AHA FIT – Page 3 – The Early Career Voice

Thoughts from a Physician Scientist Trainee During the COVID-19/SARS-CoV-2 Pandemic

April 10, 2020April 10, 2020 Sasha Prisco, MD, PhD

I had a very difficult time figuring out a blog topic for this month. It has been difficult to think about topics other than COVID-19. Like a lot of you, my usual routine has dramatically changed over the last couple of weeks. Additionally, I find myself having a difficult time concentrating with emotions sometimes fluctuating from fear, anger, grief, and frustration, to hope and pride. Some of my recent days have been occupied by reading a plethora of articles, blogs, or social media posts about COVID-19, being anxious about the next time my husband or I see patients, urging people to practice social distancing and to donate PPE, and contacting family and friends to check on their physical and emotional well-being along with trying to complete some work.

I am currently a Cardiology postdoctoral fellow who has protected time to complete basic science research. I started my postdoctoral research fellowship this academic year and my hope was to immerse myself in basic science research over the next couple of years. I was hoping to have a productive lab experience and find an area that I could ultimately build my future research career. These few years of protected research time are critical to my development as a physician-scientist. From a research perspective, I have recently experienced a multitude of failures and disappointments this year (with some intermittent successes): failed experiments that have required an extensive amount of troubleshooting, rejected papers, triaged grant applications, etc. I know that I am not alone in experiencing the frequent failures that one encounters in research. My usual strategy is to be persistent, keep busy, and continue to move all research projects forward in the hopes that at least one of the projects will be fruitful which is currently difficult to do. A few weeks ago, we were informed that all non-essential experiments should stop and that no new experiments should be started. Fortunately, my lab mentor respected this request and prioritized our health and safety. However, as we reduced our wet lab work to only essential animal experiments that were already started, I could not help but feel grief for the loss of potential research milestones.

The COVID-19 pandemic has further emphasized the societal importance of investing in research endeavors and researchers longtime. There are many articles and commentaries on early career investigators being disheartened by the challenges of an academic research career along with the diminishing pool of physician scientists. The presence of the COVID-19 pandemic has further highlighted the below changes that should be made:

Increased funding for research: The study of mechanisms of disease along with development of therapies requires extensive time and effort. Multiple valiant researchers are currently studying COVID-19/SARS-CoV-2 with the fundamental goal of saving lives. Continuous societal investment in research will hopefully lead to the prevention of pandemics and earlier development of therapies for various diseases in the future.
Increased financial and other support for trainees and early career investigators: Supporting early career investigators through training/career development grants, travel awards, local/national/international workshops, and opportunities to present work at national/international meetings will decrease attrition from academic research careers.
Consideration of changes to the peer review process: The COVID-19 pandemic has emphasized the importance of rapid dissemination of information. While the peer review process is important in trying to only publish scientifically valid results, the process is imperfect. Frequently, the peer review process is inefficient (which is difficult since reviewers and editors are busy). Often there are many additional experiments that are requested for. During a time where completing additional experiments is difficult, I think reviewers should consider whether the request to complete additional experiments is necessary and would change the conclusion or validity of the study. In order to more quickly disseminate findings, many investigators are now putting their publications in preprint servers. However, some investigators have reservations about putting unpublished material on preprint servers while their papers are simultaneously undergoing the peer review process.
Improve the efficiency of translating basic science research to the bedside: There are several bureaucratic and administrative barriers that impede translating basic science findings to the bedside. Processes that balance patient safety and improve efficiency are needed.

We will continue to learn a lot about how about to improve science and medicine during this time. Stay safe and be kind!

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

The World versus COVID-19

April 9, 2020April 9, 2020 Michel Ibrahim, MD

To whom it may concern,

We are 4 months into 2020. #24 passed away. May he rest in Peace. #19 is trending upwards. Mamba mentality is much needed in our lives in ‘’the time of the corona”. On March 11th 2020, the World Health Organization (WHO) declared the coronavirus disease of 2019 (COVID-19) a pandemic. Today is April 7^th 2020, around 1.4 million COVID-19 cases have been confirmed with almost 74 thousand deaths and counting worldwide. The health care system is bending to the point of collapse. Physicians, nurses and everyone involved are in this fight. Mamba Mentality it will be.

