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Wednesday, October 22, 2014

Ebola: Lessons from Dallas and Facts about Ebola

By James L. Holly, MD
CEO, Southeast Texas Medical Associates

The problem with information about Ebola is that simple answers are not helpful in public health and personal safety for avoiding contracting an Ebola infection. A statement by U.S. Sen. Rand Paul may true, but if it is not the whole truth, it is not helpful in to the public. The senator said, “If someone has Ebola at a cocktail party, they’re contagious, and you can catch it from them.” On the face of it, this statement is true, but it is not the whole truth about the spread of Ebola.

First, to address Ebola contagiousness, you must distinguish between contagious patients and asymptomatic patients — those who have the virus but at very low viral load, are not spreading their body fluids with sneezing or coughing, and are not manifestly sick — who are not contagious in the ordinary use of the term. It is probable, if you received a blood transfusion from this asymptomatic person with a low viral load that you would develop Ebola, but it is also probable that the casual exposure of being in the same room with this asymptomatic person would not result in your becoming infected.

While we cannot make dogmatic statements without random-controlled or double-blind studies, which are not possible due to the seriousness of the Ebola infection, we can draw inferences from the “natural experiment” that took place in Dallas. Every human death is a tragedy, but every human death does not result from culpable action or inaction on the part of a health care worker or professional. When Thomas Eric Duncan manifested Ebola and when he subsequently died, his family and other contacts were quarantined appropriately.

The good news is that no one that who casual contact with Mr. Duncan has contracted Ebola. Those who were in the emergency room when Mr. Duncan presented, those who took care of him in the emergency room, and now even Mr. Duncan’s family have completed the quarantine period without having contracted an Ebola infection. While they have not completed the 21-day observation period, no one who was on the airplane with the nurse from Dallas has developed an Ebola infection.
Being in the same room with an asymptomatic person who has Ebola is not desired and is not to be recommended, but it also is not as dangerous as some would like to say.

Fact

Ebola is a dreadful and dangerous disease. Even with the best of care, many with the infection will die. Ebola can be spread by contact with bodily fluids of an infected person, but even that must include contact with a mucous membrane or a break in the skin. Also, the infectivity of Ebola is not 100 percent. If a person with Ebola coughs on you, and if any fluids from that cough fall on intact skin, and if you wash that skin with soap and water, the probability of your contracting Ebola is very low. You will not contract Ebola simply by being in a social setting with someone who is in the early, asymptomatic stage of an Ebola infection.

Real Life Experiences

At one time there was a great fear of HIV infectivity. HIV is a much different disease from Ebola, and we are at a much different point in the history of the treatment of HIV disease. There was a time, however, when many people made statements about the infectivity of HIV like Rand Paul’s statement about the infectivity of Ebola. They were wrong, also. Children who had HIV infection were refused admission to school; people would not shake hands with those who were HIV positive. We shortly learned that casual contact with an HIV-positive person was not dangerous.

Many years ago, a physician friend called me in a panic. He had punctured himself with a needle that had been used with a patient who was HIV positive. I encouraged him to clean the wound carefully with an antimicrobial soap and copious amounts of water, and I assured him that the probability of contracting HIV from a single needle stick was very low. Twenty-five years later, he is still HIV negative. This does not mean we should be casual about needle sticks, but it does support our contention that everyone who has a needle stick will not contract HIV.

Some years ago, my wife and I had a dear friend who was HIV positive. He developed HIV-AIDS and became very ill. This was before there were good treatments for HIV. Carolyn and I were with our friend when he was actively dying at home. She held his left hand, and I held his right hand as we comforted him. When he breathed his last breath, I looked down and saw that the cuticle of the thumb of his right hand was bleeding and that the blood was dropping on my hand. Without panic, I went to the bathroom and scrubbed my hand with soap and water. I was confident that I would not contract HIV, and I did not.

The Power of Skin

I would not recommend intentional contract with blood from an HIV positive person, but I would affirm that one of the best barriers to viral illnesses is intact skin. Whether it is the highly contagious, airborne Influenza virus, or the less contagious but much more dangerous Ebola virus, skin is the first and best barrier to infection. The problem comes when a person has had exposure to a viral illness that resulted in viral contact on the hands, and then the person touches his or her eye, nose, or mouth. This by-passes the skin barrier and carries the virus straight to a mucous membrane and from there into the body.

