antiracist.

The Weekly Corona with Dr. Raquel Lamarche

As our institution, state, country, and the world grapple with the impacts of SARS-CoV-2, causing COVID-19, there are lots of ongoing discussions about coronaviruses. Dr. Raquel Lamarche is a PGY1 Internal Medicine/Pediatrics resident at UNMC, who will be sharing her thoughts and information she learns about COVID-19. You can follow Dr. Lamarche on Twitter @LamarcheRaquel. This week Dr. Lamarche discusses “The Reopening”.

“The Reopening”

At this point, (at least) the more privileged members of society are aware of the benefits of social distancing. Now we are experiencing its negative offshoots, to mention a few: schools are closed, the economy is crumbling, and as Dr. Julia Marcus Ph.D. said, “Quarantine Fatigue is Real.” In her article, Dr. Marcus discusses sustainable risk reduction and how shaming risky behaviors drives them underground. My brother, a psychologist in the Dominican Republic interested in addiction and minorities, was often criticized for providing free needles and syringes to IV drug users to decrease their risk of bloodborne infectious diseases. Preventing all bad from happening, e.g., preventing people from physically socializing (ever), was never a realistic expectation. Harm reduction (secondary and tertiary prevention) are as valuable as primary and primordial prevention (trying to prevent the harm in the first place), in the sense that it meets our public health aspirations with public reality.

Since late April, the first states began to lift the restrictions placed to control the coronavirus pandemic. The lifting of restrictions has been controversial. Dr. Fauci testified before the Congress that reopening too soon could lead to unnecessary suffering and deaths. Here in Nebraska, we never had a formal “shelter in place” executive order shutting down the state; instead, there were a series of strict Directed Health Measures which are now gradually being relaxed. Following the news lately, there are many opinions on what “reopening the economy” means.
(See which states are re-opening and which states are still shut down)

Even bacilli are social distancing!

What about herd immunity? In the US, the seroprevalence of SARS-CoV-2 is unknown, with obstacles including limited testing availability, and limited reliability of antibody tests. Scientists are still investigating how antibodies elicited by SARS CoV-2 may effectively neutralize the virus and for how long. The basic reproductive number, or R0, for SARS- CoV-2 is estimated to be 2, not as high as (real) airborne viruses such as varicella and measles (4, and 13, respectively). This means: one person with COVID-19 can spread the virus to 2 other persons (or more if they are singing in a choir). Herd immunity is the indirect protection provided to individuals in a community when most of the population is immune to that disease. Based on the R0 of SARS-CoV-2, it is thought that 60-70% of the population needs to have contracted SARS CoV-2 in order to start seeing the benefits of herd immunity, and it is unlikely that we have achieved this yet. We have achieved herd immunity to other infections like measles and chickenpox due to vaccine uptake in the community. 

Vaccine? When? Vaccines can be hard to develop. There are over 60 vaccine trials right now. The hope is that with so many trials going, we will have at least one vaccine at some point, maybe 18 months from now, we are talking about 2021 perhaps. Moderna found that its experimental SARS CoV-2 vaccine was safe and provoked a strong immune response in 8 healthy volunteers.

How should we approach the re-opening? Due to a lack of widespread testing, the initial “containment” attempt to limit the spread of this virus is long gone as a feasible idea (adios). The virus is close to all of us. The conversation we are having right now is about harm mitigation. To re-open as safely as possible, certain conditions need to be met:

  1. The rates of new cases should be low and remain low for at least two weeks.
  2. There should be capacity to test anyone who has COVID-19 symptoms
  3. Hospitals should be able to treat all cases.

