Chikungunya May Be Present In Texas, Already in Florida

texas

Physicians inside Sermo are warning of possible local transmissions of Chikungunya virus in Texas, right as the peak season for vulnerability begins. The CDC has already confirmed two cases of local transmission in Florida and a pediatrician in the Houston area tested a patient for Chikungunya.

If the CDC confirms suspicions, Texas will be the second state to have the virus on home turf.

Dr. Jim Wilson, MD, a pediatrician and infectious disease expert from AscelBio wrote to the community yesterday about the next few weeks.

“In Texas, we have word of possible indigenous transmission occurring there. This will require proper epidemiological investigation to confirm, but it highlights the potential threat this nuisance pathogen represents.

We are now entering the period for maximized potential to support transmission from an environmental perspective. This period lasts for approximately the next eight weeks. You have:

  1. Convergence of people playing outside among
  2. Maximal mosquito densities and
  3. Fully optimized ambient temperature (that supports optimal viral replication inside the mosquito vector)

The areas of concern are Texas, New Orleans, Mississippi and Alabama. All have large areas of agriculture and rural communities with contact rates with mosquitoes.”

He continues:

“We have yet to see any country successfully prevent Chik’s relentless expansion. There is a potential here to see localized medical infrastructure inundation that includes the outpatient and inpatient setting.”

Chikungunya is a fairly mild virus that causes headache, joint pain, rash and fever. It often presents as similar to dengue fever but with a low mortality rate. There is currently no cure, only rest and pain relief for symptoms, but most cases resolve on their own.

One family practitioner in New Jersey noted that 20 patients had been diagnosed so far in her state, but all had traveled to the Caribbean prior to infection. Another physician in Florida noted that he was seeing a pattern of patients with fever and joint complaints and suspected Chikungunya.

Currently, not all suspicious cases of Chikungunya are tested due to mild symptoms, lack of treatment options and lack of testing information from local public health authorities. Wilson suggested more testing to assist public health officials to determine if Chik is present in local communities.

The most important takeaway for physicians is to be watchful for people traveling from the Caribbean with Chik-like symptoms. We have been covering the spread of Chikungunya since January from the Caribbean to the U.S. for more information check out the following stories.

As a physician have you seen any suspected cases of Chikungunya? Has your local public health office contacted you about suspicious cases of testing? If you’re an M.D. or D.O. we’ll be discussing this more inside Sermo. Please join us.

 

Ebola Outbreak: An infectious disease doctor tells his story

credit: News.com.au / ebola slide

credit: News.com.au / ebola slide

Editors Note:  Dr. James Wilson, a pediatrician and infectious disease expert with AscelBio is currently traveling to Monrovia, Liberia to help with the humanitarian effort.  We had the chance to speak with him before his departure.  Please join us as we send him well wishes and prayers for a safe journey and the ability to help others.

The deadliest outbreak of Ebola ever recorded is currently overwhelming West Africa. The Liberian government has closed its borders with only three checkpoints for entry, each set up with containment centers. Since March of this year, there have been 1,201 reported Ebola cases resulting in more than 672 deaths.

We had the opportunity to speak and correspond with Dr. James Wilson, a pediatrician and infectious disease expert with AscelBio and Sermo Infectious Disease Community Correspondent. Dr. Wilson helped to develop a system of bio-surveillance that assists with disease forecasting. He led the creation of the Haiti Epidemic Advisory System (HEAS) after the 2010 earthquake and led ground operations through the ensuing cholera disaster. He has been in constant contact with medical workers in West Africa since the latest outbreak.

What is Ebola?

Ebola is a cluster of five different strains with varying levels of mortality.

1. Bundibugyo Ebola virus (BDBV)

2. Zaire Ebola virus (EBOV)

3. Reston Ebola virus (RESTV)

4. Sudan Ebola virus (SUDV)

5. Taï Forest Ebola virus (TAFV)

Of the five, three were connected to past outbreaks in Africa. The current Ebola pathogen is EBOV – the deadliest – with a 90 percent mortality rate. Due to early treatment, the current death rate has dropped to approximately 60 percent. While there is no cure for Ebola, immediate medical care increases the likelihood of survival.

