Hurricane Harvey: A “slow-motion rolling disaster” of disease has just begun

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“Infectious diseases could sweep across Texas as Harvey floods Houston … turning entire neighborhoods into contaminated and potentially toxic rivers … [and] the city into a sprawling, pathogen-infested swamp,” reports Newsweek.

Natural disasters turn real estate into virtual playgrounds for pathogens. Numerous factors combine: Advancing dirty floodwater – sewage, chemicals, tiny sharp objects of metal and glass – eventually becomes a stagnant, breeding ground for mold & bugs. A boil water advisory issued this week means tap water is contaminated – but many people won’t hear about it. Large swaths of power outages began last weekend and so air conditioning & refrigeration are gone and food will be lost. Stores are closed. Roads are underwater. Public transportation = a boat. People are unable to work and earn an income. Homes are destroyed. People are scared. All this and more at a time of sub-tropical August heat & humidity during – of all things – mosquito season.

And so the usual suspects will get to work: E. coli, Shigella, Vibrio illnesses (cholera-like illnesses), mosquito-borne pathogens like Zika and yellow fever, and even Legionnaire’s disease, inducing intestinal illness in the form of diarrhea, vomiting, fever, stomach pain and dehydration. Now imagine life in an overcrowded shelter if one of these illnesses took root. Or in your home where it’s sweltering and there’s no air conditioning and running water. Then multiply that over the whole neighborhood: that’s Newsweek’s concern of a city turned into a “pathogen-infested swamp.”

 

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There’s more. Science journalist @Maryn Mckenna who grew up in Houston and covered Katrina, wrote an eye-opening thread on Tuesday observing that: “Natural disasters have a long, long tail.… The result is a slow-motion rolling disaster in which people lose care and lose the proof they’re entitled to care, while they get sicker.” Lost is access to clinics, hospitals, pharmacies, medical records and doctor’s orders that people depend on to stay healthy – and stay alive. For instance, those requiring cancer chemo, or transplant care, or people with COPD or diabetes.

Mckenna gave special mention to dialysis patients:

Out of my experience covering Katrina and the aftermath, here’s what’s haunting me today: the average time between dialysis treatments … Houston’s floods began three days ago. That’s a normal time between treatments for someone on dialysis. Missing treatment = getting sick … In Katrina, bus convoys of dialysis patients drove out of the city to get to places where they could continue treatment uninterrupted … These were people who were not flooded out, who still had working cars (though sometimes no power, and the water in Nola wasn’t safe) …

 

She was backed up by a Houston physician speaking with NPR the following day: “If they don’t dialyze three times a week, they … can become very, very sick.” Muscles, including the heart, can stop functioning correctly. “Over so many days, they can’t survive.” Even if patients do make it to the clinic they may not be treated: “Many of our nurses are locked in, flooded out of their homes, and they’re either somewhere else, or they can’t get out of our neighborhoods…. As a consequence, we don’t have enough nurses to dialyze the numbers of patients that are coming here.”

Many others are at risk too: trapped seniors, disabled, and the bedridden; children separated from parents; mental health patients who run out of meds; stranded pets & other animals; and so on.

All told, this is “one of the largest disasters America has ever faced,” said Texas Gov. Greg Abbott, as he warned against expecting anything resembling recovery any time soon, or a return to the way things were. “We need to recognize it will be a new normal, a new and different normal for this entire region.”

The new normal is rapidly unfolding. Just this morning The New York Times reports a whole new kind of public health threat: a series of small explosions – “and a threat of additional explosion remains” – at a chemical plant in Crosby, Tex., about 30 miles northeast of Houston. More than a dozen Harris County deputies went to the hospital after inhaling fumes. Residents within a 1.5-mile radius have been evacuated.

Similarly, Democracy Now reports that “an environmental crisis is unfolding as oil and chemical industry spew toxic pollutants into air.” One specific case: “… gas leaks … in La Porte [30 mi. E. of downtown Houston; pop. 34,000] that resulted in a very, very dangerous chemical, anhydrous hydrogen chloride, and this gas mixed with the moisture in the air to produce hydrochloric acid, a corrosive that can damage respiratory organs, eyes, skin and intestines.”

Since Houston is home to the country’s largest refining and petrochemical complex this is an issue to watch.

As we move into the Labor Day weekend there is something we can do – help Harvey victims with a donation. ABC News is reporting that up to 40,000 homes have been destroyed and more than 32,000 people are in shelters. The Times has an excellent article on how to help, called “Where to Donate to Harvey Victims (and How to Avoid Scams),” available here.

 

Closing the Courthouse Door on Nursing Home Residents

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The Trump administration has drafted a binding arbitration rule that prevents nursing home residents from having their cases heard in a court of law. The Trump rule reverses Obama era policy forbidding nursing homes from doing this on the grounds that it preys on the elderly. His team was influenced by the death of 100-year-old Elizabeth Barrow.

In 2009, Mrs. Barrow (pictured above) was found murdered at her nursing home in South Dartmouth, Mass., strangled and suffocated, with a plastic shopping bag over her head. Her 97-year-old female roommate was charged with the homicide, but because of her dementia she was deemed unfit to stand trial and committed to a state hospital.