COVID-19 has not only impacted our individual lifestyle and health but has also harmed our global economy to the brink of destruction. Politics can’t fix this is now. Have we failed the health care system or has the health care system failed us? Public health crisis you say? Social distancing is proposed, knowing in some parts of the world it’s a privilege that cannot be afforded. COVID-19 is without discrimination, a pandemic that does not only involve me as individual, my home and my country but the world that has become a small place with globalization. It is about time to end disparities of care which have always been and will always be a matter of social justice. Justice hasn’t been just. We have failed years before COVID-19. Failure sometimes is what it is needed for success. #23 GOAT said, “I have failed over and over again in my life and that is why I succeed’’. We will rise. We must rise. We owe this to our planet.

Today, I am writing this blog not as a Cardiovascular Medicine Fellow in training, not as a General Internal medicine physician, not as a health care provider but as a citizen of the world. One world, one heart. Let’s beat strong, together and overcome COVID-19 and the chaos it brings. To quote Batman in the Dark Night Rises: “A hero can be anyone. Even a man doing something as simple and reassuring as putting a coat around a little boy’s shoulders to let him know that the world hadn’t ended”. It doesn’t matter if you are cardiology trained, dermatology, it doesn’t matter if you are just coming out of medical school, or without experience in health care, we can all be heroes and make a difference in this fight against the totalitarianism of COVID-19.

Thank you,

Michel

COVID-19: The Good, the Bad, and the Ugly

April 8, 2020April 8, 2020 Barinder Hansra, MD

In the 1960s a movie titled “The Good, the Bad, and the Ugly” was released. The plot revolved around three gunslingers competing to find a fortune in a buried cache of Confederate gold amid the violent chaos of the American Civil War. Despite the initial negative criticisms of the movie, it has since accumulated very positive feedback and listed in Time’s “100 Greatest Movies of the Last Century.” The Coronavirus (COVID-19) seems to be running a parallel course. The amount of media coverage surrounding coronavirus (COVID-19) over the past several months is not only shocking but overwhelming. I personally cannot recall any other illness getting as much media coverage as COVID-19 has in the past several months. On a daily basis, we are flooded with updates, changes in clinical practice, number of cases across the country, and recommendations on how to quickly flatten the curve. Here is my take on COVID-19 (and yes, I intentionally end with “the good”).

The Bad: An observation I noted was an uptick of in-basket messages from my patients who were more anxious from social media posts than from traditional news sources. Many patients mentioned posts seen on numerous social media platforms with conflicting information or claims to proven therapies. I combated these messages with clear recommendations from various professional societies but also recognizing we do not have established data in all medical arenas. This seemed to help improve my patients’ anxiety and concerns. Even too much media of any kind can amplify distress, which was evident by my own constant engagement in news sources and social media.

The Ugly: With social media being a part of everyday life, we all have seen pictures of people buy massive amounts of toilet paper, mounds of sanitizer, and selves stripped of essential goods. As increasing number of regions declared a state of emergency, panic buying was affecting the public. Panic buying occurs typically in a time of crisis resulting in increased prices and takes essential goods out of the hands of people who need it most – for example, personal protective equipment for health care workers. What’s worse is this led to price gouging where masks, sanitizers, and cleaning supplies were being sold at an exuberant price. Fortunately, several businesses across the country established hours for senior citizens to shop in peace and have access to essential good. Several communities started to help combat panic buying by donations and fundraising help offset such behavior to help those in need – keep up the strong work!

The Good: Despite the bad and ugly, COVID has had a positive impact. The biggest change I have seen is how much more cognizant we are about healthy habits. People are not going to work if they feel ill, increasing use of hand sanitizer after being in public, and encouraging proper hand washing techniques to mention a few. Granted, we think these should be the norm but COVID highlighted how this was not the case.

While countries are closing their borders, scientists are shattering their boundaries looking to collaborate with colleagues across the globe. I was able to join in on several fantastic webinars hosted by frontline healthcare staff from across the globe to learn from their experiences so we don’t make the same mistakes for our own patients. Leading institutions in America were holding lectures to share their research, clinical experience, and any clinical anecdotes to help improve patient outcomes. I believe a big part of this movement is due to the fact the virus is not limited to one remote area of the world but has spread across the globe. It is affecting every country and countless citizens – it’s hitting home. Scientists and doctors are standing together, working collaboratively, and are driven to find an effective treatment option. It’s this type of comradery that has helped all frontline health care providers to fight this pandemic.