Based on the above conditions, many states seem to be re-opening prematurely. But now that things are opening up, how can we stay safe?
1. (Sustainable) social distancing. Continue to stay 3-6 feet or more away from each other. Dr. Marcus talks about sustainable risk reduction strategies in her article, with some outdoor activities (such as walking, running, and cycling) posing less risk than indoor gatherings.
2. Hand Hygiene. We must wash hands as often as possible, especially every time we go into a new environment. Linking handwashing to mindfulness (e.g., acknowledging four tactile sensations while handwashing) has helped me reframe the experience. Also, clean surfaces at least once per day at the very minimum.
3. Perfect surveillance and contact tracing. The process should involve quarantining positive cases, followed by tracing then testing all of their contacts. In order to limit the spread of the virus, we must have the ability to test anyone who might have SARS-CoV-2. Dr. Atul Gawande, in his NewYorker article, described daily screening of all employees, patients, and visitors for symptoms of COVID-19 upon entry to any building in his healthcare system. UNMC has recently implemented a universal screening policy for all admitted patients.
4. Wear a mask! If worn appropriately, masks can help keep individuals from spreading their own droplets to others. The critical point is that these kinds of masks don’t create a perfect seal and are not meant to protect yourself: they are meant to protect those around you. If worn by everyone, we protect each other. N95 respirators block most airborne particles from being inhaled, therefore are designed to protect the wearer too. Throughout the pandemic there has been an N95 supply-demand mismatch. As ways to circumvent this problem, there have been great innovations that can help us safely reuse N95s, such as:
• Ultraviolet germicidal irradiation by UNMC
• Hydrogen peroxide decontamination system by Battelle

I find this infographic created by Dr. Julia Marcus, PhD, MPH, and Dr. Eleanor J. Murray, ScD, MPH extremely helpful. It provides with a spectrum of risk and harm reduction tips for every setting.

How do we re-open the economy and our physical social lives while still keeping each other healthy? What is going to save us, a vaccine, herd immunity, or a new treatment? I know that I did NOT provide you with perfect answers. Viruses are sometimes too smart for drugs. We continue to lack the capacity for widespread testing and contact tracing. We are far from being immune. A vaccine is many months away.

More powerful than putting our energy on hopes for a miracle, is a strong performance at applying what we already know: physical distancing, hygiene, screening, staying at home if we are ill, and wearing a mask (correctly).

Stay safe everyone!

COVID-19 disproportionately impacts minority communities

The COVID-19 pandemic has changed lives all over the world, responsible for over 4 million infections and over 300,000 deaths worldwide. As we have progressed through this pandemic, it has become clear in the United States that we need to begin and continue conversations relating to the disturbing racial/ethnic disparities we are seeing emerging from cases, hospitalizations, and death due to COVID-19. We have identified risk factors for severe disease, developed multiple testing modalities, and tested several treatment options. It is time to address the generational inequities that have allowed these health disparities to exist.

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Disparities exist
With more than 80,000 deaths in the US, we are seeing higher rates of infection, hospitalizations, and death among African Americans, Hispanic Americans, and Native Americans. In certain states, these disparities are even wider; for example in Wisconsin and Kansas, Black residents are seven times more likely to die from COVID-19 than White residents; in Washington DC, the rate is six times higher, in Michigan five times higher, and in NY four times higher. In New York City, a disproportionate number of people dying from COVID-19 are Hispanic (Source: APM Research Lab). Navajo Nation (the largest community of Native Americans living on tribal homelands across Arizona, New Mexico, and Utah) has more coronavirus cases per capita than any US state.

Where does Nebraska stand?
Here in Nebraska, over 10,000 people have been diagnosed, and over 120 people have died from COVID-19. However, Nebraska is the only state that is not only NOT reporting ANY demographic data at all about cases, so there’s no way we would be able to know race data at all on a statewide level. We do have demographic data from Douglas County and Lancaster County, where we see disproportionate numbers of cases in the Hispanic and Asian populations. In Douglas County, almost 50% of reported cases are among Hispanic persons, and 16% of reported cases are among people of Asian descent (that includes large Nepali immigrant/refugee communities). In Lancaster County, 33% of cases reported are among people of Asian descent, and 24% among Hispanic people. We are seeing these disparities play out in real time in our hospital, as a large number of our patients in COVID-19 units are minority and/or immigrant people.

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Why is this happening?
There are social, economic, and political structures embedded in our society that interact to create structural/social determinants of health, which in turn impact health outcomes. One cannot discount the disparities in the underlying medical conditions associated with higher risk of severe COVID-19. Heart disease, obesity and diabetes are risk factors for more severe disease and death, and these conditions are overrepresented in the Black, Hispanic, and Native American communities relative to their share of the population. However, generational patterns in development of these comorbidities is not proof of a purely biological explanation for the disparities.