This reminds us that the most important viral-infection prevention is frequent, vigorous washing of the hands with an antimicrobial soap and copious amounts of water. It also reminds us that if we can diminish or eliminate the spread of aerosol virally infected particles from a cough or sneeze, we can decrease the spread of viral infections. We can do that by covering our mouth and/or nose when we sneeze or cough and then by washing the body part used for that purpose immediately. If you are young enough and can bend that far, coughing or sneezing into the bend of the elbow is the best tool. This technique is not adequate protection from Ebola, but it is a first-aid means of addressing all viral infections until isolation can be achieved.

Conclusion

If a person does not have an Ebola infection, he or she cannot spread an Ebola infection. I recently heard a public health official include this in a list of high-risk situations: “if you have contact with someone who had contact with an Ebola-infected person.” The reality is if you have contact with someone who had contact with an Ebola infected person, if your contact did not have Ebola, you have nothing to worry about. And, while we Baptists would not be at a cocktail party, even if you are but no one is sick, coughing, or sneezing, you have very little, if anything, to worry about.

Dr. Holly is a Beaumont family physician, CEO of Southeast Texas Medical Associates. He is adjunct professor at The University of Texas Health Science Center and clinical associate professor Texas A&M Health Science Center.

Tuesday, October 21, 2014

Texas Doctors and Nurses Jointly Prep for Ebola

Thousands of Texas physicians and nurses last evening took part in a joint education program to learn as much as they can about the Ebola virus.

Listen to the entire program here.

Sponsored by the Texas Medical Association (TMA) and the Texas Nurses Association (TNA) — the state’s two largest health care professional organizations — the Tele-Town Hall Meeting on the Ebola virus included updates from Texas Department of State Health Services physicians and a lengthy question-and-answer session with public health experts.

“We come together tonight both as citizens of this great state and as professionals charged with protecting the health of our fellow Texans,” TMA President Austin King, MD, said as he opened the event. “As parents, friends, and neighbors, we were understandably concerned by the news from Dallas over the past several weeks. But as doctors and nurses, it is our job to know and stay up to date on the science surrounding Ebola, and it is our job to impart that information to our patients. It is our job to make sure that we … and they … are aware and prepared, but not paralyzed by fear.

“Tonight, it is our job — the job of TMA and TNA — to empower you with the information that you need.”

Using the Tele-Town Hall technology, more than 22,000 TMA member physicians and 8,000 TNA member nurses were called simultaneously and invited to join the conference.

“Every day, Texans rely on a health care team to care for them,” Dr. King added. “[Last night], the key members of that health care team came together to remain vigilant in educating and informing our members of the most current information in responding to Ebola and infectious disease.”

Since Thomas Duncan’s Ebola diagnosis was confirmed on Sept. 29, TMA has worked closely with Dallas County Medical Society (DCMS) leaders and public health experts to educate physicians statewide about Ebola and to provide accurate information about the virus to the public. Those activities included:

  • Don’t Close Schools Because of Ebola Fears — a science-based letter of guidance and reassurance that DCMS sent to North Texas school officials and that TMA is working to distribute to schools statewide.
  • Protect Yourself From the Ebola Virus — an easy-to-understand patient flyer, in English and in Spanish.
  • What If Someone Walks Into My Office With Ebola? — science-based guidelines to prepare physicians’ practices and protect staff and patients if someone presents with Ebola symptoms.
  • “Facts, Not Fear” — an outstanding town hall meeting that DCMS hosted with WFAA-TV. Watch the replay.

“We will work with elected officials and our designated public health authorities to control the immediate disease threat of Ebola,” Dr. King said. “And we will continue to advocate on Texans’ behalf at the state and federal level for policies that improve our public health system and abilities.”

Friday, October 17, 2014

Poll: Many Unaware How Ebola Is Spread

By Phil Galewitz
KHN Staff Writer

Content provided by Kaiser Health News

A new survey finds the public has a lot to learn about how the Ebola virus is transmitted, which could help explain the growing fears of the disease.



The survey by the Kaiser Family Foundation found that while nearly  all adults (97 percent) know a person can become infected through direct contact with the blood or other body fluids of someone who is sick with Ebola, there are still misconceptions. (KHN is an editorially independent program of the foundation.)

One third of respondents are unaware they cannot become infected through the air. About 45  percent are unaware they cannot contract Ebola by shaking hands with someone who has been exposed to the virus but who does not have symptoms.

And only slightly more than a third (36 percent) of respondents know that a person must be showing Ebola symptoms to transmit the infection, the poll found.

