Categories
Epidemiology

Anti-Maskers And The Company They Keep

Anti-maskers are flourishing in the era of COVID-19 but they are not new. During the 1918 influenza epidemic, the wearing of masks was mandated in many U.S. cities and “mask slackers” rebelled with one Portland, Oregon city council member arguing “Mask requirements are autocratic and unconstitutional; under no circumstances will I be muzzled like a hydrophobic dog.” The anti-maskers never went away during the past century, they’ve been quietly meeting in secret, just waiting for a new pandemic to happen so that they can once again profess the dangers of wearing masks. So, who are these anti-maskers? Most are members of a fraternity of organizations whose mission is ostensibly to protect personal liberties. Here are some of these other organizations in the fraternity of the anti-maskers:

The Anti-Hand Washing League. This secret society was created in 1848 to combat the hand washing hysteria being propagated by Dr. Ignaz Semmelweis, the physician on the lunatic fringe of medicine who had the audacity to recommend that doctors wash their hands after performing autopsies. The League’s mission is to globally eliminate hand washing in order to preserve the natural body oils of the hands. Says League president Max Saponify, “Requiring me to wash my hands after using the toilet is an infringement of my constitutional rights!

The Federation Dedicated to a Deodorant-Free World. This group has a goal of global elimination of antiperspirants and deodorants. “These chemicals are a well-known cause of armpit cancer” says Federation chairman Axilla LaPue. The Federation’s motto is that “A man should smell like a man… and a bear,… and a boar,… and a Tasmanian Devil”. Many members are also affiliated with the Anti-Bathing Guild whose motto is “Satan made soap”.

The Stogies in School Society. Formed after municipal laws against smoking in public were enacted in the early 2000’s, the Society’s mission is to preserve the rights of middle school students to smoke cigars in class. A side project of the Society is the “Spittoons in Church” project to promote legislation requiring all churches to provide spittoons in the pews for parishioners who chew tobacco during services.

The Pull My Finger Association. This organization is committed to the promotion of public flatus. The annual meeting is held in Boston every December and culminates with the group’s baked bean dinner followed by the flatus a cappella contest. Last year’s winner was the Central City Cheese Cutters with their rendition of Bob Dylan’s “Blowing in the Wind”. Afterward, the attendees went caroling in downtown Boston with their unique wordless Christmas carols.

The Anti-Vaxxers. This mainstream group opposes vaccines of all kinds. Said one anti-vaxxer: “They say vaccines prevented smallpox and polio. I don’t know anyone who ever had polio or smallpox. I think drug companies just made up those diseases so they could scare people into buying their vaccines.” Group members have determined that vaccines cause disease. “You get a flu shot and your bowels will be irregular for months… not for me!” wrote another member in a letter to the editor of the Cowtown Gazette. The group points to the Will Smith movie I Am Legend as evidence that vaccines turn normal people into flesh-eating zombies.

The Free the Snot Foundation. Dedicated to liberating oppressed nose mucus from confinement in Kleenex and handkerchiefs, the FSF is considered by some to be a terrorist group, spewing unsuspecting passersby with nasal secretions. Among the group’s more mainstream activities is the annual “Shoot the Snot” contest to see which contestant can propel sinus secretions the farthest. The current world record is held by Charlie “Booger” Snout with his 2015 performance of 15 feet, 3 inches. But a darker side of the Foundation is the rumored rite of passage for admittance that allegedly requires initiates to clandestinely launch snot over the rail of the Empire State Building creating the so-called “rhinitis rain” that the City of New York is widely known for.

The Anti-Trouser Alliance. This male-only organization seeks to overturn local ordinances requiring men to wear pants. “If God wanted us to wear them, we’d be born with pants” said the Alliance’s spokesman I. M. Stark. The Alliance’s annual project this year is the “Butts on Buses” initiative to promote the freedom to sit on public bus seats pants-free. The initiative was conceived after the enormous success of the “Butts on Banisters” project last year.

The MPH Liberation Club. This group hopes to eliminate speed limits in school zones. “Those roads were built with my tax dollars. If I want to drive 60 miles an hour in front of St. Mildred’s Elementary School, then it should be my right!” said member Phlatt N. Quash. The group also seeks to eliminate stop signs, traffic lights, and center lane lines on public roads.

The Sidewalk Turd Confederation. The Confederation’s mission is to eliminate public bathrooms. It is composed of individual groups including libertarians that want to eliminate highway rest areas in order to reduce government costs, the gas station worker’s union that objects to requiring employees to mop restroom floors, and environmentalists seeking to save trees by abolishing toilet paper. Said the Confederation’s Secretary General, P. N. Yard, “Squirrels do it, birds do it, dogs and cats do it. Don’t we have the same rights as the animals?”

The Yell “Fire” In Movie Theater Consortium. This organization’s goal is to preserve the First Amendment right to free speech. Members are encouraged to walk through maternity wards and randomly tell new parents that they have an ugly baby, to tell their mother-in-laws that her cooking is terrible, and to  shout “Shark!” at public beaches.

