Thursday, November 30, 2017

World AIDS Day 2017 Is Tomorrow

By Alan Howell, MD, Temple Infectious Disease Specialist
Member, Texas Medical Association Committee on Infectious Diseases

The first World AIDS Day was marked on Dec. 1, 1988. The brainchild of two World Health Organization (WHO) public information officers, World AIDS Day serves to raise awareness of the AIDS pandemic. Dec. 1 also provides a day to mourn those whose lives were cut short by the disease.

During the past 29 years, significant strides have been made in respect to HIV/AIDS public education, diagnostics, treatment, and prevention. With the 2017 observance upon us, I thought this would be a great time to take stock of where we’ve been — and where we hope to go in respect to the pandemic.

HIV remains a significant global public health issue. To date, 35 million people worldwide have died as a result of the virus. In 2016 alone, 1 million people perished because of HIV. That’s approximately 2,700 people a day, or 114 per hour.

The WHO Africa region is the most affected region, where 25.6 million people live with HIV. This region also accounts for almost two-thirds of the global total of new HIV infections. Part of the problem is that far too many people are not aware of their HIV status.

Fewer than three out of four (70 percent) of people with HIV are estimated to know they are infected. The goal is for nine in 10 (90 percent) of people with HIV to be aware of their condition. To achieve this goal, an additional 7.5 million people need to have ready access to HIV testing. To this end, the Centers for Disease Control and Prevention (CDC) recommends HIV screening in the United States be performed routinely for patients aged 13-64 in all health care settings. Patients who continue to be at high risk for HIV need to undergo repeat screening at least annually.

Despite the grim statistics, antiretroviral therapy (ART) and education programs around the globe are working. Between 2000 and 2016, new HIV infections fell by 39 percent. HIV-related deaths fell by one-third, with 13.1 million lives saved because of ART. In 2016, 19.5 million people worldwide living with HIV were receiving ART.

On the topic of ART, many patients are surprised by the treatment’s convenience. For most people starting HIV treatment, one pill once a day will suffice. Occasionally, a physician or health care provider may determine two pills once a day or three pills once a day are necessary. Side effects are much improved compared to the medications used as recently as 10 years ago.

While there is no cure for HIV, treatment can successfully control the virus to the point it is no longer detectable in the bloodstream (viral suppression). This means people who take ART daily as prescribed, and achieve and maintain an undetectable viral load, have effectively no risk of sexually transmitting the virus to an HIV negative partner.

In addition to the aforementioned treatment as prevention, pre-exposure prophylaxis (PrEP) is another great option for preventing the spread of HIV. PrEP consists of a daily pill. When taken as directed, PrEP can reduce your risk of acquiring HIV through sex by more than 90 percent. Among patients who inject drugs, it reduces the risk by more than 70 percent. Additionally, is an online tool that can help individuals determine which plans offered in the Health Insurance Marketplace cover this prevention option.

World AIDS Day 2017 is a great time to celebrate the progress we’ve made curbing the pandemic. It also is a time to stop and reflect on the horrible human toll HIV has taken in the United States and around the world. To make this a truly successful World AIDS Day, consider these ways to show support:

  1. Wear red on Dec. 1;   
  2. Volunteer your time or make a monetary donation; 
  3. Take time to educate yourself and share your knowledge (hopefully this post helped in some small way, and I encourage you to share it); and 
  4. Get tested if you think you might be at risk.

Wednesday, November 15, 2017

Be Antibiotics Aware: Smart Use, Best Care

It’s Antibiotic Awareness Week — Nov. 13-19

Jane D. Siegel, MD
Pediatician/Pediatric Infectious Diseases Specialist
Chair, Texas Medical Association Committee on Infectious Diseases

Editor's Note: November 13-19 is Antibiotic Awareness Week. The following post offers recommendations to limit exposure to antibiotics to only those people who truly need them, in order to avoid development of bacterial infections for which there will be no effective therapy. 