The survey, which was fielded after a Liberian man was diagnosed with Ebola in Dallas, and remained in the field after a nurse who helped care for him contracted the disease, finds most Americans say they trust local, state, and federal health authorities to contain the disease  in the U.S.

The public was near evenly split on the federal government’s response to the crisis. About 45 percent said the government was doing enough to fight the disease in Africa and 48 percent said it was doing enough to protect Americans.

The telephone poll of 1,503 adults was conducted from October 8-14 and has a margin of error was plus or minus 3 percentage points.


Thursday, October 16, 2014

Watch Yesterday’s Ebola Town Hall Meeting

Dallas physician leaders responded to the public’s concerns about Ebola at a town hall meeting yesterday. The meeting was hosted by WFAA and held in the community where a nurse diagnosed with the virus lives. The purpose of the event, titled #FactsNotFear, was to present the facts about Ebola and the situation in Dallas, and to calm escalating public fears about the disease.

Below is a sample of questions audience members asked the physician panelists:

  • How long can the virus live outside the host? 
  • Who is most at risk for contracting Ebola?
  • Is there any chance the virus can become airborne? What does the term “airborne” mean?
  • How did the two nurses become infected, and what is being done now to prevent further infections in health care workers?
  • If you survive Ebola, can you relapse or get the disease again?
  • Where are we today on finding a cure or vaccine for Ebola?

You can get in-depth answers to each of these questions and the entire town hall event in the videos below, also found on the WFAA website.

Part 1:

Part 2:

Part 3:

For more information, TMA has created an Ebola virus resource center that organizes the numerous bulletins, guidelines, and other materials issued by the various county, state, and national health departments and agencies to help physicians and health care workers respond to the Ebola outbreak.

Wednesday, October 15, 2014

#FactsNotFear: Dallas Doctors Host Ebola Town Hall Meeting Tonight

This post has been updated with new information regarding tonight's physician panelists.

Dallas physicians answered the public’s questions about Ebola through a Twitter chat under the hashtag #AskDCMS on Tuesday. More than 2.5 million people tuned in to discuss and learn about the disease that has killed a Texas Health Presbyterian Hospital patient and infected two of the nurses who cared for him. Tonight, Dallas physicians again will answer your Ebola questions and separate fact from fiction.

The #FactsNotFear Town Hall Meeting will take place at Lakewood Theater, 1825 Abrams Pkwy., Dallas, at 6:30pm in the neighborhood where the second nurse diagnosed with Ebola lives. It is open to anyone.

The physician panel includes:

  • Todd Pollock, MD, plastic surgeon and Dallas County Medical Society President
  • John Carlo, MD, chief executive officer of AIDS Arms and former medical director of Dallas County Health and Human Services 
  • Robert Haley, MD, professor of Internal Medicine and director of the Division of Epidemiology at The University of Texas Southwestern Medical Center
  • Richard Besser, MD, ABC News chief health and medical editor

News 8’s John McCaa will moderate the event. Dallas County Judge Clay Jenkins, the leader of Dallas’ emergency response to Ebola, will be there as well.

Anyone unable to attend the event can watch it live on WFAA.com.

Tuesday, October 14, 2014

Choosing Wisely – Created By Physicians For Physicians

By Elizabeth Torres, MD
President, Harris County Medical Society

This article originally appeared on the President's Page of the Harris County Medical Society's Physician Newsletter.

As physicians we know that sometimes the most difficult part of our profession is managing patient expectations. Those expectations often come from advertising, newspaper articles or the television news, promising that new treatments and diagnostic tests are available. So patients, having diagnosed themselves with the help of friends or internet site questionnaires, come armed to their office visit with this new information to share and expect to receive certain tests, treatments and/or prescriptions. We often feel compelled to accommodate these requests, knowing that sometimes the testing or treatments are not necessary, could be harmful and costly, and certainly will not change the outcome of their care. We also know that we cannot diagnose all illnesses with certainty, which is what patients really want. Our listening skills and physical exam are our best diagnostic tools. Symptomatic treatment and watchful waiting is all that is needed in many cases. Indeed, we do see patients that require specific testing/treatments that they may not like, and we must justify the need for such testing as well. Additionally, discussion with our patients about the need for certain tests or treatments can be challenging for us and may be disappointing for our patients if we don’t take the time necessary for them. Patients may lack the knowledge and/or understanding to fully comprehend the situation, and it’s sometimes difficult to fully communicate the scientific background behind our reasoning. The Choosing Wisely® campaign is an initiative that was started by the American Board of Internal Medicine (ABIM) Foundation that aims to help physicians begin these conversations. It now includes more than 60 specialty organizations.