Anti-mask = Anti-business

The reality is that masks work. The COVID-19 virus is spread through the respiratory tract – when you cough, sneeze, or talk loudly, you exhale viruses. If you want to stop a respiratory virus from spreading, you have people wear masks to catch viruses contained in exhaled breath. Wearing masks is the fastest way to re-open stores, stadiums, bars, churches and restaurants. Anti-maskers have the confused notion that masks infringe on their human rights; the reality is that the more people wear masks, the sooner the economy recovers and jobs return. Don’t be a member of one of these fraternal organizations, wear a mask!

November 1, 2020

 

Categories
Epidemiology

(Age + BMI) x Hemoglobin A1C = COVID Mortality Risk

OK, not really. This title is not a scientifically-proven equation and so don’t quote me on it. But it does underscore the observations that there are both powerful modifiable risk factors and non-modifiable risk factors for death due to COVID-19. We started anecdotally noticing this in our ICU in the spring as the COVID-19 outbreak unfolded in Ohio. Patients who ended up in the ICU and who died were older and/or had co-morbid diseases. And since then, several studies have confirmed these observations.

Age is the strongest risk factor for death from COVID-19. In a previous post, I noted that in a report of COVID-19 infections in California, for people under age 18, death from COVID-19 infection is exceedingly rare. But for every decade older, the risk of dying if a person becomes infected increases, culminating with a 25% mortality rate in those over age 80. This striking of an age effect on mortality is not seen with other respiratory viruses, such as influenza, which causes death in both the very young and the very old. This was especially true of the influenza pandemic of 1918 and the H1N1 pandemic of 2009 when younger persons who became infected had a higher mortality than older persons.

Obesity is also a predictor of death from COVID-19 infection. In a study of 17 million people in England, morbid obesity (BMI > 40) was associated with a 2-fold risk of dying from COVID-19. This may be why the United States has been so disproportionately affected by COVID-19 compared to other countries. According to the Organisation for Economic Co-operation and Development (OECD), the United States has the highest prevalence of obesity of all developed nations with 40% of Americans having a BMI > 30. In contrast, the average prevalence of obesity in OECD countries is only 24%.

Obesity goes hand-in-hand with diabetes and so not surprisingly, uncontrolled diabetes is also a risk factor for death due to COVID-19 infection. The same study from England found that uncontrolled diabetes (defined as a hemoglobin A1C > 7.5%) conferred a 2-fold increase in likelihood of dying from COVID-19 compared to a normal hemoglobin A1C. Once again, the United States has a higher prevalence of diabetes than the world as a whole with 10.8% of Americans being diabetic and 8.8% of the world being diabetic according to data from the world bank. The U.S. leads all other large developed nations with regards to diabetes prevalence. Like obesity, uncontrolled diabetes is a modifiable risk factor. Obese persons are more likely to become diabetic and diabetics with reduced access to healthcare are more likely to have uncontrolled diabetes. Despite spending more money per capita on healthcare than any other country in the world, Americans see a physician fewer times per year (4) than inhabitants of other OECD nations (6.6) suggesting that the access to healthcare in the United States is actually quite low compared to other countries.

Whether or not a risk factor is considered modifiable or non-modifiable depends on the event horizon of the disease in question. A disease like coronary artery disease results in a fatal myocardial infarction years or decades after coronary artery disease first begins. This gives people ample time to modify their risks for coronary disease. With COVID-19, the event horizon is short and measured in weeks and months, not years. Thus, the “modifiable” risk factors needed to be modified years ago in order to reduce the chance of dying of COVID-19 next today. It is not possible to significantly lower one’s BMI or hemoglobin A1C fast enough to make much of a difference of surviving the current pandemic.

But there are lessons to be learned. If you are 18 years old with a BMI of 22 and a hemoglobin A1C of 4%, then you have higher chance of dying in a motor vehicle accident than from COVID-19. But if you are 70 years old with a BMI of 40 and a hemoglobin A1C of 9%, you would be advised to find an abandoned missile silo, close the door, and leave it locked for the next 12 months.

August 29, 2020

Categories
Epidemiology

Mask Myths

One of the most effective ways of controlling the spread of respiratory viruses, such as the COVID-19 virus, is by wearing face masks. Last weekend at the Ohio Statehouse, a group of anti-maskers protested the wearing of face masks, complete with an escort of camo-wearing, body armor-clad, AR-15-wielding gun enthusiasts, presumably there to protect the protesters from throngs of violent mask-wearers. The protesters offered a multitude of reasons why people should not wear masks and so I thought this would be an opportune time to examine some common mask myths.

