Thursday, July 9, 2015
New Novel is out: The Rat Catcher and the Mole
A satirical look at civil service, government and small town politics through the eyes of a public health fellow who is more Holden Caulfield than John Snow. Available at Amazon.com.
http://www.amazon.com/Rat-Catcher-Mole-Don-Weiss-ebook/dp/B0118KYX2G/ref=sr_1_3?s=books&ie=UTF8&qid=1436486116&sr=1-3&keywords=don+weiss
Sunday, October 12, 2014
Second Ebola Case in Dallas
http://news.yahoo.com/texas-health-care-worker-tests-positive-ebola-095758341.html
A second Ebola case has been reported in Dallas in a health care worker who attended Mr. Duncan and reportedly wore full personal protective equipment (PPE) without a specific breech. When Mr. Duncan returned to the hospital on September 28th he was in day 5 of his illness. Thus far none of his household contacts have become ill and none of them wore PPE. So, what does this tell us about Ebola and how we can attain control?
One, that Ebola patients become more infectious as the illness progresses. The newly reported case in a healthcare worker had onset on October 10th. If we take 9 days as the mean incubation period for Ebola this means the healthcare worker's exposure was sometime around October 1, which was day 8 of Mr. Duncan's illness. This is similar to what was seen with SARS, that patients become more infectious (and dangerous) with time.
Second, that only hospitals that are well prepared to care for highly infectious patients should be allowed to do so. Standard practice is to have a staff person dedicated to observing the donning (putting on) and doffing (taking off) of PPE. This observation should continue throughout the period of clinical care (from an ante-room with a window). Perhaps gentle reminders during the doffing can avoid the presumed situation in Spain where the nurse may have touched her face with a gloved hand.
When a patient presents to a hospital early in the illness there is time to transfer to such a facility. That's the plan here in NYC. Bellevue hospital has a specially equipped ward to care for Ebola patients. Their staff are well trained. The number of healthcare workers entering the room should be kept to a minimum, especially after day 7 of the illness.
Still holding my breath.
A second Ebola case has been reported in Dallas in a health care worker who attended Mr. Duncan and reportedly wore full personal protective equipment (PPE) without a specific breech. When Mr. Duncan returned to the hospital on September 28th he was in day 5 of his illness. Thus far none of his household contacts have become ill and none of them wore PPE. So, what does this tell us about Ebola and how we can attain control?
One, that Ebola patients become more infectious as the illness progresses. The newly reported case in a healthcare worker had onset on October 10th. If we take 9 days as the mean incubation period for Ebola this means the healthcare worker's exposure was sometime around October 1, which was day 8 of Mr. Duncan's illness. This is similar to what was seen with SARS, that patients become more infectious (and dangerous) with time.
Second, that only hospitals that are well prepared to care for highly infectious patients should be allowed to do so. Standard practice is to have a staff person dedicated to observing the donning (putting on) and doffing (taking off) of PPE. This observation should continue throughout the period of clinical care (from an ante-room with a window). Perhaps gentle reminders during the doffing can avoid the presumed situation in Spain where the nurse may have touched her face with a gloved hand.
When a patient presents to a hospital early in the illness there is time to transfer to such a facility. That's the plan here in NYC. Bellevue hospital has a specially equipped ward to care for Ebola patients. Their staff are well trained. The number of healthcare workers entering the room should be kept to a minimum, especially after day 7 of the illness.
Still holding my breath.
Labels:
Dallas,
ebola,
outbreak,
viral hemorrhagic fever
Saturday, October 11, 2014
Ebola in the US: is NYC prepared?
Many of us in public health have been holding our breaths
and it is not because Ebola can be transmitted though the air. We’ve been
awaiting the outcome in Dallas. We’re not fully out of the woods just yet but
there is little cause for additional alarm.
Mr. Duncan left Liberia on September 19th, four days after he reportedly carried a woman dying from Ebola to and from her
apartment. By one account he had
held her legs while the woman’s family held her upper body. Mr. Duncan
is said to have ridden in the taxi with the woman to the hospital. The woman was refused entry at the hospital and has subsequently
died.
