Author Archives: Eric Garcia

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Zika virus walk-in testing available

Call us at 713-550-2000 for details, including whether your healthcare insurance will cover Zika virus walk-in testing.

See our detailed information here on the latest CDC recommendations for Zika virus testing, especially for those traveling through or living in at-risk areas for Zika virus infection (such as Texas) and who are of child-bearing/conceiving age.

Fill out this Zika Disease NP Intake Form ZD2 2017 prior to your appointment and fax it to:

713-973-0805

Edward Rensimer, MD, FACP

Mosquito Repellents

Zika Readiness: DEET & Permethrin

Other than killing mosquitoes per se, the standard of care for preventing mosquito bites, the main risk for transmission of Zika virus, is topical skin application of DEET repellent and treating clothing with permethrin to make them a fatal chemical barrier to insects. This is the best possible protection against infected mosquitoes.

For more detailed information check out “Mosquito Measures”.

Zika Commentary

APRIL 5, 2016

General Perspective

Zika Virus (ZV) disease manifests as actual illness in only about 20% of those infected. That fact alone makes it a difficult situation, since there’s no knowing if you’ve acquired the virus in an exposed area. Only blood tests can determine that. The good news is that if you get ZV, you will at most have a illness for 2-7 days. The bad news is that if you are sexually active and of childbearing age, such exposure may pose a risk to your developing child for a yet unknown time, though at least as long as 10 weeks per a recent case.

ZV is thought to have emerged in Uganda, Africa around 1920 and made its outbreak debut in 1947. Populations in Africa and Asia have shown evidence of widespread infection by blood tests.

During 2014-2015, joined to international attendees of the FIFA Soccer World Cup Games, ZV exploded throughout Brazil, and then Colombia. It now occupies much of South and Central America and the Caribbean, soon to arrive in the Southern United States.

Why? Because there are no ecological or epidemiological barriers. The former refers to the Aedes aegypti mosquito vector that carries ZV which resides throughout the Americas and Carribean, and up into lower California, Arizona, New Mexico, South Texas, and Florida. “No epidemiological barriers” means that for our population (and our southern neighbors), there is no pre-existing immunity… it is a “novel virus”. Our part of the human herd has not experienced ZV, the key circumstance for rampant spread in the next few years. With the large influx of illegals across the southern border, ZV will be imported by people who have not even been clinically ill. Once our mosquitoes feed on them, person-to-person spread will be established and our resident mosquito population permanently an infected reseviour. This phenomenon of a massive virus disease outbreak was most recently seen a couple years ago with the African, multi-national Ebola pandemic, largely attributed to social unrest and civil war, and so disruption of sovereignty of bordering countries by uncontrolled immigration and emigration of their populations.

So far, U.S. cases have all been imported by travelers to Zika disease (ZD) areas. But, as we now enter mosquito season in the South, look to explosion in incidence across the country. It is unclear how restricted to the South all this will be. The Asian tiger mosquito, Aedes albopictus, ranges from the U.S. South to as far north as New York State, and it has been shown to be a vehicle for ZV.

We have seen “novel” viruses before. The Spanish Flu of 1918 caused a worldwide flu pandemic accounting for 50-100 million deaths (5% of the world’s population then) over a few years. It was a mutated virus which human immune systems had not “seen” before. Fortunately, ZV does not have that virus’s destructive potential. However, the “novelty” of this virus will be the tale of the next few summers as mosquitoes emerge, and it will be felt most by the developing unborn.

Zika Tolerance

This may be the most important part of the commentary and I have not seen the current Zika knowledge base developed into these ideas anywhere.

Zika virus infection is not experienced as a clinical illness (symptoms or physical signs) in about 80% of those infected. Last week a woman infected in Guatemala was found to have the ZV in her bloodstream 10-weeks after she first acquired it. She was pregnant and it is unclear whether the ZV just remained in her bloodstream the entire time, or whether it was cleared by her immune system and then entered a secondary phase of bloodstream infection by way of her infected fetus’ placenta infection. Either way, ZV sustained for a very long time in the bloodstream without observable illness– similar to HIV, hepatitis C virus, and hepatitis B virus (after the initial, acute infection). This suggests “tolerance” biologically between humans and this virus. The ZV can apparently fly below the radar screen of the immune system in some individuals. It is unknown how frequently this is the case since the natural history of ZV infection is still being worked out.