  1. You can get carbon dioxide poisoning. This theory espoused by anti-maskers proposes that carbon dioxide builds up inside of masks and then when one inhales, they inspire toxic quantities of carbon dioxide leading to disease and death. Carbon dioxide is a gas and cannot build up in a cloth or fiber mask. If it did, we would have to pay surgeons and OR nurses hazard pay since they have worn masks daily for decades. It appears that the protestors confused wearing a cloth mask with tying a plastic trash bag over one’s head.
  2. Masks cover up the image of God. This is the reason that state representative Nino Vitale from Urbana, Ohio used when he refused to wear a mask over his face inside the Ohio Statehouse. Mr. Vitale has quite a celestial opinion of himself and it is suspected that he refuses to wear pants in public for the same reason.
  3. Only N-95 masks protect you. N-95 masks are only necessary when performing aerosol-generating procedures and not when performing routing patient care or when out among the public. As long as you are not performing an upper endoscopy or colonoscopy inside of a McDonalds restaurant, you don’t need an N-95 mask.
  4. Masks only need to cover the mouth and not the nose. This one is partially true… as long as you are holding your nose, it won’t matter if your mask covers it. However, if there is air coming out of your nose, then it needs to be covered.
  5. If you’re not sick, you don’t need to wear a mask. Unfortunately, only about two-thirds of people infected with the COVID-19 virus have symptoms. In other words, one-third of those infected are asymptomatic. The guy sitting on the bar stool next to you who is yelling, laughing, sneezing, or coughing could quite easily be passing the virus on to you whether or not he has a fever.
  6. You only need to wear masks indoors. The idea is that sunlight kills the virus. Although it is true that most of the virus on surfaces is killed after about 20 minutes in direct midday sun, being in the sun will not kill viruses being passed through the air when someone coughs toward you, unless you can hold your breath for 20 minutes.
  7. Wearing a mask shuts down your immune system. Cloth masks are made of cloth, just like clothing is made of cloth. As long as your shirt is not causing you to get leukemia, your mask won’t either.
  8. Masks should be soaked in Clorox bleach before being worn. The idea behind this one is that since bleach kills viruses, any virus in the air that you breathe in will be dead-on-arrival when it gets into your lungs. Pulmonologists, such as myself, wish that this was true because if so, we would have lifetime job security from all of the asthma and lung damage caused by people inhaling bleach vapors.
  9. Wearing masks hurts the economy. Increasing numbers of viral infections hurts the economy. The economy will recover when it is safe to go to the store/theater/stadium/restaurant. Personally, I won’t walk into a public building if I seen other people not wearing masks. Wearing masks is the fastest way to rejuvenate the economy. Countries that enacted mask requirements early have recovering economies and are about to eat the United States’ lunch.
  10. Masks go against the American spirit of freedom. American freedom does not mean you have the right to infect other people with the virus. If a person is asymptomatically infected with the COVID-19 virus that person can infect others who are in contact with him/her. And if 4 of those others who get infected are over age 80, then statistically 1 of them will die. As a physician, I do not have the freedom to deny treatment to a mask-slacker who develops COVID-19 respiratory failure.

Anti-maskers join the legion of anti-vaxxers, anti-hand washers, anti-tooth brushers, and anti-bathroom users. Until we have an effective vaccine, the fastest way to get back to life as normal is to wear a mask.

July 22, 2020

 

Categories
Epidemiology

You Are Safer From COVID-19 In The ICU Than In The Grocery Store

This summer, COVID-19 numbers keep going up. Five months ago, we thought COVID-19 would behave like other respiratory viruses: have peak incidence in the winter and then drop off in the summer. But that has not happened. Across the United States, there is a second surge in new infections and southern states that seemed to be spared from the initial outbreak now have rapidly escalating numbers of new cases. As our hospitals admit record-breaking number of these patients, all of us in healthcare jobs wonder “Are we safe in our workplace?“. It looks like the answer is… we probably are.

In intensive care units full of COVID-19 patients, we are hyper vigilant about using personal protective equipment. Face masks, eye protection and hand sanitizer are mandatory. For patients undergoing aerosol-generating procedures, disposable gowns, gloves, and N-95 masks are added. It turns out that the coronavirus has a hard time penetrating all of that PPE to get to our mouths, noses, and eyes. Infection control procedures work surprisingly well.

The home is a dangerous place

On the other hand, in our homes, grocery store, bars, churches and restaurants, we let our guard down. The masks come off, we don’t use hand sanitizer every 5 minutes, and there are no plastic face shields to protect our eyes. Even worse are those around us who refuse to take any precautions, either because they believe that they are invincible, they are trying to make a political statement, or they are just plain ignorant. During the influenza pandemic of 1918, these people were called “mask-slackers”. Not only were there individuals who refused to adhere to infection control practices, there were entire cities that refused to adhere to these practices. St. Louis was an early adopter of closing schools and businesses whereas Philadelphia did not close businesses and instead held a public parade – the peak death rate in Philadelphia was 257/100,000 whereas the peak death rate in St. Louis was only 58/100,000.