Although there are is plenty of “bad” and “ugly” surrounding COVID, the amount of “good” is far reaching, inspirational, highlighting the need of team work and intense desire of all of us to help #FlattenTheCurve.

How Researchers Can Support Our MD Colleagues During the COVID-19 Pandemic

April 7, 2020April 7, 2020 Christa Trexler, PhD

I’ve thought a lot about what to write this month. There’s no way to sugar coat that things are intense right now. Most basic research labs are shut down right — and they should be. As a basic researcher whose work can’t be relegated to the COIVD-19 battle, I’m finding myself in a weird limbo. Also, as a new mom, I don’t have childcare, so I am all of a sudden — like many people — trying to figure out a way to work from home and take care of my baby. We are trying to do it all while maneuvering through a pandemic.

But guess what? I’m home safe. So many of our community members don’t have this luxury because they are busy making sure the world keeps spinning.

So, I wanted to take this space to write about what basic researchers, who all of sudden find themselves without bench work, can do to support our physician colleagues.

Stop Doing Non-Essential Research: Look, I understand you think your research is important — we all love our science. Can your research be helpful in understanding more about the SAR-CoV-2 virus/COVID-19 disease? If so, awesome — switch gears and contribute to the effort. If not, please stop. I know that many universities have effectively shut down, but many have only stated that “non-essential” research should stop without really defining what “essential” actually means. So, I know of some labs are that kind of skirting around this issue and having people work on projects that could otherwise be left for later. I get it. We will all need grant money. But right now, those pipette tips, gloves and other reagents you are using on your “non-essential” work could be better used elsewhere — especially since ordering and delivering goods is so tough right now. If you are in a situation where someone is making you work when you feel like you shouldn’t, speak up.
Work to Flatten the Curve: This goes with #1 above, please stay home. More importantly, talk with your friends and family about what flattening the curve I don’t know about you, but I have several family members who aren’t taking this seriously. I think a lot of people still feel like they’re watching a movie on the news — like what’s happening in New York or Seattle isn’t real. But it is.
Donate Your Lab’s Personal Protective Equipment (PPE): Many health care workers don’t have the PPE they need to treat their patients, so a lot of universities are stepping up to donate their supplies. Contact your department to see if your university has something like this in place and if not, considering organizing a donation drive.
Hone Your Science Communication Skills: As scientists, this is the most important thing we can all do right now. I asked fellow Early Career Blogger, Jeff Hsu, MD, what he as a physician would like help with from his research colleagues and he said: “I think having basic scientists explain these things — all the COVID-19 diagnostic tests, treatment options & technology — in digestible formats is really helpful to clinicians.” We need to help the community, our family and friends, understand what is going on right now because things are changing drastically every day — it’s hard for even us to keep up with what’s new. If you are new to science communication, Liz Neely’s recent piece about how we are all science communicators now, is a really great primer. Also, like many news outlets, the Atlantic is making their COVID-19 collection publicly accessible for free, so that is a great source of reliable, well-written information to share. A great way to get involved is to see if your university’s communications department, who is undoubtedly overwhelmed right now, has a blog that they want pieces for. This is a great way also to channel all of that anxiety news reading you’ve been doing.

Obviously, I’m sure there are a million different things we all could be doing, but these options are a great start. Also, be kind to yourself — this is an unprecedented time and there’s no right way to navigate through this experience.

RNA, DNA, and COVID-19

April 6, 2020April 6, 2020 Nosheen Reza, MD

As my co-blogger Jeff Hsu, MD, PhD said to me this week, the COVID-19 pandemic has created the ultimate hackathon – the world’s smartest people hyperfocused on the same problem. For this month’s blog, I am outlining few ways that genomics researchers are hoping to advance our understanding of SARS-CoV-2.

Pathogen Evolution and Transmission

Scientists around the world have pledged to openly share genetic data to aid in the understanding of pathogen spread, and one of these collections of open-source tools is Nextstrain.¹ Nextstrain is a database of viral genomes, a bioinformatics pipeline for phylodynamics analysis, and an interactive visualization platform that presents a real-time view of the evolution and spread of seasonal endemic viral pathogens (e.g. influenza) and emergent viral outbreaks (e.g. SARS-CoV-2, Zika, Ebola).¹ Over time, viruses naturally accumulate random mutations into their genomes, and these mutations can be used to identify infection clusters that are closely genetically related. Therefore, this can lend insight into introduction events and growth rates. The Nextstrain 2019-nCoV page shows incredible graphical displays of the inferred phylogeny, global transmission events, and genomic diversity over time. At the time of their most recent Situation Report and Executive Summary (dated 3/27/2020), the Nextstrain team had analyzed 1,495 publicly shared SARS-CoV-2 genomes and provided transmission pattern reports for North America, Europe, Central and South America, Asia, Africa, and Oceania.