There aren’t any direct flights from Liberia to the US. Mr.
Duncan transferred planes in Brussels, landed in the US at Dulles International
Airport in Washington, DC and then continued on to Dallas. He was not yet ill so there wasn't any exposure to his fellow passengers. Nine days after he helped carry the Ebola patient in Liberia, on
September 24th, Mr. Duncan
began to feel ill. This is a typical incubation period for Ebola lending further credence to Mr. Duncan's likely exposure to Ebola. His symptoms were fever, stomach pain and severe headache. He
presented to the emergency department of Texas Health Presbyterian Hospital on the evening of September 25th. According to one reporter with access to the medical
records Mr. Duncan’s temperature was 103°F. The hospital performed a number of tests and eventually released him with a
prescription for antibiotics. After it was later discovered that Mr. Duncan had
Ebola the hospital admitted that protocol had not been followed. While it was
ascertained that Mr. Duncan had traveled to the US from Liberia in the 21 days
preceding his illness this information did not trigger the appropriate
response. The failure was initially
blamed on the electronic medical records system and then hospital
administrators admitted there had been a serious a miscommunication.
Since this story broke every city in the nation has asked
themselves could what have happened in Dallas happen here? There are over fifty acute care
hospitals in NYC and thousands of private practice offices and urgent care
centers. Weeks before the case in Dallas left his home in Liberia NYC hospitals
received from the health department an alert with instructions on how to screen
and isolate sick travelers from the affected countries and posters to alert
patients to announce that they had recent travel. Numerous conference calls
with hospital leadership have been held. Health Department staff have made the hospital Grand Rounds circuit to spread the word. The task while simple, must be universally applied. Ask patients about travel and immediately isolate those with fever (or worrisome symptoms) who have been in an affected country within the preceding 21 days. The city has a 24-hour hotline for doctors
to call and through that mechanism there have been nearly 100 reports (see link
below). Most of the travelers had not been to an affected country, which just
goes to prove how vigilant the NYC medical community has been. Doctors and
nurses aren’t taking any chances opting to consult with the health department
rather than risk making a Dallas-type error. And this suits everyone just fine.
You might be reassured that CDC Director, and former NYC
Health Commissioner, Dr. Tom Frieden has said there won’t be an Ebola outbreak
in the US, but here’s more reassurance: it has been 16 days since Mr. Duncan’s
illness first began and there have been no secondary cases in Dallas. The
people at greatest risk, his family and household contacts, are in quarantine.
So, even if one of them should become ill there should be no further spread. As
I said, we aren’t yet out of the woods. We must wait 21 days after the last
exposure date, the moment Mr. Duncan was placed in isolation. That date is October 19th.
Will another traveler incubating Ebola arrive in the US? It
is possible. NYC is more likely than most cities in the US to receive such a
traveler. Screening at airports, the latest defense tactic that is starting this
weekend, will only catch people who know they had an exposure and are willing
to confess this to federal authorities. Yes, we’re dubious too. At least in NYC
we are confident that the medical community is aware, vigilant and prepared,
despite what a fear mongering, headline grabbing, Professor of Health Policy
and Management might otherwise claim.
Labels:
Dallas,
ebola,
outbreak,
viral hemorrhagic fever
Saturday, September 27, 2014
Enterovirus D68. The new polio?
News from CDC
is that there have been more cases of a strange paralytic syndrome in children
in which limbs go limp following what appears to be an upper respiratory
illness (http://emergency.cdc.gov/han/han00370.asp).
Some, but not all, of these children have tested positive for Enterovirus D68
(EV-D68). The cluster announced yesterday is in Colorado and involves 9
children. Earlier this year California reported twenty cases of the same
illness that had occurred over a 2-year period (http://www.nytimes.com/2014/02/26/health/unknown-form-of-paralysis-strikes-california-children.html?_r=0).
So, has polio
returned in a new guise?