A recent study from JAMA looked at 3,056 healthcare workers at a hospital in Belgium who underwent antibody testing to identify those who had become infected with the COVID-19 virus. All of them additionally completed a survey about exposures. 197 staff were identified as having been infected. But there was no correlation between taking care of COVID-19 patients and becoming infected oneself. Even working in the hospital was not associated with becoming infected. The only correlation was when a healthcare worker had a family member who was infected. The study indicated that healthcare workers who got infected did not get infected from hospital exposures but instead got infected from family members at home. U.S. hospitals are finding the same thing – when healthcare workers are identified as being infected, it is home exposures that are the cause and not patient exposures.

There are steps our hospitals can take

All of us in hospitals feel the risk. Many healthcare workers have decided to just retire or seek other jobs. Others have gone on disability purely due to perceived risk of becoming infected. But we know that strict use of personal protective equipment and hospital visitor limitation works. So what can we do to ensure our staff safety as elective procedures resume and visitors return? Fortunately, there are some specific things that we can do:

  1. Universal masking. Every person in the hospital should be wearing a mask unless they are alone in a room. This means not only doctors and nurses but also visitors and administrative staff. A mask for every person, all the time.
  2. Eye protection during patient care. In addition to face masks, goggles or face shields should be worn whenever a staff member is in a room with a patient.
  3. Hand hygiene every time. Alcohol hand sanitizer needs to be available throughout the hospital and must be used before and after every patient encounter.
  4. Beware of the break room. In hospitals, we often assume it is the patients who could be infected and are thus dangerous to us. However, we are more likely to get infected from a co-worker in the cafeteria, the conference room, or the office suite when we let our guard down by taking off our masks and not using hand sanitizer. It is probably more dangerous to eat in the doctor’s lounge than it is to intubate a COVID-19 patient while wearing PPE. When it comes to who hospital workers get their COVID-19 infection from, in the immortal words of Pogo: “We have met the enemy and they is us“.
  5. Limit visitors. Statistically, the more people that are in the hospital building, the more likely one of them is infected with COVID-19. Some studies indicate that as many as one-third of infected persons have no symptoms so simply screening visitors by symptoms or body temperature will not catch all of those people who can potentially spread the virus.
  6. PCR test all patients. Not only can visitors have asymptomatic infections but so can patients. So the patient coming in with appendicitis, a heart attack, or a bleeding ulcer can also have subclinical COVID-19. Every patient should be treated as if they have the infection until proven otherwise.
  7. Work from home. Healthcare workers can also have asymptomatic infection and so the fewer healthcare workers are in the building, the less likely one of them is going to inadvertently infect someone else. If you can do your job equally well from home, you should not be in the hospital.
  8. Encourage smart behavior outside of the hospital. We cannot control what our healthcare workers do when they leave the hospital but we can at least encourage them to do the right things. Avoid indoor gatherings. Always wear a mask in public. Avoid places where other people do not wear masks. Practice hand hygiene.

The COVID-19 virus is all around us. But it just may be that the safest place to be right now is working in the COVID-19 ICU.

July 19, 2020

Categories
Epidemiology

The Effect Of Age On COVID-19 Mortality Rates

Last week, I was asked if it would be OK if 20 family members visited one of my patients who is in his 80’s over the holiday weekend. My reflexive response was “Don’t come!” but it raised the question of what is the probability of dying should this patient get infected by COVID-19 and how does age effect mortality rates? Although we all know that age is a risk factor for death from COVID-19 infection, it turns out that specific probability statistics are hard to come by.

The U.S. Centers for Disease Control regularly posts information about the COVID-19 hospitalization rate by age and we know that older persons are more likely to be hospitalized than younger persons. For example, the hospitalization rate for people age 18-29 years old is 34.7 per 100,000 whereas the hospitalization rate for people over the age of 85 is 573.1 per 100,000. That means that an elderly person at 85 years old is sixteen times more likely to be hospitalized with COVID-19 than a young adult who is 25 years old. But this data does not tell us about the probability of death for different age groups.

The Ohio Department of Health regularly posts information about the number of Ohioans who have died from COVID-19 by age. This graph shows the COVID-19 deaths in Ohio as of July 1, 2020. It is striking that 1,516 deaths (53% of the total) occurred in people over the age of 80 whereas only 2 deaths have occurred Ohioans under the age of 20. However, the Ohio ODH does not post the total number of cases by age and so we still cannot determine the probability of death for different age groups. For that information, we have to turn to California.

The California Department of Public Health regularly posts both the number of infections AND the number of deaths for different age groups. This is the data from California as of July 1, 2020. By dividing the number of deaths by the number of cases for each age group, we can calculate the probability of death if a person in that age group becomes infected with COVID-19. The numbers are astounding: 25% or one out of every four people over age 80 who get infected with COVID-19 will die of the infection. On the other hand, a young adult between age 18-34 years old who gets infected with COVID-19 has a 0.084% chance of dying (or 1 death for every 1,196 infected persons). That means that an 85 year old person is 300 times more likely to die if infected with COVID-19 than a 25 year old infected with COVID-19. One a more personal front, if one of my children and I both get infected with COVID-19, I am statistically 38 times more likely to die than my child.