For a great introduction to the importance of genomics in identifying the emergence of SARS-CoV-2, check out this Cell Leading Edge Commentary, authored by two of the scientists who were involved in the initial genomic sequencing of the virus.²

Global map of inferred 2019-nCoV transmission from Nexstrain.

Genetic Influences on Disease Outcomes

In addition to collecting data on viral genomics, researchers have come together to pool genetic data from patients to try to answer urgent questions regarding the variability in clinical outcomes across patients with COVID-19. To investigate the genetic susceptibility to disease, these researchers will be comparing the DNA of different cohorts of patients with COVID-19, for example, those with serious disease to those with more mild manifestations. The COVID-19 Host Genetics Initiative is one of the largest collaborative initiatives with now over 75 biobanks and studies from around the world listed as partners. Their aims are to facilitate sharing of COVID-19 host genetics research, identify genetic determinants of COVID-19 susceptibility and severity, and provide a platform to share the results to the scientific community. Other large national biobanks like UK Biobank and Iceland’s deCODE Genetics are also planning to add COVID-19-related data to their genomic databases.

The COVID-19 Host Genetics Initiative at http://covid19hg.org

How can you keep up with the explosion of data in this space? The Centers for Disease Control and Prevention has created an online Coronoavirus Disease Portal, which is a continuously updated database of scientific literature, CDC and NIH resources, and other materials that pertain to genomics, molecular and other precision medicine and precision public health tools in the investigation and control of coronaviruses, such as COVID-19, MERS-CoV, and SARS.

References

Hadfield et al., Nextstrain: real-time tracking of pathogen evolution, Bioinformatics(2018).
Zhang and Holmes, A Genomic Perspective on the Origin and Emergence of SARS-CoV-2, Cell (2020), https://doi.org/10.1016/j.cell.2020.03.035

#COVID-19: Universal Mask Policy, Universally, Now.

March 31, 2020March 31, 2020 Jeffrey Hsu, MD, PHD

As the COVID-19 pandemic has wrought havoc in major American cities over the past few weeks, particularly in New York City, a common refrain from health care workers (HCWs) on the front line continues to be: “Get Us Personal Protective Equipment (#GetUsPPE).” Yet intertwined in this tragedy of a gross undersupply of PPE has been the problem of mixed messages about the level of PPE that should be used by HCWs, which stemmed from dynamically changing recommendations from the Center for Disease Control (CDC).

Ultimately, the current CDC recommendations, which advise the use of surgical masks when with a symptomatic COVID-19 patient and N95 masks only during aerosolizing procedures, were borne primarily out of an anticipated shortage of PPE, and these recommendations differ from earlier ones that recommended N95-level masks whenever with a patient with suspected COVID-19. Justification for this effective reduction in PPE levels stemmed from the CDC’s thought that COVID-19 is primarily spread via droplet transmission.

In light of this CDC guidance, many hospitals implemented policies that similarly aimed to preserve PPE supply, anchoring on the notion that COVID-19 is transmitted by symptomatic patients via droplets. Many of these policies restricted hospital staff from wearing masks outside of patient rooms, and ultimately led to numerous reports of staff (including house staff trainees) being reprimanded for doing so.

Yet as hospitals in countries like Italy and Spain and in major American cities such as Boston are experiencing alarming numbers of their HCWs test positive for COVID-19, it is crucial for us to reassess whether our current PPE policies are adequate to protect HCWs from infection and to prevent nosocomial spread. Indeed, prominent academic medical centers such as Partners Healthcare, University of Pennsylvania, New York Presbyterian, and University of California San Francisco (UCSF) have already adopted a “Universal Mask Policy” to help address this vital issue.

In order for us to more effectively contain the rapid spread of COVID-19 in our communities, I strongly believe that all hospitals should adopt a Universal Mask Policy, in which hospital staff are required to wear surgical masks in all areas of the hospital. This step is crucial for the safety of our team members, our colleagues, and our patients.