No physician wants to see a patient with a serious infection for which we have no antibiotic to treat it effectively. That is why this week, the Centers for Disease Control and Prevention (CDC) is asking us — physicians and patients — to rededicate ourselves to improving the use of antibiotics. 

For physicians, this means limiting prescriptions for antibiotics to conditions likely to benefit patients, thereby reducing the risk of the emergence of antibiotic-resistant bacteria. If we overuse antibiotics, we run that risk, as treatments for infections from these bacteria stop working because the antibiotics no longer kill the bacteria.

The Texas Medical Association is collaborating with the Texas Department of State Health Services on activities to improve antimicrobial use. Antibiotic Awareness Week, which coincides with similar efforts in Europe, Australia, and Canada, and by the World Health Organization, reminds us to think about how we use antibiotics.
Here are two activities physicians can initiate or emphasize this week, incorporate into our practices, and explain to patients and their families:

1. Antibiotic time out: Right drug, right bug, right duration                                                          
This practice of fine-tuning of physicians’ decision-making involves a few straightforward steps to ensure we use antibiotics only when needed according to established recommendations. 

CDC has some excellent graphics and information for patients and their families so they understand how physicians make treatment decisions and why they might not prescribe an antibiotic in a given situation. This practice is applicable to long-term care facilities (LTCFs) and is a component of the antimicrobial stewardship program that the Centers for Medicare & Medicaid Services will require in all LTCFs in coming years. 

Patients: These are the rules your physician applies to prevent antibiotic overuse when they care for an ill patient:
  • Does this patient have a bacterial infection that requires antibiotics? If the physician believes a patient’s illness could be caused by a bacterial infection, he or she will run appropriate diagnostic tests and prescribe a drug that will be effective against the organisms likely to cause the infection.  The physician might write a prescription for three days with a refill to complete the medication course. If the physician and patient cannot determine whether the patient has a penicillin allergy, the physician may recommend testing the patient to know if drugs containing penicillin are safe to use. Alternatively, the physician may watch and wait without antibiotics and reevaluate later.                      
  • Reevaluate at 48-72 hours. The physician then assesses how the patient is feeling. If any diagnostic test results identify the cause of the infection, the physician may prescribe a more narrow-spectrum antibiotic (a drug that treats only a specific family of bacteria). This helps prevent antibiotic resistance by targeting only the specific bacterium in play and would be effective for the remainder of the patient’s treatment for this illness. If there is more evidence to support a viral infection, the physician will discontinue antibiotic treatment, as antibiotics do not treat viral infections.
  • The physician will determine the necessary duration of the antibiotic course, based on evidence-based clinical pathways, which are clinical guidelines physicians can follow to treat various clinical conditions. Such guidelines are developed by reviews of carefully conducted studies and are endorsed by professional societies. 
2. Buy meat and poultry products that come from animals NOT fed antibiotics as growth factors.   
      The practice of using antibiotics as growth-promoting elements is an important risk factor for antimicrobial resistance. Antibiotics used this way encourage emergence of resistant bacteria in the animals. These resistant bacteria reside on the surface of meat or poultry products and are passed on to humans inadvertently if not handled safely.
Farmers and veterinarians have been educated to stop this practice, and we are making progress in the United States. But there is more work to do. When you go to the supermarket, buy only meat or poultry that says specifically, “No antibiotics used.” Designations such as “organic” or “no growth hormone” do NOT mean the meat or poultry is free of antibiotics. If you do not see this type of packaging in your market, ask the store to start carrying products from antibiotic-free animals. The more demand for these products, the more supply we will find. Both patients and physicians can heed this advice. Visit the CDC website for more information on antibiotic-resistant solutions, food safety challenges, and a U.S. Food and Drug Administration question and answer page

Monday, November 13, 2017

How Overuse of Antibiotics Is Creating Drug-Resistant Bacteria

By John P. Fardal, DO
Austin Family Physician

Editor's Note: November 13-19 is Antibiotic Awareness Week. The following post explains the differences between bacterial infections and viral infections, and how antibiotics can be used to treat bacterial infections but not viral ones. It also explains how overusing antibiotics can be harmful to public health, and urges patients to think twice before automatically asking their physician for antibiotics when they are ill.