I am not old
enough to remember polio. I remember receiving the oral vaccine and seeing old
black and white newsreels of children in iron lungs, but no one I knew had contracted
the disease. Even during my training I didn’t see a case. Although the disease
is believed to have been around since Greco-Roman times, it wasn’t until the
late 19th and early 20th centuries that humanity was
plagued by epidemics. Like EV-D68,
polio belongs to the enterovirus family and is transmitted person to person via
the fecal-oral route. Believe it
or not the epidemics of last century are attributed to improved hygiene. With
less exposure to the virus during infancy there was a decline in immunity that
resulted in a more severe illness later in life when exposed. Most polio
infections (95%) are inapparent, meaning they don’t result in any symptoms or paralysis,
yet the person is capable of transmitting the virus. Among those with symptoms only
about 1% get paralysis. To any individual the risk was low, however, on a
population scale this was disastrous. During the peak years there were about
20,000 cases of paralytic polio per year in the US. After vaccine was
introduced in the 1950s there was a dramatic decline and polio in the United
States was all but forgotten.
I was
speaking to a public health historian the other day. She told me that when she
was in graduate school she was told that infectious diseases had been conquered
and that it was pointless to study them. Chronic disease was the new frontier. Short sighted to say the least. Ebola,
Legionnaire’s disease, HIV, Hantavirus, SARS, Nipah and MERS have all emerged
since this professor was told to forget about the field. West Nile virus moved
into a new hemisphere, we’ve had an influenza pandemic and Chikungunya exploded
in the Caribbean. Forget what you were told, infectious diseases will be with
us as long as there still is a planet earth.
Consider
this. Your 4-digit PIN number has 10,000 possibilities. There are ten options
for the first digit, i.e., zero through nine. Since one can repeat numbers there
are also ten options for the next three digits. That’s 10x10x10x10, or 10,000. A computer program can run through every
possible PIN number very quickly. Supposing a thief had a program that could
submit the guessed PINs to your account. It wouldn’t take long before he or she
was staring at your account balance.
Now consider the
ever-changing world of nature. Instead of PIN numbers we are talking about the
genetic code, large sequences of DNA or RNA. Each location is like the digit of
a PIN number. Nature is like a huge supercomputer, changing the genetic code
constantly. The change here is a mutation and instead of allowing access to
your bank account the mutation of concern is one that improves the organism’s
chance of survival or increases virulence. Millions and millions of mutations
don’t, but by chance alone, sooner or later, a mutation is going to result in
is a more virulent organism or one that can cross species. This is why there
will always be new infectious diseases on the horizon. EV-D68 is a RNA virus.
RNA viruses are more prone to mutation (influenza for example). But has EV-D68
somehow mutated to become a paralytic virus like its cousin polio? We don’t
know yet. Right now the occurrence of paralysis is quite rare.
Saturday, September 6, 2014
Meningococcal disease in young men of color, Brooklyn, New York
Meningococcal disease is
a severe bacterial infection often called “spinal meningitis” or just
“meningitis” by the media. Although it can spread from one person to another it
is not as contagious as the popular press makes it out to be. Household
members, sexual contacts and persons who share cigarettes or drugs are at the
highest risk for catching the disease which is potentially deadly, claiming as
much as 20% of victims. There is good news though, there are vaccines for
meningococcal disease.
Meningococcal disease can
be insidious. Often it looks like the flu at first, with fever, sore throat, chills, muscle pain and
just feeling punky. A rash might develop which looks like small red dots that
don’t go away when pressed with a finger (known as blanching). If meningitis
develops these signs are much easier to recognize: headache, stiff neck, eye sensitivity
to light, vomiting and a fogginess of mind. If you have any of these symptoms
don’t delay. Especially if you have HIV. Contact your physician. This disease is readily treatable with simple antibiotics.