The starting symptoms of Ebola are flu-like which progresses quickly to vomiting, diarrhea, organ failure, and internal or external bleeding. The incubation of the virus is between two and twenty-one days resulting in death from major organ failure, loss of blood, or shock. Those who survive can still spread the virus to others for up to seven weeks after recovery.

Containment Issues and the Outbreak Today

In fact, two more staff members at Samaritan’s Purse have been diagnosed with Ebola in the last 24 hours. Wilson writes inside the Sermo community:

  1. The security situation has dramatically deteriorated in the last 24 hours.
  2. Providers in Monrovia believe they are only seeing 25 percent of the actual Ebola cases in the community.

“Folks, this is about as bad as it gets in today’s world.” ~ Wilson

The disease, which broke for the first time in an urban area has quickly spread through Guinea, Liberia, Sierra Leone, and now via air transport to Nigeria. Sanitation, lack of understanding about the disease, and local traditions have created problems for governments and medical aid workers.

  • Under-educating residents of the deadly impact of this virus has caused mistrust. In Sierra Leone, locals who believed foreign healthcare workers were using Ebola to kill people and steal their body parts attacked a hospital. Police had to use tear gas to fight off the crowd. Some also believe the virus is being carried in by foreign aid workers.
  • Religious practices have contributed to the spread as families sneak bodies – dead or alive – out of isolation. The deceased are mourned through their religious ritual, which involves close contamination, and the sick are taken to local alternative treatment options.
  • While the initial spread of the disease was likely through bush meat, such as primate or fruit bats, the majority of the transmissions now are human to human.

The residents of these districts are not the only ones in danger of contracting Ebola. Humanitarian workers are also falling victim. “History has shown that failure to be vigilant, failure to implement and properly execute barrier nursing techniques, and lack of overall experience in medical management have led to healthcare worker infection and death,” says Dr. Wilson.

There are some untested vaccines available, but according to CNN, “It is too late in this outbreak for vaccines to have enough of a preventative impact, but Ebola will emerge again in the future. If safety can be proven, the stockpiling of vaccines could improve the outcome of future outbreaks.”

Ebola Threat in the U.S. and Abroad

The Centers for Disease Control has deployed more members to West Africa for support. Though they will not be interacting with the infected, the goal is to assist in the training and education of those who may have been exposed. Wilson is traveling today to Monrovia today to join the aid effort.

“It’s improbable, but not impossible, that it could reach the U.S.,” says Wilson. “If [Ebola] moves, France will be hit the hardest. Given the number of urban areas with international ports of entry that are involved, the risk for translocation by air flight continues to increase. France is for us what Canada (i.e., Toronto) was for SARS. Meaning we expect to see translocations to France before the U.S., but anything is possible at this point.” According to NPR, about 10 percent of flights leaving from Conakry, Guinea fly to Paris.

Due to better sanitary conditions, superior health care, and cultural factors, if an infected individual made it into an industrialized country, any outbreak would likely be small and easily contained.

What Can U.S. Doctors Do?

The CDC has released a series of preventative alerts and warnings for health workers and travelers. Wilson advises “anyone receiving a patient in an ICU setting suspected to have come from Africa should be vigilant for viral hemorrhagic fever until proven otherwise.”

As the probability of translocation by air flight increases, extra caution and attention are highly recommended within emergency departments, inpatient, and intensive care settings.

As an M.D. or D.O., what are your thoughts about this outbreak? How do you feel about the likelihood that this will travel to the United States? We will be discussing this further inside our community and would like to hear your thoughts.