What this all means is that ZV should spread immediately as a “novel” virus (to most of our immune systems, as we’ve never before encountered it in the U.S.) through our human and mosquito population in the southern-most U.S. over the next few years. Once the population has been largely immunized by passage of the ZV through “the human herd”, the incidence of ZV infection and resulting complications to both adults and unborn children will decline substantially. The incidence of these problems will then vary according to the density or scarcity of total mosquito populations. For instance, if we entered a period of several years of relative drought, causing decline in mosquito numbers, then the percentage of humans growing up never having been infected would increase. Once drought conditions reversed, mosquito numbers would increase and there would be a substantial fraction of the general population that would be at risk– and so, there would be another outbreak of ZD. This is how contagious illnesses cycle according to ecological factors, disease vectors, and community-wide immunity (or declining immunity) to the infectious agent (ZV, in this case). Understanding these associations and the biology in this model of infection will be the best predictor of future events in the U.S.

What’s Next

  1. This summer, we will see ZD explode across our South. Next summer, possibly there will be spread northward.
  2. Public officials will emphasize mosquito control efforts, both by local government and individual homesteaders (see our other piece on this on the website).
  3. Very likely, there will be increasing numbers of microcephalic/neurologically damaged babies, especially among the poor with little access to reliable information and healthcare (lower socio economic groups have much more mosquito exposure).
  4. ZV will become permanently endemic in the U.S.
  5. Guillain-Barré (polyneuritis) syndrome will increase in association with ZD, though it will not be a prevalent issue, any more than it is in association with other preceding viral diseases, like influenza.
  6. Vaccine development will start in earnest. Why? Because there will be a huge market for it– young U.S. couples who want to have children will demand and pay for it. Third World diseases do not get capital directed at them until the West sees it as an existential threat to itself. Ebola vaccine development became a priority when exportation to the West was a reality.
  7. ZV science will evolve- its biology and the medically relevant issues. For instance, now it is known the ZV can be sexually transmitted. However, it is not known how long after the initial infection the ZV remains viable in semen and remains transmissible that way. ZV has also been found in urine and saliva, but it is unclear whether it can be transmitted that way. Chemical issues regarding saliva and urine may alter the virus so it cannot  then effectively invade. Information on Ebola virus is still emerging from the last pandemic. Nine months after infection, the New York physician who was repatriated with Ebola disease was found to have viable Ebola virus in his eye fluids. So, ZV/ZD will be a work in progress for some time as our scientific community turns on it; revised ZD guidelines will continue to be announced over the next couple years (stay tuned as we post them).
  8. Be always aware that public officials may downplay the facts (knowledge is the antidote for panic), because part of their job is to maintain order. See my writing on the 1918 Spanish Flu Pandemic and how the highest level San Francisco government officials gave the public misinformation to maintain order- costing thousands of lives of an overly-pacified general population. This is not that situation, but you get the idea. (CDC officials similarly “laundered” their statements during the Ebola outbreak).

What Can you Do?

1.Stay on top of this, especially if you are sexually active and of childbearing age.

2.Until ZD becomes endemic in the U.S. (probably this summer), be attuned to your exposure risk in any country where it is endemic.

  • Women to consider pregnancy test before and after such travel.
  • Mosquito repellents on skin and clothing during and for 2 weeks after such travel (to prevent our local mosquitoes from picking it up from you if you are not ill but have the virus in your blood the last day of your trip and for an as yet undefined time after).
  • Attention to mosquito bite prevention while traveling: air conditioning, airtight windows/screens, etc.
  • Birth control and safe-sex methods the week before, during, and after travel in ZD areas.
  • Refrain from birth conception for 6 months after ZD zone travel.
  • If sexually intimate with someone in the past 6 months who had been in a ZD zone, get tested for ZV by an expert.

3. If actively attempting pregnancy during “mosquito season”,

  • Keep clothing treated with permethrin.
  • Maintain DEET-containing repellents applied to exposed skin.
  • Once pregnant, both parents should be tested for ZV; if positive, consult with an expert on proper monitoring of the fetus’s development.

4. Stringently attend to mosquito control around property and neighborhood (see elsewhere on our website: “Mosquito Control”).

Periodically, we will update this information

 

Ed Rensimer, MD

Zika Mosquito 64020541_Medium 1300 x 757

Zika Virus Disease (ZD)

DISEASE: A viral infection,

  1. 1 in 5 infected w/ virus become ill.
  2. Symptoms: fever, rash, joint pain, conjunctivitis (red eyes); muscle aches, headache.
  3. Incubation time from exposure to symptoms unknown: likely a few days to a week.
  4. Illness usually mild: several days to a week
  5. Virus remains in blood for a week while person is ill.
  6. Hospitalization uncommon and death rare.