What we are witnessing is the impacts of structural racism (systems that perpetuate and reinforce racial inequities) on minoritized communities. The differences we are seeing are a manifestation of the systemic differences in food insecurity, housing insecurity, financial insecurity, lack of access to healthcare, lower quality healthcare, and inability to shelter at home, that predispose these minority groups to have worse health outcomes. The virus, SARS-CoV-2/COVID-19 is NOT Racist. However, societal structural racism plays a significant role in creating conditions that put minority communities at risk.

What needs to be done now?
There needs to be a structured, coordinated effort to collect and report data here in Nebraska (and more completely across the country) on COVID-19 that includes demographics. This will help with creating targeted testing strategies in communities that are most at risk. In Nebraska, we have several immigrant populations whose first language is not English, therefore as healthcare professionals and an organization, we must ensure that we are helping to provide communication/education in a culturally congruent manner. If a language does not have a reliable written component or most people cannot read, we must be innovative with videos, television, social media, and personal community outreach in the language that people understand. Couldn’t we leverage our own healthcare professionals who speak different languages to help with this?

In the long term, there are many more things that need to be done to address the impacts of structural racism in the community. Dealing with these will help to ensure that the next time we are dealing with a pandemic or major health crisis in our nation, we will not be talking about these kinds of disparities.

Want to learn more?
Here are some recent opportunities to hear or read more about this topic:
• North Omaha Information Support Everyone (NOISE) Facebook Live April 30,2020
• UNMC Internal Medicine Grand Rounds presentation May 8, 2020
• Infectious Diseases Society of America Podcast published May 12, 2020
• Omaha World Herald Opinion piece (co-authored with UNMC medical student Rohan Khazanchi) published May 14, 2020

Peer-reviewed references included in this post:

Here is a list of selected publications you can access to learn even more

The Weekly Corona with Dr. Raquel Lamarche

As our institution, state, country, and the world grapple with the impacts of SARS-CoV-2, causing COVID-19, there are lots of ongoing discussions about coronaviruses. Dr. Raquel Lamarche is a PGY1 Internal Medicine/Pediatrics resident at UNMC, who will be sharing her thoughts and information she learns about COVID-19. You can follow Dr. Lamarche on Twitter @LamarcheRaquel. This week Dr. Lamarche discusses a pediatric Infectious Diseases primer on SARS-CoV-2.

Children are not tiny adults; thus, it is not surprising that many infectious diseases affect children differently from adults.

We don’t know why COVID-19 appears to be less frequent and severe in children compared to adults. Some considerations include a less vigorous immune response to the virus in children, potential viral interference in the respiratory tract of young children leading to a lower viral load, and perhaps the receptor for SARS-CoV-2, the angiotensin-converting enzyme 2 receptor, is expressed differently in the respiratory tract of children compared to adults. As the pandemic progresses, we expect to learn more from data being published.

Some Epidemiology
• In a case series of >2000 children from China, there was no statistically significant difference in incidence between girls and boys; another case series reported a higher COVID-19 case rate in boys (61%) compared with girls (39%)
• It appears that children are less affected by COVID-19 than adults. This could reflect a lack of widespread availability for SARS-CoV-2 testing or the fact that children are less likely to be tested due to milder disease.
• Coinfection of SARS-CoV-2 and multiple respiratory pathogens can occur in children
• Children account for 1 to 5 percent of diagnosed COVID-19 cases.

Transmission

  • Large droplets: this type of transmission can be prevented using face masks
  • Fomites: (objects on which the virus containing droplets have settled) the virus may remain on surfaces for up to 4 days.
  • Aerosols: it appears that the virus may also be aerosolized, with a UNMC study finding evidence of (noninfectious) viral particles in the air

Pregnancy and newborns

  • Data in pregnancy is minimal. The most extensive case series had 38 cases
  • Currently, the virus is not definitively known to be transmitted vertically.
  • Of note, there are isolated cases of potential vertical transmission as demonstrated by baby’s elevated IgM against SARS-CoV-2 (IgM does not cross the placenta). The latter is relevant because infants seem to be one of the most vulnerable groups for severe disease in the pediatrics population.
  • SARS-CoV-2 does not seem to be transmitted through breast milk. However, droplet transmission can occur through close contact during feeding.
  • Healthy pregnant women seem to have the same risk as adults who are not pregnant; however, the CDC warns that contracting the coronavirus while pregnant could make you more vulnerable to severe respiratory problems. This is because pregnant women already have a physiologic restrictive lung disease and relative immunocompromised state.
  • One unknown is the impact on women who get sick early in pregnancy and their developing fetus. This is a new virus and nobody who was in the first trimester when they developed COVID-19 has delivered yet.