So, why is age such a striking risk for death by COVID-19? Although it is true that older people are more likely to have debilitating diseases such as heart failure and COPD that could make death more likely, I do not believe that this fully explains the association of age with COIVD-19 mortality. Furthermore, children almost never die of COVID-19; in Ohio, there have only been 2 deaths in those under age 20 and in California, there have been no deaths in those under age 18. One possible explanation that has been proposed is age-related changes in the level of the cell membrane receptor ACE2, a protein that the COVID-19 virus binds to in order to get inside of cells.

Virology research will eventually give us an answer to the question of why COVID-19 preferentially kills older people. But for now, I’ll stick to my original answer to my 83-year old patient’s family members question about having a family reunion at his house over the holiday weekend… don’t do it.

July 3, 2020

Categories
Epidemiology

Good News For The 2020-2021 Influenza Season?

I have a confession… I am a flu nerd. Every winter, I check the Center for Disease Control’s FluView website every Friday for epidemiology updates and I track the number of cases of influenza in our own hospital weekly. Most years, what happens in Australia in August and September predicts what will happen in the United States in February and March. And this year, there may be some good news from down under.

When it is summer in the United States, it is winter in Australia and so Australia’s flu season is the opposite months of the year as the United State’s. Last year, the Australian flu season was unusual: it started earlier in the year and there was a much higher percentage of influenza B than normal. Sure enough, last winter in the U.S., our influenza season also started earlier than normal and was characterized by mostly influenza B in the beginning of the winter and then mostly influenza A later in the winter. This graph shows the number of influenza cases by week of the year for 7 recent flu seasons (week 1 is in January). The red line is the 2019-2020 flu season (the gray line was the H1N2 pandemic of 2009).

Some studies of COVID-19 infections that occurred last winter indicated a high rate of co-infection with other viruses, particularly in children. The most common co-infecting virus was influenza. A fear of epidemiologists is that when the U.S. has its next influenza season in the winter of 2020-2021, co-infection of influenza and COVID-19 could result in an accelerated spread of COVID–19.

But it turns out that the same public health measures that help control the spread of COVID-19 also help control the spread of other respiratory viruses. Many physicians have wondered why there have been fewer emergency department visits for respiratory illnesses and fewer patients with asthma exacerbations in the past few months. The reason is likely because social distancing, wearing face masks, and frequent hand washing reduces the spread of all respiratory viruses, not just COVID-19.

The epidemiologic data coming from the Australian Department of Health Influenza Report indicates that this is going to be an influenza season like no other in modern history. What is so remarkable is that there is hardly any influenza this year. This graph shows the number of influenza cases over the past 6 seasons in Australia with the current influenza season in red and last year’s season in dotted green. Up until late March, the 2020 Australian influenza season appeared to be almost identical to last season. But then the number of influenza cases plummeted and there has been very few cases of influenza in April, May, and June.

It is still early to be sure since the peak of influenza in Australia normally occurs in August and September. But the early indication is that this is going to be one of the lightest influenza seasons on record in Australia and if so, then history tells us that the U.S. could have a light influenza season, also.

However, for this to happen, the U.S. will need to keep up social distancing and hand hygiene. As schools re-open in the fall and as workers return to their jobs, it may be very difficult for us to maintain our public health momentum next winter. So, this year Australian influenza epidemiology may not predict U.S. influenza epidemiology. Nevertheless, the information indicates that influenza can be controlled the same way that COVID-19 is controlled: staying home when you’re sick, washing your hands regularly, and avoiding those people who are sick.

But all Americans still need to get a flu shot this fall.

June 24, 2020

Categories
Epidemiology

When It Comes To COVID-19, Are We Testing The Right Thing?

During this COVID-19 outbreak, I have the dual roles of overseeing our hospital’s response to the pandemic and also of rounding in our ICU and taking care of COVID patients first-hand. One of issues that I struggle with in both of these roles is how accurate is our testing? Currently, we have 3 ways that we test for active COVID-19 infection: a nasopharyngeal swab for a rapid molecular test (made by Abbott Corporation), a nasopharyngeal swab for a PCR (polymerase chain reaction) test, and bronchoalveolar lavage fluid for a PCR test. We use the first two a lot and use the last one rarely. But do we have this backward?

The rapid molecular test by Abbott is very quick and our lab can have the results in < 1 hour. The criticism of this test is that it is less sensitive than the PCR tests so you can miss patients who are infected with COVID-19, particularly if they have mild symptoms or are asymptomatic.

The nasopharyngeal PCR test is currently considered the “gold standard” test for COVID-19. It appears to be more sensitive than the Abbott rapid test so it pick up more patients infected with the virus. However, it takes longer – 8-12 hours if your hospital does testing for it in-house and 2-3 days if it has to be sent to an outside lab. We primarily use this test if the Abbott rapid test is negative and we still clinically suspect COVID infection or if a patient without symptoms needs to be cleared of having the infection prior to undergoing an elective surgery.