 

TRANSMISSION

  1. Some mosquitoes (daytime feeders) that cause dengue and chikungunya: illness similar.

 

COUNTRIES WITH ACTIVE ZD,

  1. Samoa, Cape Verde, Africa; SE Asia
  2. Barbados, Bolivia, Brazil, Colombia, Dominican Republic, Ecuador, El Salvador, French Guiana, Guadeloupe, Guatemala, Guyana, Haiti, Honduras, Martinique, Mexico, Panama, Paraguay, Puerto Rico, Saint Martin, Suriname, U.S. Virgin Islands, Venezuela (check the cdc.gov website for updated information on ZD activity areas)

 

DIAGNOSIS

  1. Antibody testing (see item 5 under Pregnancy)
  2. RT-PCR test for viral genetic material (done at CDC)

 

TREATMENT

  1. Rest, fluids
  2. Tylenol for discomfort, fever; NO aspirin or other ant-inflammatories until rule out dengue or bleeding tendencies.

 

PREVENTION (no vaccine)

  1. Wear long-sleeved shirts, pants
  2. Use air conditioning, window/ door screens, mosquito bed nets
  3. Empty standing water containers
  4. Repellants*: DEET, picardin, IR3535, para-methane-diol products, or oil of lemon eucalyptus

*If pregnant or breastfeeding, use an EPA-registered agent.

 

ZD AND PREGNANCY: ZD infected pregnant women may birth newborns with microcephaly (disproportionately small heads) or have other adverse outcomes of their pregnancies.

  1. In any trimester of pregnancy, postpone travel to ZD areas.
  2. Sexually active women of childbearing age who are heading to ZD areas should,
  • Get a pregnancy test prior.
  • Practice birth control during and for a week after travel exposure (and have a pregnancy test upon return if usual menses are missed).
  • Strictly prevent mosquito bites.
  • Consult with your gynecologist or an Infectious Diseases specialist.

3. Once the ZD virus is cleared from the blood, a fetus will not be infected.

4.  ZD testing should only be done in pregnant women WHO HAVE HAD ILLNESS consistent with ZD, because there may be false-positive antibody tests (cross- reactions with dengue, West Nile, and yellow fever viruses or yellow fever and Japanese encephalitis vaccines).

EBOLA: Are We Ready, (Part II)?: Clearly Not

U.S. Healthcare System Crisis Readiness

In my earlier pieces, I speculated on the complexity of a lethal, communicable disease entering a U.S. healthcare system that likes to promote itself as excellent, and so fire-walled against any real danger of Ebola Virus (EV) spreading out into our communities should a case arrive on our shores. However, that excellence is only in comparison to much of the non-developed world medical systems and in reality probably only exists with uniformity in the best urban, academic medical centers. Anyone who has practiced at a subspecialty level on medically critical cases in the broader healthcare system where most of us end up when we’re in need knows that the intellectual and operational processing of a difficult, complex case is often mediocre or unacceptable at many levels – lab, nursing, and, yes, physician expertise and capability. Anyone who has been a patient or had a loved one with a problem outside the norm has seen this. It is a complex question why this is so, given what is charged for the service. But, our payor system obstructs, harasses, and pressures under-utilization of testing (which is sometimes a product of efficiency, but more often the result of shallow thinking, lack of professional focus, intellectual apathy, and/or poor training). Add in dispirited performance from increasingly employed and controlled healthcare workers in a system that rewards “team players”, deliberately undermining individualists and non-conformists, and you get a broken mediocracy, most evident when the stakes are highest. This is the corporatized medicine model (as hospitals unite into “systems” of care). I am tempted to say, “you get what you pay for.” But, you don’t. You pay a lot for uninspired, worrisome performance. Hold onto all this and we’ll come back to it as the context which surrounds the Ebola virus disease (EVD) cases that are now headline news. I want to now fill in that picture.