Her family didn’t have a problem with that: “It’s like charging a 2-year-old who happened to take a gun off a table and shoot a sibling,” her son told The New York Times. But he did want justice for his mother’s death because, among other things, he said the nursing home knew the roommate was dangerous. For example, file notes described her as being “at risk to harm herself or others.”

So he filed a civil suit on his mother’s behalf alleging wrongful death. But the court refused to hear the case because his mother’s contract with the nursing home contained a clause that forced any dispute into private arbitration; i.e., no judge or jury – the “judge” is some private entity, typically a law firm – and the proceedings are hidden from public scrutiny. So the case was referred to arbitration.

However, the notoriety of the case coupled with the industry wide practice of requiring vulnerable people to give up their right to sue if they want into a nursing home, resulted in the Obama administration enacting a rule forbidding the practice.

But that was then. This past June the Trump administration decided to make America arbitrate again on the basis that it’s simpler, fairer and faster for all parties concerned.

Fairer? The CDC says that about half of nursing home residents have Alzheimer’s disease or other dementia. Second, the arbitration agreement may be just one page in a voluminous contract of 30 to 40 pages. Thus, according to one federal court judge who blocked enforcement of an arbitration contract:

Most of the people who come to me have no idea they’ve even signed an arbitration agreement…. the practice of executing arbitration contracts during the nursing home admissions process raises valid concerns … since many residents and their relatives are ‘at wit’s end’ and prepared to sign anything to gain admission.

 

There’s an important infectious disease tie-in because nursing homes are a hotbed for infections, especially drug-resistant ones. For instance, according to James A. McKinnell, MD, an infectious disease specialist at the Harbor-UCLA Medical Center and the Los Angeles Biomedical Research Institute:

Current data suggests that here are nearly 3 million infections in nursing homes every year, resulting in 150,000 hospital admissions and 30,000 deaths.  As the US nursing home population is expected to increase from 3 to 5 million by 2030, we can expect to see a larger burden of these types of infection.

 

Mckinnell’s research also found that: (1) Almost half (47.5%) of the people in nursing homes are colonized with at least one drug-resistant bacterium (2) Nursing homes themselves are awash with superbugs: 88% of the rooms are contaminated with at least one, and (3) The big dog is Methicillin-resistant staphylococcus aureus (MRSA). They were found in almost 2/3 of the rooms (65.2%).

 

So what legal mechanism best protects our health: the age-old one of full access to a court of law, or the newer one of binding arbitration that’s forced on you – or you’re denied admission to the nursing home – at a vulnerable time in your life?

Elizabeth Barrow knows the answer. The arbitrator ruled against her and in favor of the nursing home. However, according to a report in the Times, only later did the Barrow attorneys learn something outrageous: the private firm running the hearing had previously handled more than 400 arbitrations – everyone of them for the very same law firm that represented the nursing home.

 

 

 

 

 

 

So wrong, for so long: No, you don’t have to finish that long course of antibiotics. Stop when you feel better and do so in consultation with your physician. Better yet, get yourself a short course of antibiotics instead.

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To borrow from the great Patsy Cline: “I’ve been so wrong, for so long … I was wrong, oh, so wrong,” could well be a new meme for docs across the country when it comes to their advice about taking antibiotics. We all know the rule: Always finish your course of antibiotics even if you’re feeling better because it’ll ensure that you kill all those bad bugs and, (not that you care) it helps prevent antibiotic resistance.

And that’s flat wrong. Compelling evidence from a group of scientists published July 26 in the prestigious BMJ says it’s not only wrong – the exact opposite is correct:

We … encourage policy makers, educators, and doctors to stop advocating ‘complete the course’ when communicating with the public. Further, they should publicly and actively state that this was not evidence-based and is incorrect …

The key argument for changing how we discuss antibiotic courses with patients is that shorter treatment is clearly better for individual patients. … In hospital acquired pneumonia, for example … data indicate that short treatment strategies have equivalent clinical outcomes to longer courses and are associated with lower rates of infection recurrence and antibiotic resistance. (My emphasis)

 

Good grief – so how did we get it so wrong for so long?

Enter Brad Spellberg, MD, an infectious disease specialist and chief medical officer of the mighty Los Angeles County + USC Medical Center, and who, as you might expect, comes with a sterling resume. But here’s the thing: When deciding how much weight to attach to the words of guys like Spellberg (this is, after all, a paradigm shifting issue) understand that his views are really the synthesis of the best and brightest, not just in his hospital or even across the country but across the world. If somebody’s doing interesting ID work in, say, Boston, New York, London, Paris, or Tokyo, he can call them and inquire – and they’ll take his call asap. And I suspect this has been the case much of his storied professional life – RHIP.

So, what does he say?