My belief stems from the following:

Precedent from countries with effective control: On March 18^th, the American College of Cardiology held a joint teleconference with the leadership from the Chinese Cardiovascular Association, which included a section on recommendations from their physician leaders on how to adequately control COVID-19 spread at our hospitals in the U.S. They strongly urged us to wear surgical masks in all areas of the hospital, and they also used N95 masks during all encounters with patients with suspected COVID-19. They felt these measures were pivotal in their ability to protect their staff members and control the rampant spread of the virus throughout their hospitals. Further, the Director of the Chinese Center for Disease Control and Prevention, Dr. George Gao, told Science that it is a “big mistake” that people in the U.S. are not wearing masks everywhere in public, let alone not wearing them everywhere in the hospital. Similar public masking policies are in place in South Korea, Japan, and Singapore, where COVID-19 disease spread has also been more effectively controlled.
Likelihood of asymptomatic spread among HCWs in the hospital: It is becoming increasingly clear in the literature that a large portion of the disease spread is from asymptomatic individuals (Li et al, Science, March 16, 2020; CDC MMWR March 27, 2020), with a long incubation time of 5 days median (Lauer et al, Ann Intern Med, March 10, 2020). Hospital staff, who are only advised to stay home from work if symptomatic, may still present to work asymptomatic but infected and contagious. Without at least wearing a surgical mask throughout the hospital, we are at increased risk of spreading infection among each other.
Transmission by talking: By the nature of our work, we are not used to routinely standing 6 feet away from each other in the hospital as we communicate; in a small Twitter survey, >60% of respondents said that #SocialDistancing is not currently practiced in their hospital. Further, we are all touching common surfaces (e.g., keyboards, computer mice, phones) that will inevitably carry droplets that are inevitably spread from unmasked mouths when we talk. While surgical masks are not the perfect solution to filter out the droplets emitted from our mouths when we talk, cough, or sneeze, they undoubtedly reduce emission into the ambient air around us (Figure 1) and should reduce the likelihood of asymptomatic hospital staff from transmitting infection among each other and to our patients.

Figure 1: Two-way protection provided by masks (from Medium blog post by Sui Huang, MD, PhD at the Institute for Systems Biology)

In summary, I urge all hospitals to implement a Universal Mask Policy to account for these data and expert recommendations. As mentioned above, the lack of a clear, effective message has led to conflict between care teams, leading to discord at a time when unity is so critical. Although no randomized clinical trial has yet to show that a Universal Mask Policy is the most effective way to reduce nosocomial transmission of COVID-19, the “absence of evidence is not evidence of absence.”

When there is enough reason to believe that a Universal Mask Policy should help to protect our staff and patients, we need to err on the side of safety when the consequences are life- and livelihood-threatening. While anticipated mask shortage is clearly an issue, the remarkable resourcefulness, philanthropy, and ingenuity of our communities will come through.

In the meantime, we need a Universal Mask Policy to protect us. We need a Universal Mask Policy to unite us. We need a Universal Mask Policy now.

Social distancing in the time of COVID-19

March 26, 2020March 26, 2020 William Aitken, MD

I was just getting to work when I received a text from one of my chiefs, “can you call me?”. Not usually the start of a conversation you want to have. A person I had been exposed to had tested positive for SARS-CoV-2 and they suggested I put a facemask on and head home to self-quarantine and monitor for symptoms. Walking to my car, I realized I couldn’t stop at a friend’s apartment or my parent’s house for coffee or to decompress. The social distance hit me.

At home we had already been staying in, washing our hands, and seeing the “flatten the curve” graphs floating around twitter and online. But going to work still provided a sense of normalcy, and my social distancing felt more like a choice than an obligation. Over the next few days, keeping in touch with friends, family, and co-workers via iMessage, Whatsapp, or Zoom really helped close that social gap I felt as I was driving home. Keeping my social distance from others has given me a new found respect for what our global community is really doing to fight this thing.

[1]

This past week I’ve been amazed not only at how empty the roads have been, but by how many more people I’ve seen out walking their dogs, jogging, or riding bicycles. When I get back into the clinic, I’m looking forward to talking to patients about how they’re incorporating physical activity among the other AHA Life’s Simple 7 lifestyle changes into their new routines [2]. Unfortunately, in many places around the world curves aren’t flattening yet. All the more reason to stay home and give our healthcare workers and their patients a fighting chance.