The bronchoalveolar lavage (BAL) PCR test requires the patient to undergo bronchoscopy, an invasive procedure that requires sedating the patient and can put hospital staff at risk due to aerosolizing infected lung fluids into the air. Doing bronchoscopy on patients with suspected COVID-19 infection is generally discouraged because of the risk to the staff and the risk to the patient of an invasive procedure. Therefore, we don’t do a lot of BAL COVID tests.

Most respiratory viruses affect either the upper respiratory tract alone or both the upper and lower respiratory tract. The upper respiratory tract consists of the nose and throat; the lower respiratory tract consists of the lungs. COVID-19 is unusual among respiratory viruses in that it primarily causes symptoms in the lower respiratory tract resulting in cough, low oxygen, and shortness of breath. COVID generally does not cause much upper respiratory tract symptoms, such as sneezing or a runny nose.

So one has to wonder, if COVID does not affect the upper respiratory tract, how good is testing nasopharyngeal secretions?  Most of us who care for patients with COVID infection have encountered patients who had 1 or more nasopharyngeal Abbott rapid tests or PCR tests that were negative only to have the 2nd or 3rd PCR test end up being positive. We are also now seeing patients who have multiple negative nasopharyngeal PCR tests who then get a bronchoscopy and their BAL COVID PCR test comes back positive.

We spend a lot of energy debating whether the nasopharyngeal Abbott rapid or the PCR test is the best test. But maybe we ought to be asking whether the BAL is really the best test. When asked why he robbed banks, Willie Sutton famously said “Because that’s where the money is”. For those patients who present to the hospital with COVID-like signs & symptoms but have a negative nasopharyngeal PCR test, we may need to start doing more bronchoscopies with BAL COVID testing before pronouncing those patients virus-free.

May 17, 2020

Categories
Epidemiology

Imagining Life After COVID-19

It is mid-April and physicians and hospitals are already planning on how and when to re-institute normal operations, like flowers poking through snow after a cold winter. But it is pretty clear that the normal operations of the future will not be like the normal operations of the past. I’m using this post to speculate on how things may be different.

Hand sanitizer will become the new tabletop condiment

If  you go to a breakfast restaurant, you’ll find pitchers of syrup and honey on the tables. At lunch and dinner, there will be bottles of ketchup, mustard, and hot sauce on the tables. In the future, look for bottles of hand sanitizer on your restaurant tables.

Obstetricians will be busy in January 2021

“Blizzard baby booms” are a debated phenomenon that lie somewhere between urban myth and obstetric reality. I am a member of the baby boom generation, a surge in babies born after soldiers returned to the U.S. after World War II and the Korean War. That baby boom was a reality but whether there is a mini-boom of babies born 9 months after hurricanes and blizzards keep people indoors for a period of time is more uncertain. A blizzard or hurricane keeps people cooped up together for just a few days but COVID-19 keeps couples isolating at home with little to do for weeks. Will the social isolation of March and April result in a lot of babies in December and January?

Infectious disease physicians will be hospital medical directors

In a war, Majors are promoted to Colonels and Colonels are promoted to Generals by demonstrated success in battle. Similarly, hospitals select their medical directors based on administrative success in leading individual hospital programs. Throughout the world, hospitals are having their COVID-19 response led by epidemiologists and infectious disease specialists. Those who successfully steer their hospital through the infection control and financial perils of the pandemic will find themselves in line for promotion to hospital leadership positions.

Surgical masks won’t just be for surgeons any longer

Wearing a surgical mask does help prevent one from becoming infected with respiratory viruses when an infected person coughs or sneezes in your face. But when everyone wears a mask, there are two other important infection control effects. First, if the person wearing the mask is unknowingly infected with a respiratory virus, it helps prevent that masked person from coughing or sneezing on others. Second, when a person is wearing a mask, it reduces the chance that the person will touch their nose, mouth, or eyes with hands that could have picked up respiratory viruses from fomites such as a door handle, shopping cart, or elevator button that harbored viruses. In the future, people may likely feel more safe when those around them are wearing masks and that may be doubly so for their doctors and nurses wearing masks. Look for future masks emblazed with people’s favorite NFL team, alma mater, or beer maker.

A COVID-19 PCR test will become a routine admission order

When most patients get admitted to the hospital through the emergency department, they get “routine admission labs” – generally a CBC and chemistry panel. Look for a COVID-19 test to be added to that list of routine tests. Right now, there is near-paranoia by many physicians that their patients will have asymptomatic and potentially contagious COVID-19 to the point that they will not do procedures unless their asymptomatic patients have a negative COVID-19 PCR test. Even then, many demand that they be allowed to wear an N-95 mask for patients with a negative test because of the theoretic possibility that the test is a false negative.

Public health nurses will have job security

Countries that have been successful in controlling the COVID-19 outbreak have had very strong case isolation and contact identification. This takes manpower – primarily public health nurses that can go out in the community to interview patients and do testing of contacts. Public health departments are often underfunded  and understaffed. There will be increased demand for public health nurses for the foreseeable future.