Some bacteria split every eight minutes. They can go from a single cell to more than a trillion in less than half a day.

One of the most important advances in health care was the discovery of the antibiotic penicillin. It gave people a very big stick with which to fight bacterial infections. Unfortunately, one of the biggest health threats facing the world is the rise of drug-resistant bacteria, and part of the reason for that rise is the overuse of antibiotics.

How bacteria work:

Bacteria are everywhere, and are mostly beneficial. They help digest food, provide essential vitamins, and compete with bad bacteria. The bad bacteria, however, can make people very sick. Luckily, bacteria are different enough from human cells that scientists have been able to discover or invent chemicals that target them. This is how antibiotics usually work, either disrupting bacterial cell structure or shutting down their molecular workshops.

How viruses work:

Viruses, however, are very different from bacteria. While bacteria stay outside of human cells, viruses invade them and hijack our molecular workshops. Viruses then use their own blueprints to make what they need. They make thousands of copies of themselves in each cell they invade, and then burst out of the cell to invade more cells and repeat the process. Because they hide inside our own cells and use our own workshops, it's hard to shut down their production without shutting down our own normal body processes.

It's not possible to shut down viral workshops, but it is possible to go after the viruses directly. This is where antivirals come into play. They are the viral version of antibiotics, but they are different in an important way ― they generally target one virus strain, while antibiotics usually affect many different bacteria.  There are a lot of viral strains out there. The common cold has more than 200 viral strains all by itself. Antivirals are only effective for a few select viral infections.

How your immune system works:

Our immune system is usually very good at fighting both bacteria and viruses. In rough terms, it first has to notice that something is in our body that doesn't belong there. Once the intruder is noticed, our workshops ramp up production of antibodies that target it so the rest of our immune system can kill it. This can take a few days and is when people usually feel worst.

The problem with antibiotic overuse:

When we use antibiotics, they effectively kill a very large portion of the bacteria, but some bacteria are able to survive through variations of their genetic code ― also known as just being lucky. Usually, our immune system kills off those last few lucky bacteria, but every now and then one slips out with a cough or sneeze, and is able to set up shop in another person. Now there is a strain of the bacteria that can't be killed with that antibiotic, and it can make a trillion copies of itself in half a day. It's ironic, but antibiotics use is the single most important factor in the development of antibiotic-resistant bacteria worldwide.

Drug-resistant bacteria are scary ― really scary. In the days before antibiotics, people died from bacterial infections at a rate we would have a hard time believing today. Last year, about 2 million people in the United States were hospitalized with a drug-resistant bacterial infection. There are a few very strong antibiotics that are kept in reserve just to be used for those resistant bacteria, but eventually, the bacteria will become resistant to them as well. Luckily, it is possible to slow the development of this particular catastrophe by only using antibiotics when fighting a bacterial infection. And that's where the virus comes back into the picture.

Antibiotics are for bacterial infections, not viral infections

Most people go to the doctor with upper respiratory symptoms and expect an antibiotic prescription. They believe antibiotics can make their illness go away much faster than just relying on their immune system to do the job. And they are right ― antibiotics can be very helpful when someone has a bacterial infection. However, when they have a viral infection, all the antibiotic will do is kill off good bacteria. This may give the patient diarrhea, and every now and then cause a resistant bacteria to emerge, all without making the patient's infection any better. Nevertheless, some health care providers prescribe antibiotics when it's much more likely that their patients have viral infections, such as the cold, because they want to both keep their patients happy and cover a possible bacterial infection in situations where the diagnosis is not clear cut.