 

Sources

1. Ebola Virus Disease

http://www.who.int/mediacentre/factsheets/fs103/en/

2. Ebola outbreak: Is it time to test experimental vaccines?

http://www.cnn.com/2014/07/25/health/ebola-outbreak-experimental-vaccines/

3. Ebola epidemic in West Africa ‘out of control’

http://edition.cnn.com/2014/06/23/health/ebola-virus-outbreak-west-africa/

4. 5 Things to Know about Ebola Outbreak in W. Africa

http://bigstory.ap.org/article/5-things-know-about-ebola-outbreak-w-africa

6. Samaritan’s Purse

http://www.samaritanspurse.org/article/samaritans-purse-doctor-serving-in-liberia-west-africa-tests-positive-for-ebola/

7. Sierra Leone Police Use Tear Gas to Curb Ebola-Related Riot

http://www.bloomberg.com/news/2014-07-25/sierra-leone-police-use-tear-gas-to-curb-ebola-related-riot.html

8. What is Ebola? – Truthloader

https://www.youtube.com/watch?v=crBe9D-nos0

9. Burying Ebola’s victims in Sierra Leone

http://www.ifrc.org/en/news-and-media/news-stories/africa/sierra-leone/burying-ebolas-victims-in-sierra-leone-66528/

10. Ebola Not a Significant Threat to U.S. , CDC Says

http://www.huffingtonpost.com/2014/07/28/ebola-united-states_n_5628364.html

 

54% of Physicians Agree with SCOTUS Birth Control Decision

SCOTUS birth control poll

A recent SermoSays Physician Poll shows a narrow majority of physicians support the Supreme Court decision to allow closely held corporations an exemption from covering contraception on religious grounds.

The question asked, “Do you agree with the Supreme Court’s ruling that closely held corporations can be exempt from covering the cost of birth control if they are opposed to doing so on religious grounds?”

  • 54% said yes, they support the ruling
  • 46% said no, they do not support the ruling

More Women Receive Birth Control Coverage

Despite the decision, recent data from IMS Institute show a sharp increase in coverage for women with birth control due to changes from the Affordable Care Act (Obamacare).

In 2012, only 14 percent of women received birth control pills without a copayment. By the end of 2013, that number had surged to 56 percent. The ACA requires most health plans to cover birth control as prevention, at no additional cost to women.

The Institute estimates the savings at about $269 per woman annually. Some have speculated increased access to free or inexpensive birth control would spur an uptick in use. However, their research indicates there has been only a modest increase since the law was enacted, consistent with growth from prior years.

As an M.D. or D.O. what do you think about corporations making decisions for employees about birth control? Have you noticed an increased demand for birth control from your patients? If you’re a physician we’ll be discussing this further inside the community, come join us.

A Calling Laid Bare: Practicing Medicine in Egypt

credit:  Linda Girgis, MD

credit: Linda Girgis, MD

The Hippocratic Oath states: “I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.” Most doctors take this oath very seriously and for many of us, medicine is truly a calling rather than just a profession.

Sometimes, this oath is a brutal task and impossible to fulfill.

I recently had a chance to visit a home for the disabled in Rashid, Egypt, a very poor town outside Alexandria.  What started out as a medical mission visit became an exceedingly humbling experience.  There are 50 residents in this home, 30 who have no family whatsoever.  They all have some mental malady. Patients must travel to a nearby town to receive medical care. This has been working out for them, although not the most convenient way of seeking medical care.

While there, an elderly woman asked to speak to me. “My hand is frozen,” she told me or at least what I understood in my limited Arabic. She said she had fallen and broken her arm, in a remote area of Upper Egypt, an area so removed she did not receive medical care immediately. She ended up having three surgeries to try to repair the damage the delay caused. After speaking with her, I became increasingly convinced she was suffering from RSD (Reflex Sympathetic Dystophy) and that she would never get better.

I met another woman who was so poor, her kids took turns eating breakfast. It is hard to imagine how a child’s medical care would be a priority when food was not even available. People there are struggling to eat and have adequate clothing and shelter.  Diseases come and go with little attention to treating them.