References:

Attribution: Siouxsie Wiles and Toby Morris, This file is licensed under the Creative Commons Attribution-Share Alike 4.0 International license https://commons.wikimedia.org/wiki/File:Covid-19-curves-graphic-social-v3.gif
The American Heart Association’s “Life’s Simple 7” cardiovascular health risk factors that people can improve though lifestyle changes https://www.heart.org/en/professional/workplace-health/lifes-simple-7

COVID-19 Pandemic: 5 lessons about the way we practice medicine

March 24, 2020March 24, 2020 Amr Barakat, MD

I know that this blog was supposed to be Part 3 of the “building an academic portfolio during medical training” series, however, it’s very difficult these days to talk about anything other than COVID-19. This pandemic that has taken the whole world by storm, and reminded us all about how fragile our whole world is! Amidst all the angst and frustration, it is important to focus on positively learning from such an unprecedented experience in our lifetime. The lessons are innumerable, yet I wanted to share with you 5 points that, in my humble opinion, were highlighted by these extraordinary circumstances:

Telehealth is no longer a luxury. Despite having the technology available for years, the health industry has been lagging behind when it comes to telehealth. It took a pandemic and thousands of lives for us to realize that most of the outpatient services we provide (and arguably some of the inpatient ones even) can safely be delivered virtually. The degree of disruption to one’s life and the time wasted outside the actual doctor’s visit, between taking time off from work, physically making it to the medical facility, parking, checking-in, and so forth, can easily be omitted by a technology that is readily available but we have been reluctant to use (or don’t have insurance approval to do so). There will always be a place for in-person visits, but at least we would have more time for patients that actually need to be seen in-person.
Many hospitalizations and tests are unnecessary. As the pandemic worsens, physicians started to be judicious with ordering tests that require moving patients around the hospital. They also started thinking twice about who needs to be in the hospital, to begin with. We are now realizing how many tests and hospitalizations can safely be avoided, and I am hoping that we will carry these revelations with us as we move past the current circumstances.
Incorporating research into clinical practice needs to be seamless. Despite major advances, the way we conduct research has not yet been optimally incorporated into our daily clinical activities. We are in desperate need to develop the necessary infrastructure that instantaneously translates patient-care input into organized data that can be used to improve the way we manage our patients. Ideally quickly enough to potentially help some of the patients who generated these data. This necessary infrastructure also extends to research regulations, which need to strike the appropriate balance between scrutiny and practicality.
In a world of “evidence-based medicine”, clinical acumen remains paramount. The sudden exposure to this COVID-19 pandemic has reminded us all that often times, as physicians, we are required to operate in evidence-free zones. As much as we need to always look for evidence behind everything we do in medicine, it is essential not to forget that taking care of patients is both a science and an art. And this is why physicians can never be replaced by computers.
Prevention is ALWAYS better than cure. With the great technological and pharmaceutical advances, we tend to develop great confidence in our ability to improve life expectancy. This is particularly true in procedural fields such as Cardiology. Then comes a sobering pandemic, to remind us that when it comes to public health, prevention always wins! Fortunately, we rarely need drastic measures such as quarantines and social distancing. But addressing smoking, obesity and blood pressure control will always have much more impact on our community than stents and ablations.

We will continue to learn from this world tragedy – lessons in medicine, philosophy and life in general. But, above all, this is a reminder of how noble and unique our healthcare profession is. Stay safe everyone!

The COVID-19 pandemic: In this together, a call for collective responsibility

March 23, 2020March 23, 2020 Aaysha Cader, MD, MRCP

On March 11 2020, following a 13-fold rise in COVID-19 cases outside China, the WHO declared the disease a pandemic. The novel coronavirus is now spreading in exponential proportions across the globe, crippling even some of the best healthcare systems. There are unprecedented events: there’s a sense of uncertainty, and for most of my generation, this is the “war” of our time. Times like these also call for a collective responsibility, for each of us to do our part. We are in this together, for the long haul. And I mean that in the most literal, least metaphorical way possible.

The epidemiology explained

An epidemiological study of the outbreak in China estimated the basic reproduction number (R₀) of COVID-19 to be 2.68. ¹That essentially means that early on, every COVID-19 infected person can transmit the disease to an average of 2.5 others.