This is where we can all help to save the world in a very literal sense. If your physician thinks you have a viral infection and does not recommend that you use an antibiotic, please consider giving it a few days, to see if your immune system ramps up and fights the virus off on its own. If it doesn't, odds are better that it's bacterial, and a physician will almost always be happy to prescribe antibiotics at that point.  Waiting just a few days can make a really big difference.

Tuesday, November 7, 2017

Doctors Warn of Hurricane Harvey’s Hidden Aftermath

There is a hidden danger beyond the piles of debris and damage left behind by Hurricane Harvey, and it might come as a surprise. Besides mold-related respiratory illnesses, disease from exposure to floodwaters and even mosquito-borne sickness like West Nile and Zika viruses, Texas physicians warn of another, unexpected post-hurricane health concern: Mental and emotional health. Texas physicians warn that stress and grief in the aftermath of the storm may have longer lasting effects on the mental health of some hurricane survivors than storm-related injuries and physical ailments.

After a natural disaster, grief over the loss of homes, jobs, schools, friends, and neighbors takes its toll on a large share of the population. A November Texas Medicine magazine article covering Harvey’s aftermath says some survivors will be diagnosed with varying degrees of post-traumatic stress syndrome (PTSD), experience higher levels of family stress, suffer injuries from domestic abuse, and even see flashback memories of past traumas.

“I think the increase in family stress surprises some people,” said John Mutter, PhD, professor at Columbia University’s Earth Institute, who studies the impact of natural disasters. “It shouldn’t surprise you, but it does. People who live in a [Federal Emergency Management Agency] trailer who used to live in a house get sick of each other quickly, and that leads to trouble. … Post-disaster health issues are as much mental health issues as they are physical health issues.”

Many survivors will endure the five stages of grief: denial, anger, bargaining, depression, and acceptance of loss. As many as one-fifth to one-third (20 percent to 30 percent) of people even go on to meet the full criteria for PTSD. Valerie Rosen, MD, an assistant professor of psychiatry at Dell Medical School at The University of Texas and an expert in PTSD, said most people will have some symptoms consistent with PTSD, but most of these will recover without medical help and not suffer full-blown post-traumatic stress. However, she recommends primary care physicians in Texas, especially those in the coastal areas, screen their patients for signs of emotional distress. “If someone has not recovered on their own, they probably do need to seek treatment to prevent it from being lifelong,” Dr. Rosen said in the Texas Medical Association (TMA) magazine. “But it is something that is very treatable.”

Natural disasters also can kick up memories of past traumas like childhood sexual abuse. A person might function well under normal circumstances but face difficulty after a major storm. Jeffrey Levin, MD, professor of occupational and environmental medicine at The University of Texas Health Northeast in Tyler, said survivors of past traumas deal with stress and loss in their own way. “We’ll be progressing through that, and everyone does that at a different rate,” said Dr. Levin, a former chair of TMA’s Council on Public Health. “There will be a sense of being physically and emotionally drained. People may experience difficulty making decisions, staying focused.”

Dr. Rosen says while there is reason for concern about the mental health of Texans in the aftermath of Hurricane Harvey, not all of the storm’s effects will be harmful or create more problems; some outcomes even could be beneficial.

“There’s also post-traumatic growth, or positive outcomes, where people can really prioritize their lives differently and get a different perspective on things,” she said. “They can also increase their faith in humanity with all the volunteers and increased social connectivity. I think sometimes people are surprised at their own ability to skillfully manage new challenges or adversity.”

TMA’s Disaster Relief Program Awards $83,000 More to Medical Practices Damaged by Hurricane Harvey

Even as physicians anticipate long-term effects of Hurricane Harvey, many of them along the coastal bend are struggling to reopen their own practices and serve their patients — so TMA is offering help. TMA Disaster Relief Program officials recently distributed $83,000 to nine practices damaged by Hurricane Harvey.