Our current health care delivery system does too little to coordinate care for patients with chronic conditions and the government and payers are requiring physicians to invest in expensive health information technology (HIT) without ensuring that the investment translates into better patient care. Additionally, the government imposed metrics to measure effectiveness and efficiency are often off-target. For physicians, the way to save money is not through rationing of care but to ensure the right professionals provide the right care, at the right time and place. Therefore, the responsibility to coordinate patient care falls to physicians.

Choosing Wisely is physician created, physician driven, and physician supported. The goal of the national campaign is to improve quality and reduce waste by having physicians and patients talk about medical tests and procedures that may be unnecessary and possibly harmful.

In 2010, Howard Brody, MD, University of Texas Medical Branch Institute for the Medical Humanities, published an article in the New England Journal of Medicine challenging the medical profession to lead the charge in defining quality care and reducing waste in the health care system. This article served as the catalyst for what is now the Choosing Wisely campaign. Recognizing that each physician specialty is unique in what it considers low value tests and procedures, the campaign challenges every specialty to develop its own list of five diagnostic tests that are overused and potentially harmful to their patients. We need to explain to patients that our differential diagnosis is based on their history and physical exam. We also need to explain why certain tests or treatments will be needed and discuss our plan of action. This removes the shroud of mystery or lack of understanding that patients feel when they leave the office and their family asks “What did the Doctor say?” The Choosing Wisely program also provides help by including handouts for patients on its website.

Participating medical specialty societies range from the American College of Physicians, the American Academy of Neurology to the American College of Surgeons. Each specialty creates its own top five tests or procedures. For example, the American College of Physicians recommends to not obtain imaging studies in patients with non-specific low back pain. Separately, the American College of Surgeons recommends avoiding routine use of whole-body diagnostic computed tomography (CT) scanning in patients with minor or single system trauma.

These lists provide support to physicians by allowing our patients to see that our recommendation came from a consensus of national expertise. However, each patient situation is unique, physicians and patients should use the recommendations as guidelines to determine an appropriate treatment plan together. Choosing Wisely should never be used to establish coverage decisions or exclusions nor interrupt the patient-physician relationship. This is a tool to help us talk with patients when it comes to choosing any test or treatment for them.

With the passage of Tort Reform in Texas, defensive medicine does not have to get in the way of talking to the insistent patient about not needing that antibiotic, CT scan, or other procedure. One of the most common discussions we have with patients concerns giving antibiotics. As we all know, antibiotic resistance is getting to crisis levels in the U.S. from overuse, fostering the emergence of drug-resistant germs. In September 2013, the Centers for Disease Control and Prevention issued the first solid numbers on the extent of the problem. It said that at least two million Americans fall ill from antibiotic-resistant infections each year, of whom at least 23,000 die from the infections. It is up to physicians to reduce the use of antibiotics, when there is evidence to show lack of effectiveness and real risk of harm.

In the current health care environment, every health care entity is looking at ways to increase efficiency and reduce cost. We physicians, by virtue of our daily practice and scientific literature, know which procedures and tests are valuable and which are not. To protect the safety of our patients, we must be stewards of quality initiatives and lead instead of follow.  Engaging patients in these types of discussions will improve communication and understanding with our patients and should lead to better outcomes and patient satisfaction as well.

If you would like to learn more about the Choosing Wisely campaign, go to the Texas Medical Association website at www.texmed.org/choosingwisely/ or take a continuing medical education (CME) webinars (free for a limited time) for 3.75 ethics credit by going to www.texmed.org/ChoosingWiselyCME.

Thursday, October 9, 2014

Mental Health Awareness Week This Week

Chances are high you know someone struggling with a mental illness. It may even be you. According to Mental Health America, approximately one in five U.S. adults has a mental health disorder, and half of us will develop at least one mental illness in our lifetime.

Mental health is as important as physical health to a person’s overall well-being. If left untreated, mental illnesses can affect physical health and can even be fatal. Suicide is the 10th leading cause of death in the United States, claiming more than 38,000 American lives each year, according to MentalHealth.gov.

If you believe you may be suffering from a mental illness, talk to your doctor. Mental Health America created online mental health screening tests you can take to learn if you show signs of mental illness, as well as resources for seeking help.

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