 

The Emory University Ebola #1 Case Experience

This past week I attended the Infectious Diseases Society of America (IDSA) annual “IDWeek” in Philadelphia, PA. One of the presentations was by Dr. Bruce Ribner, the team leader at Emory University on the first U.S. Ebola virus disease case that our government imprudently brought to our homeland from West Africa. His observations are shocking if you take them as a whole and consider the implications, in contrast to statements U.S. government officials have been floating to the American people on Ebola virus. By the way, virtually everything I recommended in my warning letter regarding Ebola virus disease preparedness to our local hospital system in Houston in August turned out to be so by Emory’s experience with an actual case. Realizing that Emory is the hospital in Atlanta intimately tied to the Centers for Disease Control (CDC), also in Atlanta, and among perhaps 4 U.S. hospitals capable of highest level infectious agent containment, let’s look at their experience with their Ebola virus disease case,

  1. Dr. Ribner stated that in Africa clinical evaluations of patients (meaning by those educationally and intellectually capable to do so for Ebola virus disease) were limited and there was virtually no lab-support (testing). The take home? We have no real idea how bad the Ebola virus outbreak is in scope or rate of growth. We know it is unprecedented. We know it is a tsunami compared to the beach wave prior Ebola virus outbreaks. We know it is continuing to build and will go on for months. Cases will be showing up across the world unless we strictly quarantine those countries.
  2. Clinical Care: The patient required around-the-clock nursing attention at the bedside. There were huge physiological problems with massive bodily fluid losses and shifts between tissue compartments, resulting in rapidly dangerous electrolyte disturbances, heart arrhythmias, and circulatory malfunction. The clinical staff had to be nimble, entirely attentive, and expert to deal with these fast-breaking problems. The Ebola virus caused the circulatory tree to be a hole-ridden, leaky sieve. Without the highest level ICU care, survival would be highly unlikely.
  3. Lab: If just one specimen from an Ebola virus disease case spilled in the lab (not unusual), the entire lab would be closed down for hours until the environment could be certified as clean. What about all the other hospital patients’ labs? They would not be done. Their care would be compromised. The possibility of collateral damage or secondary deaths of other patients was virtually certain.

Furthermore, the Emory team dealt with the real concern that on-site lab technicians, at the premier hospital for communicable disease cases, would refuse to run tests on Ebola virus disease patients (not wanting to handle their specimens).

The team’s answer? They set-up lab testing at the point-of-care (adjoining the patient’s room), away from the hospital lab.  Think about this. One of the hospitals in the country designated for such care and you have support staff refusing to do their jobs on an Ebola virus disease case that requires almost continuous lab samples. Because of this, the team kept lab testing to a minimum, per Dr. Ribner. Did this compromise care? Maybe.

  1. Specimen Handling: Ebola virus is a Category A infectious agent – the highest CDC level precautions in handling and isolation. Category A’s require special packaging and shipping for clinical specimens. Despite such packaging, commercial carriers refused to accept Emory’s Ebola virus disease specimens for shipping.
  2. Regulatory Expertise: The hospital safety officer needed to navigate numerous federal, state, and local regulatory requirements. Expertise was needed to not break laws and to protect public safety. Do you think this would be possible at your local community hospital? Or even at your local academic hospital not accustomed to Category A agents?
  3. Waste Management: CDC guidelines say that sanitary sewers are acceptable for patient waste, but Atlanta’s local water authority disagreed. It did not trust the CDC or Emory U (they’re not alone).

Emory had to disinfect all patient liquid waste with bleach or quaternary detergents for
5 minutes before flushing into the general water waste system.

Furthermore, the hospital waste disposal contractor would only pick up materials certified as EV-free. So, the hospital had to dedicate an autoclave sterilizing unit (and physically move it) to process everything used in the Ebola virus disease case in order for its acceptance as regulated, safe medical waste. By the end of the Ebola virus disease case’s hospital stay the autoclaved and boxed materials “filled several trailers”.

 

DISCUSSION

The Unexpected and Our Medical System

So, a highest-level U.S. expert hospital with all academic staff virtually joined at the shoulder to our federal center for infectious diseases capabilities had these problems. Do you recall Thomas Frieden, MD, head of CDC and Anthony Fauci, MD, National Institutes of Health (NIH) Chief, assuring us that we have Ebola virus disease covered in the U.S.? Do you think so when you hear of the operational breakdowns at the starship hospital? Support services were running for the hills. How would that translate in the type hospitals accessible to most of our citizens?

Well, we have a healthcare worker Ebola virus disease case who “violated” isolation protocol… they think. But, do they know? No one has said what that break was. Otherwise, is it still possible, as I have discussed before, that the Ebola virus is more easily transmissible than they have been letting on? Of course, these government- paid officials are still digging in on their premises. However, Dr. Ribner even detailed how crude is the information on the African outbreak – all we know is that at least 4,000 have died (possibly many more), and counting.