In, Egypt, there is no healthcare insurance, no Obamacare, no prior authorizations. However, diagnostic tests are not readily available like in the US. People can see a private doctor and pay the costs out-of-pocket. Or they can go to one of the few public hospitals, which have clinics, for treatment. These are available only in the larger cities such as Cairo and Alexandria. Many people travel far and then wait hours just to receive basic clinic care. Even more people simply choose to go without any medical care. Preventive medicine simply doesn’t exist.

credit: Linda Girgis, MD

credit: Linda Girgis, MD

There are also no social services, welfare, food stamps, WIC programs or any government sponsored assistance.  An eight-year old boy I met, never knew his father. His father was murdered while his mother was pregnant with him. Unable to work, the mother went to live with her parents, who were very poor. The boy’s mom now works as a teacher, but in Egypt, teachers like many other professions, are poorly paid. Her parents are now sickly, and she needs to support them. There is no Medicare or retirement savings in Egypt. They struggle just to have enough to eat.  While eight-year olds in the USA are dreaming of their favorite electronic toys or are asking for updated laptops, this boy has little chance to escape his poverty.

Outside the home for the disabled, I walked through streets of abject poverty. As I climbed back onto the microbus for the ride back to Alexandria, I could no longer hold back the tears. My thoughts wondering who would remember those the rest of humanity forgot?

My oath lain trampled on the ground too heavy to carry.  Who could feed all these people, yet alone help them with their medical health.  My heart shattered remembering the faces of the kids I had just visited.  My calling completely laid bare knowing there are many forgotten corners of humanity and too few people who care.

Perhaps, if we all pause, not just the doctors among us, and all stepped up to remember one forlorn person, the world would be a better place. It is a good reminder to all those given the responsibility of treating medical diseases to look for the humanity in each of our patients.  We all need to keep in mind that many suffer from the illnesses of society, as well as the body. Some people are too poor to pay for their medications. Keeping our oath in mind, we need to do no harm while we alleviate suffering.  Many people doing small things can achieve greatness together. Imagine the world if everyone just tried to help alleviate the suffering of one person? Wouldn’t that be a much better world for all of us to live?

credit:  Linda Girgis, MD

credit: Linda Girgis, MD

Bio:  Dr. Linda Girgis MD, FAAFP is a family physician that treats patients in South River, New Jersey and its surrounding communities. She holds board certification from the American Board of Family Medicine and is affiliated with both St. Peter’s University Hospital and Raritan Bay Hospital. Dr. Girgis also collaborates closely with Rutgers University, University of Medicine and Dentistry of New Jersey (UMDNJ), and other universities and medical schools where she teaches medical students and residents.  She recently completed a medical mission in Egypt.

Poll: Who is your favorite fictional doctor?

credit: IMDB.comWe had a little fun with our latest poll.  We asked our physicians, what is your favorite fictional doctor of all time?  The favorites were “Hawkeye” Pierce from “M*A*S*H,” Gregory House, MD from “House M.D.” and “Bones” McCoy from “Star Trek.”

The results are below:

  • Dr. Benjamin Franklin “Hawkeye” Pierce 29%
  • Dr. Gregory House 19%
  • Dr. Leonard H. “Bones” McCoy 15%
  • Dr. John H. Watson (Sherlock) 13%
  • Dr. Percival “Perry” Ulysses Cox (Scrubs) 9%
  • Dr. Quinn Medicine Woman 4%
  • Dr. Beverly Crusher (Star Trek, Next Gen) 4%
  • Dr. Henry Jekyll 3%
  • Dr. Kerry Weaver (ER) 1%

Both Pierce and House are flawed characters who showed their struggles with real issues as they cared for patients.  Pierce, famously dealt with PTSD (post-traumatic stress disorder) as the series final story line and House wrestled with drug addiction through part of the show.  Both men always showed a deep commitment to their patients and a commitment to giving the best care to patients.  And yes, even McCoy in his way, did the same.

For more information about PTSD and veterans, our post about what medical symptoms doctors look for in patients with PTSD is insightful.

As a physician, what do you consider compelling attributes for fictional doctors?  Do you think showing flaws is a good thing?  While we do have some lighter topics inside Sermo, about 60 percent of the discussion is about clinical and practice management topics.  If you’re an M.D. or D.O. please join us.

Photo credits:  IMDB.com