Don’t expect your hospital to replace the old MRI machine

Although many U.S. hospitals have their ICUs full of COVID-19 patients, their overall medical/surgical census is generally low. That is because elective surgical procedures have all been postponed. Not only are surgeries not being done but neither are non-emergent diagnostic tests such as MRIs, CT scans, cardiac non-invasive tests, and pulmonary function tests. Hospitals don’t make much money off of medical admissions and depend on those surgeries and diagnostic tests to show a positive financial margin at the end of the year. Currently, hospitals are burning through their reserves (“days cash on hand”) with all of these surgeries and procedures not being done. With days cash on hand depleted, hospitals will be postponing large expenditures over the next couple of years.

The handshake will be a custom of the past

When a patient is infected with COVID-19, their hand becomes a fomite that can transmit the virus to everyone that they touch. Overnight, the handshake has changed from a greeting of politeness to a gesture of threat. Look for the handshake to disappear as an American social convention.

Telemedicine will come of age

Until March 2020, telemedicine was relegated to a few specific circumstances and primarily used in rural, sparsely populated areas of the nation. With the federal government relaxing rules for telemedicine, physicians all over the country are realizing that a lot of routine outpatient care can be done by telemedicine. Medical practices are adopting video telemedicine platforms through their electronic medical record or through separate commercial video applications. I have found that video telemedicine works very well for many of my patients, for both new and return visits. For patients who lack transportation or who live long distances from the office, the convenience of a video visit is a game-changer.

Anti-vaccine proponents will finally be quiet

One of the reasons that anti-vaxxers have flourished is that enough other people get vaccines so that devastating diseases such as polio, measles, and hepatitis B are uncommon enough that herd immunity protects the anti-vaxxers. If there were no influenza vaccines, then even influenza could periodically be as threatening as COVID-19. The current pandemic is a reminder of just how deadly infectious diseases can be and how much they can disrupt the economic structure of a community. An effective vaccine against COVID-19 will hopefully silence the anti-vaxxers since COVID-19 is unlikely to otherwise go away – it will just periodically die back and flare up as long as there are immunologically susceptible people for it to affect. The older the anti-vaxxers get, the more likely they are to become critically ill and die should they become infected and this will hopefully motivate them to forget their conspiracy theories and get a COVID shot.

It will be safe to go outside when your doctor has a beard

All of a sudden, most doctors and nurses in the United States became clean-shaven. That was because they needed to get fit-tested for N-95 face masks and a couple of years ago, OSHA made a rule that men with beards could not undergo fit-testing. Because I normally see patients in the hospital in airborne isolation (for example, those who are suspected of having tuberculosis), I have had an annual N-95 fit test for many years. And each year, I always passed my fit test, even though I had a beard. When OSHA came out with their rule, I was no longer permitted to wear an N-95 mask and had to switch to a PAPR hood but with PAPRs in short supply nationwide, men who provide inpatient healthcare had to shave and be fit tested. Just like robins are the first sign of spring, doctors with beards will be the first sign that the hospitals are no longer full of COVID-19 patients.

April 16, 2020

Categories
Epidemiology

Droplets, Fomites, and COVID-19

The disease COVID-19 is caused by the virus SARS-CoV-2. This is a member of the coronavirus family. These are viruses that can infect humans, other mammals, and birds. Most coronaviruses are rather benign respiratory viruses that account for about 5-10% of annual colds and flu-like illnesses. But occasionally, a coronavirus will successfully jump from one species of mammal to humans. When this happens, humans have never encountered that particular strain of coronavirus and so we have no immunity against it. Recent examples of coronaviruses making this zoonotic jump include SARS (from bats) and MERS (from camels). Although we do not know for sure, it is believed that SARS-CoV-2 originated in bats.

Coronavirus are transmitted the same way as other respiratory viruses are transmitted, by droplets of respiratory secretions. There are two ways that droplets can spread the virus. Either an infected person can cough or sneeze in another person’s face with the result that those respiratory droplets land on the second person’s nose, lips, or face. Or, the the infected person can get those respiratory droplets on their hands by coughing into their hand or touching their nose or mouth with their hand; when the infected person’s hand then touches a surface such as a door knob, light switch, keyboard, or television remote control, then those droplets get passed to those surfaces.

Those surfaces now become fomites. A fomite is any surface that that can serve as a intermediary conduit to get a virus or bacteria from an infected person into another person so that the infection spreads. Fomites are coronaviruses best friends. Certain types of surfaces make better fomites than others. For example, copper surfaces kill viruses whereas stainless steel surfaces do not kill viruses. Smooth surfaces, such as metal of glass, make better fomites than porous surfaces, such as upholstery or fabric, because viruses and bacteria tend to get wedged in between the fibers of fabrics making them harder to be picked up by another person’s hands.