And at this IDSA meeting a CDC epidemiologist even admitted that the premise that Ebola virus is only transmissible after the patient develops symptoms is based on “observational” epidemiological data. In other words, experience in prior epidemics shows that people who get Ebola virus disease had been around symptomatic (sick) Ebola virus disease people. And people who were in contact Ebola virus disease patients only prior to onset of illness did not tend to become ill. But, it is not a solid, scientifically proven fact that Ebola virus disease cases might not be shedding virus hours or a few days before they have symptoms. Remember, we are talking about a fact-basis for these Ebola virus disease premises developed in Third World countries with only relatively limited, short outbreaks before. Yet, the “21-day incubation period” and “no-risk prior to illness onset” are being proclaimed bedrock fact as though from biblical tracts.

 

Ebola And The New U.S. Healthcare System

Now that we have our own, homegrown Ebola virus disease case contracted here, the reassurances about our healthcare system’s tacit superiority are a bit hollow. I think this will only get worse. Go back to my opening paragraphs about the actual day-to-day performance of the healthcare system at the community level and you know we will have more such cases, and the breakdowns and accidents are inevitable. When I penned my letter to our Houston-based hospital system leadership in August, 2014 warning then of all that has since happened and the need for a tight operational plan, the leadership had not even thought about all this. Ebola virus disease was somewhere across the globe and irrelevant. I do credit them with taking action immediately. But, do you think this is so in most communities?

 

ObamaCare and Ebola

Think about all the problems at Emory, and then multiply them exponentially when you realize that hospitals are more focused on their business model than anything else. You can see it in everything they do. If Medicare told them to paint themselves red and to blow out all the windows, they would do it. That’s why they’ve all gone over to electronic health records (EHRs), one of the problems (aside from mindless nursing and poor physician performance) that sent the first Dallas Ebola virus disease case back to his apartment complex where he could expose many people, including the ambulance crew and other professionals. EHRs have been required by payors so they can tabulate data and control the profession. They are an immature technology tool, not ready for prime-time. They have fragmented communications between doctors and nurses and have created a cumbersome, error-prone interface with the hospital support services (lab, pharmacy, etc.). Yet, hospital physician staff and nurses are mandated to use the EHR by the hospital, no matter the time-waste, interface generated mistakes, and adverse work cultural changes imposed by machines that distance physicians and nurses from the bedside. Been to a hospital lately? See how many of the nurses are staring at video screens instead of answering patient calls or talking with them or their families. I don’t want this to sound like a rant (probably failed already), but when you try to understand the missteps in that first Dallas Ebola virus disease case, you can see what changes in healthcare culture imposed by the Affordable Care Act as well as by the corporate-federal medical complex have brought about.

You can appreciate the tenuousness of the local healthcare system in dealing with life-critical problems like Ebola virus disease that require oversight by proactive (not reactive) medical experts and individualists who are not controlled by corporate bosses, other employers, and payors who have steadily eroded the medical profession and are increasingly controlling it. The public interest needs financially and professionally autonomous physicians – unencumbered by ties to the hospital business, payors, or other third parties whose interests often are truly at odds with those of patients and the profession. You must conclude we are headed for trouble, with all due respect to Drs’ Fauci and Frieden.

 

Inescapable Conclusions

With the comments about Emory’s experience, could a local hospital handle three Ebola virus disease cases? Two? One? What ambulance crew would want to go there with someone evolving a stroke or heart attack? What patient there would want their blood drawn knowing the technician may have been near an Ebola virus patient? Who would want elective surgery there? Once there is a reasonable doubt that risk of acquiring a lethal pathogen cannot be assured, the entire care model breaks down and the hospital is a modern leper colony. And yet, hospitals are a vital community institution whose accessibility to handle your acute medical problem is a personal and public interest necessity.

When you take all this in you must conclude that countries with endemic Ebola virus activity must be completely quarantined until this outbreak is over. Not controlled.

By the way, to end with irony, apparently the healthcare workers in some of the West African Ebola virus countries are demanding “risk” pay, or they may walk. These are countries with terrible economies on their best days, abject poverty, social disorder, and healthcare systems that are pathetic. Who do you think they are looking to for bonus pay for their own, homegrown epidemic? I think we all know that answer. Be clear. They are not satisfied with just help. They want a personal bonus to take care of their own, while we send our own in harm’s way to help them. The world has gone insane.

Everything written in these articles are my personal opinions based on available information, training, and experience.

 

Edward R. Rensimer, MD

Director, International Medicine Center