This second funds distribution amounts to $424,590 in total that TMA has sent to help physicians with Harvey-damaged or destroyed practices. The funds have assisted 37 medical practices throughout federally designated disaster areas, including Beaumont, Columbus, Houston, Orange, Aransas Pass, and Victoria. The practices employ 116 physicians and 967 nonphysician staff.

The TMA Disaster Relief Program has collected almost $1 million in donations to help physicians whose practices sustained physical Harvey-related damage not covered by insurance or other sources of assistance.

TMA’s Disaster Preparedness & Response Resource Center has guidance on how to donate and for physicians who need assistance for their practice.

Friday, November 3, 2017

Vaccinations Help Ensure Holiday Merriment

Neatly wrapped packages, pies fresh from the oven, and a peck on the cheek make holiday gatherings merry for the youngest to the oldest. Sadly, someone’s cough or sneeze could spread a life-threatening illness to grandma or your new grandbaby whose bodies are less able to fight off infection. That’s why Texas physicians say making sure your family is up to date on vaccinations, including flu, is key to keeping everyone healthy this holiday season.

“Making sure your vaccinations are current protects you and others you’ll be around — from your new niece or nephew to your grandparent in a nursing home,” said Arathi Shah, MD, a pediatrician based in Arlington and member of the Texas Medical Association’s (TMA’s) Be Wise — ImmunizeSM Physician Advisory Panel. “Diseases like flu and whooping cough can’t spread when many people in a community (and family) are vaccinated.”

Infants, pregnant women, and the elderly are among those most likely to get sick and develop a serious complication from a vaccine-preventable illness. Two vaccinations are key to protecting you and others this holiday season:

  • Influenza (or flu): Everyone six months of age and older, including pregnant women, needs a yearly shot.
  • Tdap (protects against tetanus/lockjaw, diphtheria, and pertussis/whooping cough): Pregnant women need this shot in the third trimester of every pregnancy to protect their infant. Other adults need this shot once, then a Td (tetanus/diphtheria) every 10 years. Children and teens receive this shot as part of routine childhood and adolescent vaccinations, so those who are up to date on their vaccinations should have received this.  

Flu season can last from October to May; in most years, it peaks in December through February. Flu can become serious for anyone. The youngest and the oldest are most at risk, as are people with chronic medical problems like asthma or any condition that weakens their body like cancer.

As many as 26,000 U.S. children younger than 5 years of age have landed in the hospital with pneumonia or other flu complications annually in recent years, according to the Centers for Disease Control and Prevention. Most flu-related hospitalizations (nearly 70 percent), as well as flu-related deaths, occur in people over age 65.

Babies can’t be vaccinated for flu until they are at least six months old. That means those around them must protect them from the flu. The flu shot mom gets during pregnancy protects her and baby until the infant can get vaccinated, said Dr. Shah.

Whooping cough, or pertussis, is especially dangerous for infants. The Texas Department of State Health Services says more than half of babies under 1 year of age who get pertussis must be hospitalized. Many will have serious complications, like pneumonia or difficulty breathing, which can be life-threatening.

Pregnant woman are urged to get a pertussis shot during pregnancy to protect their newborn. Family members who will be around an infant also should get vaccinated against pertussis. Infants often catch pertussis from other family members or caregivers who don’t know they have it because their symptoms can be mild.

“Vaccinations are one of the best ways to prevent illness,” said Dr. Shah. “Don’t miss out on a holiday celebration or keep someone else away by getting or passing along sickness that could have been avoided — or worse, unwittingly pass along a potentially deadly illness to a loved one.”

For flu and whooping cough shots, your body needs about two weeks to develop the strongest protection, so doctors urge people to get vaccinated now for protection through the holiday season.

And based on people’s age and health conditions, vaccinations are needed throughout life to protect them from other illnesses like measles, chickenpox, and bacterial pneumonia. Dr. Shah suggests everyone check with their doctor to make sure they have all the shots they need.

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