Face masks can help prevent spread of viral-laden droplets from an infected person to an non-infected person, both in the hospital and in public. In the hospital, doctors, nurses, and respiratory therapists wear masks when caring for patients with respiratory viruses such as coronaviruses because they often have to get close to infected patients who can cough or sneeze in their faces. So in the hospital, it is the uninfected people who should wear masks.

In public, it is just the opposite; the infected person should wear the mask and not the average uninfected person. As long as you are maintaining social distancing by standing 6 feet from someone who is infected, even if that person coughs, those droplets are going to fall to the ground by gravity before they reach you. By having the infected person wear the mask, when they cough, they cough into the mask, thus substantially reducing the ability of those respiratory droplets to reach someone else. In fact, when healthy people wear masks when they are out in public, those masks get moist from the humidity of breath and most masks tend to get colonized with bacteria and fungus that can then make that previously healthy person sick.

So, it turns out that most respiratory viruses don’t get transmitted through the air, they get transmitted by fomites. And that means that the most important way to prevent spread of those viruses is by washing one’s hands after touching fomites.

If I could only have one thing to reduce the spread of COVID-19, it would not be a surgical mask or a face shield, or an N-95 mask. What I would want instead is soap and water.

March 30, 2020

Categories
Epidemiology Intensive Care Unit

Re-Using N-95 Masks In The Time Of COVID-19

The geniuses at Battelle have done it again. This time, they have invented a process for sterilizing and re-using N-95 masks using vaporized hydrogen peroxide. Battelle Memorial Institute is a non-profit scientific research and development institute here in Columbus, Ohio that is located about 3 blocks from the OSU hospital. Researchers at Battelle were the ones who invented the photocopier (and then launched Xerox Corporation), the cruise control for automobiles, the first nuclear fuel for nuclear-powered submarines, and the reusable insulin pen for injecting insulin for diabetics. In full disclosure, about 25 years ago, I had a grant from Battelle to assist with development of inhaled chemotherapy for lung cancer and that led to my receipt of the endowed Battelle Professorship in Inhalational Therapeutics that I held until assuming my position as the medical director of our hospital.

N-95 refers to a mask that can filter 95% of airborne particles. In medicine, we use N-95 masks when we care for patients with infectious diseases that are transmitted by airborne routes, such as tuberculosis, disseminated varicella, and measles virus. The virus that causes COVID-19 is the SARS-CoV-2 virus and this is believed to be transmitted by droplet spread rather than by airborne spread. Normally, viruses spread by droplets do not require the use of N-95 masks; a simple surgical mask with a plastic face shield will suffice. However, certain medical procedures, such as endotracheal intubation, can result in aerosolization of droplets containing viral particles and that is when the N-95 masks are needed.

For an N-95 mask to work properly, a healthcare worker must be fit tested to determine which specific type of N-95 mask fits tightly against the face. If a type of mask does not pass the fit test, then it will not filter out 95% of airborne particles and is no better than a regular surgical mask. Everyone’s face is shaped a little differently so different people will need different N-95 mask types. All healthcare workers who use these masks are required to get fit tested once a year to ensure that the mask that they are wearing actually does what it is supposed to do. Recently, OSHA declared that men who wear beards should not be fit tested because beards can interfere with a tight fit of the masks. For many years, I always passed my fit test with a specific type of N-95 mask despite my beard but because of OSHA’s rules, I was not able to be fit tested last year. Two weeks ago, our hospital required all men who could be involved in the care of a COVID-19 patient to shave their beards (so that they can be fit tested for N-95 masks) and thus, I shaved for the first time in 37 years!.

N-95 masks have come to the forefront of public consciousness recently because the COVID-19 outbreak is causing many hospitals to run low on N-95 masks. A misconception has arisen that N-95 masks are safer than regular surgical masks plus a face shield. For day-to-day care of patients with COVID-19, this really is not true because unless you are performing a procedure such as endotracheal intubation, an N-95 mask is unnecessary. Overuse of N-95 masks in situations when they are not necessary now will result in inadequate supples of these masks in situations when they are necessary in the future. In addition, the over emphasis on N-95 masks could lead the public to overlook the single most important way to prevent the spread of viruses spread by droplets, namely washing one’s hands after they touch various surfaces that those droplets land on (such as door handles and elevator buttons).

With supplies dwindling, Battelle invented a process for sterilizing N-95 masks so that they can be reused up to 20 times. They built the equipment to process 160,000 masks per day and this would greatly improve the nation’s N-95 mask inventory. However, medical equipment is overseen by the Food and Drug Administration. The FDA would only grant Battelle’s mask sterilization equipment limited approval, meaning that they are only permitted to sterilize 10,000 masks per day and only here in Central Ohio. That’s good news for our hospital because now we can count on a steady supply of masks in the upcoming weeks of the COVID-19 surge. But it is bad news for every other hospital in the United States.

Desperate times call for desperate measures. This may be a time for the FDA to take the desperate measure of cutting through bureaucracy.

March 29, 2020