That we’ve made two mistakes. The first was to misinterpret a foundational study on the subject, which he said almost a year ago in this paper.:

The modern concept that we should continue treating bacterial infections past the time when signs and symptoms have resolved can be traced to 1945. Meads et al wrote that they administered penicillin to patients with pneumonia, ‘until there was definite clinical improvement and the temperature had remained below 100°F for 12 hours…then given for another two to three days.’ The perceived need to treat beyond resolution of symptoms was driven by a desire to prevent relapses. However, the recurrent infections seen in the case series were caused by isolates with distinct bacterial serotypes, indicative of reinfection rather than relapse. It is unclear how this confused desire to prevent reinfections subsequently transformed into the illogical dogma that antibiotic resistance could be prevented by continuing therapy beyond resolution of symptoms.

 

So how does this big misread turn into a come hell or high water ritualistic 7 or 14-day course of antibiotics? This second mistake turns on how our species tracks time. It’s both funny and sad and deserving of Spellberg’s mockery:

The truth is, we do not know how long a course of antibiotics is necessary to treat most types of infections. Even in the modern scientific era, the primary basis for the duration of most courses of antibiotics is a decree Constantine the Great issued in A.D. 321 that the week would consist of seven days. That’s why your doctor gives you seven or 14 days’ worth of antibiotics!

If good old Constantine had decreed four days in a week, doctors would be prescribing antibiotics in four- or eight-day courses, rather than seven- or 14-day courses. I refer to seven- or 14-day antibiotic courses as “1 or 2 Constantine units” to underscore the absurdity of the basis for these durations.

 

That’s from his piece this week in the online journal The Conversation. And of the 3 articles mentioned above, this one is easily the most readable. The best part is that he concludes with spot-on practical advice on how we should handle this “to stay the course or not” issue, reprinted below. But before we get there we need to consider this looming storm cloud called antibiotic resistance, which the BMJ paper spent most of its time on. Yes, we’d all rather go clean our oven than get into this, but it’s a Huge Deal, so we’ll try an analogy (and no fancy words).

Imagine – for everyone who lives on your block there’s just one car that has to last for the foreseeable future. It’s a community car so its use is based on need – emergencies first, work or university second, food shopping third and so on. It’s a precious resource because we know that one day it will run down and no longer work. So we have to take good care of it: use only when necessary, keep a record of its use, keep it fueled & maintained, and don’t abuse it – no drag racing. Because one day you might to need to rush your bleeding child to the local hospital a mile away. Should that day ever come you don’t want to jump in turn the key and … uh-oh … it won’t start. It’s out of gas. Now what?

Antibiotics are the only kind of drug on the planet that are a community drug, just like that car is a community car: The more we use them the less effective they become. And that’s because with bugs, the more they’re exposed to the drugs, the more they develop tricks, or “body armor,” to defeat them. Bugs are funny that way, like us they too resist efforts to be killed – except they’re better at it. For example, a blueprint for a new anti-antibiotic weapon that one bug develops can be shared with his buddies and suddenly they’re all invincible. A cartoon nicely captures this unique biological ability (if you’re curious, see here).

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But this really isn’t funny. Antibiotics are woven into the fabric of the everyday practice of medicine, here and across the world. Just a glimpse: Cancer patients live on antibiotics because radiation and chemo destroys their immune cells along with their cancer cells. For every serious surgery, say an organ transplant or a hip replacement, antibiotics are used to prevent or treat an infection. Neonates & children, and the elderly, are especially at risk for infection because the immune system isn’t fully formed in the young and isn’t as strong as we want it to be in the old.

But a numbers analysis doesn’t capture the heartbeat of the issue. Ultimately it’s a personal, intense reckoning. You’ll notice the shadow over your doctor’s face as he walks to your hospital bed. You tense up. I’m sorry, he says … the antibiotics aren’t working. You put on a brave face: We out of gas, doc?

Spellberg and company are doing their best to avoid that reckoning. But they need help. We the People, have to be antibiotic-smart: Use them only when necessary and even then, a shorter course is better. Here’s his game plan, titled: “So, what should we do about antibiotic courses”?

Medicine in the 21st century is a team sport. You and your physician need to be partners in decision-making. If you are sick and your doctor mentions antibiotics to you, the first thing you should say is, “Hey, doc, do I really need the antibiotic?”

Doctors may otherwise prescribe an antibiotic even when you don’t need one, out of fear that you will be unhappy without the prescription. Flip the script on them. Help them to know that you’d prefer not to take the antibiotic unless it is really necessary.

If your doctor says, “Yes, I believe you have a bacterial infection and you need the antibiotic,” the next question is, “Okay, can we treat for a short course?”

Third, after you begin taking the antibiotics, if you feel much better before you complete the course, give your doctor a call and ask if you can safely stop therapy.

So, the bottom line is, doctors should prescribe as short a course of antibiotics as possible to treat your bacterial infection. If you feel completely well before you finish that course, you should be encouraged to call your physician to discuss if it is safe to stop early.

 

Which means doctors have to be willing to have that conversation. And as Spellberg said to the journal STAT: “You should call your doc and say ‘Hey, can I stop?’ … If your doctor won’t get on the phone with you for 20 seconds, you need to find another doctor.”

Because that, too, would be wrong – oh, so wrong.

 

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