Symptoms and signs in children

In case series of >2000 children from China:

• 4% of virologically confirmed cases had asymptomatic infection [this rate could be underestimating the accurate scale of asymptomatic infection because many asymptomatic children are unlikely to be tested. On the other hand, children with congenital and chronic diseases are living longer in the US, which means we might have a larger population that is potentially vulnerable to symptomatic and severe disease]
• Among symptomatic children, 5% had dyspnea or hypoxemia, and 0.6% progressed to acute respiratory distress syndrome.
• Some children presented with only gastrointestinal symptoms
• It appears that children generally have a significantly milder disease

One caveat about this observational study:
• Out of the 2135 cases, 66% were “suspected cases” (not test confirmed) defined as a child who was exposed to COVID-19 within the last 2-weeks, or lived in an epidemic area, had 2 of the following conditions: (1) fever, respiratory, digestive symptoms (eg, vomiting, nausea, and diarrhea), or fatigue; (2) laboratory test white blood cell count was normal, decreased, or had a lymphocyte count or increased level of C-reactive protein; or (3) abnormal chest radiograph imaging result. Children often get sick multiple times per year with many of the above findings, completely unrelated to COVID-19 – could some of these “suspected cases” have had symptoms caused by other viral illnesses?

In a US case-series (n=296) the most common symptoms in children were:
• Fever (56%), Cough (54%), and Shortness of breath (13%)
• Less common symptoms: myalgia, fatigue, sore throat, rhinorrhea, nasal congestion, headache, diarrhea, and vomiting
• 73% of pediatric patients had symptoms of either fever, cough, or shortness of breath compared with 93% of adults aged 18–64 years

In another series of 171 children with confirmed SARS-CoV-2 infection,
• 42% had fever, median duration of 3 days (range 1-16 days)
• 49% had cough, and 16% were asymptomatic
• 19% had upper respiratory infection, but 65% had pneumonia.
• 29% had tachypnea, 42% had tachycardia on admission, and 2.3% had O2 sat <92% during hospitalization
• 77% of children with COVID-19 were in contact with a family member with confirmed SARS-CoV-2

Newborns and infants

In young infants, SARS-CoV-2 can cause fever without any other manifestations, including respiratory symptoms and signs. A 3-week old baby boy who tested positive for SARS-CoV-2 and developed hypercarbic respiratory failure. He had an otherwise negative sepsis workup.

Deaths in children with COVID-19
Although severe cases of COVID-19 in children, including fatal cases, have been reported, most children appear to have a mild or moderate disease and recover within one to two weeks of disease onset.

Laboratory findings

Laboratory findings in children with confirmed infection from Wuhan were variable.
25% had white blood cell count <5.5 x 109/L (5500/microL)
3.5 % had lymphocyte count 46 pg/mL)
20% had elevated C-reactive protein was elevated (>10 mg/L)

Radiographic findings

Radiographic findings may be present before symptoms. CT chest abnormalities noted were:
33% ground-glass opacity
19% patchy local shadowing
12% bilateral patchy shadowing
2% interstitial abnormalities

Risk factors for severe disease
• It appears that infants <1 year of age and children with certain underlying severe conditions are at higher risk for severe disease.
The most commonly reported underlying conditions were:
• Chronic pulmonary disease like asthma
• Cardiovascular disease
• Immunosuppression (cancer, chemotherapy, radiation therapy, hematopoietic cell or solid organ transplant, high doses of glucocorticoids)
• Based on data extrapolated from adults, other medical conditions that may increase the risk of severe disease in children include CKD undergoing dialysis, chronic liver disease, pregnancy, diabetes mellitus, and severe obesity.

Many of these risk factors are similar to adults. But while much of the conclusions about risk may be extrapolated from adults, children still appear to be affected differently than adults, and this is probably a good reason why more widespread testing, especially in children, may be a good idea, particularly as we look toward the fall and reopening of schools.

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