NYC has had two large
outbreaks of meningococcal disease in the last decade. One in 2006 and another
in 2011-2013. Both outbreaks were centered in Brooklyn, specifically the
neighborhoods of Bedford-Stuyvesant, Crown Heights and Brownsville. The most
recent outbreak affected men who have sex with men (MSM), many of whom were
HIV-infected. The outbreak was thought to have been conquered in February 2013
but there have been 4 recent cases in HIV-infected MSM prompting new concerns
and efforts to quell the disease. It is not yet known exactly how the disease
is moving through the community but there is some evidence to suggest that
multiple anonymous sex partners and sharing of drugs is involved.
The response to these
outbreaks has been vaccine campaigns. One issue is that the vaccine’s
effectiveness in HIV-infected is unknown and two of the recent 4 cases had
been vaccinated with the recommended two doses. Still it is better to be vaccinated,
as there may be some level of protection and prevention of the most serious
outcome. Death.
Another issue is that
there is a population of young men who are bisexual or not openly gay who have not
gotten the message about vaccine. Many of the recent cases fall into this
group. This is where the greater community can help. If you know someone who is
at risk for meningococcal disease tell him or her about the vaccine. Urge them
to protect themselves. Friends and family want them to stick around, so perhaps
they’ll do it for you. One needn’t announce their sexual preferences to receive
vaccine. Walgreens/Duane Reade and CVS pharmacies will give the vaccine no
questions asked. Check to see that your local pharmacy has it in stock or where
the nearest store with the vaccine is located. For those without insurance, you
can visit one of the City’s free clinics. The Fort Greene location has Saturday
hours. There will be a free vaccine event Sunday (September 7, 2014) at the 3rd
annual Bushwig event. Look for the van near the venue at 389 Melrose Street, Brooklyn.
Lastly, don’t allow fear
to paralyze you into inaction.
Labels:
AIDS,
Bushwig,
HIV,
men who have sex with men,
meningitis,
Neisseria,
vaccine
Monday, September 1, 2014
Ebola won't be a pandemic
Between 2,000 and 5,000 travelers arrive monthly in the New
York City metropolitan area from the West African Countries currently
struggling to contain the Ebola Virus outbreak. It is highly unlikely though
that an individual infected with the virus will arrive here without the medical
community knowing about him or her.
Any passenger found to be sick on the flight would be reported to the
CDC Quarantine Station by the flight crew and whisked into isolation with full
infection control precautions in place. If the illness starts after arrival all
emergency departments are prepared to isolate the sick traveler and determine
the etiology of the febrile illness. Typhoid fever, cholera and malaria are
infinitely more likely than Ebola.
Of the fifty or so people who have arrived in NYC from West
Africa sick none have even had an illness worrisome for Ebola let alone the
disease. This includes the well-known patient at Mt. Sinai. Should a patient with
Ebola arrive in NYC there would still be little reason for the general public
to be concerned. The primary transmission risk for Ebola is to health care
workers who do not have adequate personal protective equipment and persons
handling infected bodies during burial rites. The health care systems in the
affected countries are both understaffed and under resourced, a problem not
present in NYC (or anywhere in the US for that matter). NYC has the ability to rapidly test
suspect patients, something that isn’t easily done in West Africa. Additionally,
Ebola, unlike say measles, isn’t contagious until after symptoms begin, so
there is time to implement control measures. Ebola isn’t airborne so to be
infected one needs to come in contact with body fluids. The risk of Ebola transmission
is low during the beginning of the illness, therefore hospital infection
control precautions can be put in place in time and reduce the risk to health
care workers. Ebola just isn’t the type of disease to pose a risk to the
general US population. It’s not the Andromeda strain.
Monday, August 25, 2014
New Book The Ratcatcher and the Mole is Coming Soon!
Book three in the Mackey Dunn series is the prequel to Mailaise and introduces Mackey as the protagonist. The story is told through the eyes of Will Benes, a CDC pubic health trainee assigned to the woeful River City Department of Health. Will is the literary nephew of Holden Caulfield, and is a few shavings short of a chip off the old block. In Mackey Dunn he finds a kindred spirit and the only person whose misfortunes seem worse than his own.
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