The epidemic doubling time of COVID-19 is 6.4 days.¹ That means every 6-7 days, the number of cases increases by a factor of two. Exponential growth. This is the reason why the spread can be seemingly slow initially, only to lead to a sudden outbreak in a matter of days to weeks. It’s also why reducing transmission as early on in the outbreak as possible can dramatically reduce this exponential explosion of cases.

Social distancing & “flattening the curve”

Social distancing is key to slowing down rates of transmission and might very well be the most responsible act in the face of this pandemic. This includes keeping a safe distance (at least six feet) between others, avoiding social gatherings, public transport, non-essential travel/ commutes and working from home, if one can. Needless to say, these measures must be accompanied by the consistent practice of healthy hygiene.

And it works: these simulation graphics by Harry Stevens of the Washington Post are a superb demonstration of the impact of social distancing on halting disease transmissions.²

The concept of “flattening the curve” alludes to reducing the number of cases over time by slowing the rate of transmission of the disease so that healthcare systems are not overwhelmed beyond capacity. COVID -19 can be fatal in anyone, with the elderly and those with comorbidities such as diabetes, heart and lung diseases at higher risk of severe infection.³ Latest reports from the WHO now emphasize that young people are not off the hook either, with data from countries showing that people under 50 make up a significant proportion of patients requiring hospitalization.⁴

The fundamental idea of social distancing is to reduce disease transmission to EVERYONE, not just oneself. The incentive is not just preventing oneself from catching it. Even seemingly healthy individuals might develop a milder or asymptomatic form of the disease, retaining the ability to transmit it to the elderly (the worst hit) and other vulnerable groups they encounter, including young people. This leads to a rapid growth of the pandemic, overwhelming the healthcare systems beyond their capacities. An overwhelmed health care system will not be able to treat all the COVID-19 cases coming its way, and will also be limited in resources to care for someone who has a heart attack, an accident or cancer.

However, turns out staying at home is easier said than done, with some still struggling to grasp the concept. “I’ll just be a while, what can happen?” they’ll say. At a time, where testing for COVID-19 is also rationed, staying away from large gatherings is ever so much more important, especially when one shows symptoms. In the fascinating case of Patient 31 of South Korea, we see the dangerous potential of a “super-spreader” phenomenon, in a 61-year-old woman who by virtue of attending religious gatherings prior to testing positive for COVID-19, transmitted the disease in large clusters, leading to a sudden surge of cases in South Korea.⁵

Sharing information: Responsible information, not misinformation

In a pandemic such as this, there’s also a tendency for rampant misinformation, easily transmitted through social media channels. This calls for the responsible dissemination of information, and while this is applicable to everyone, the onus is more so on healthcare personnel.

Social media can be used positively and responsibly to educate the public and refute myths: platforms such as Instagram, Facebook and Twitter are proving to be a great way for healthcare personnel to reach out to communities, explain epidemiology and create awareness of healthy practices during this pandemic. The WHO website has also detailed some of the more common myth-busters: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters

Keep updated

With the volatility of the situation and the torrent of information flooding in from multiple sources, it can be difficult to sift between what’s reliable and what isn’t. These are some reliable channels you can turn to for correct information and updates. It’s also important to seek out your local source of information depending on geographic location.

The World Health Organization (WHO) Coronavirus disease (COVID-2019) situation reports (updated daily): https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports
The WHO also has an interactive Whatsapp bot: +41 79 893 18 92 (Type “hi” and send to get started)
Centers for Disease Control & Prevention (CDC) Coronavirus (COVID-19) website: Latest updates, information for healthcare professionals and resources for the community: https://www.cdc.gov/coronavirus/2019-nCoV/index.html
MedShrOpen: Coronavirus COVID-19 Daily Update at 12pm GMT: aims to provide clinicians and the public with an overview of the latest data, guidelines, key publications and policy around COVID-19: https://en.medshr.net/covid

Show solidarity

Check on your elderly friends and relatives. Refrain from hoarding essential items, thereby potentially creating a shortage, making things difficult for senior citizens and those living on a daily wage.

Donate

The economy has taken a hit, but the hit on health care is bigger. With severe shortages of essential items, those of us with the capacity to donate locally, in whatever way we can, should be doing so. The WHO also has a COVID-19 Solidarity Response Fund: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/donate

Check on your colleagues

For healthcare personnel and their families, this can be a particularly overwhelming time. Some of us may not be on the frontlines, but have friends and family who are. Just those words, “on the frontlines”, sends a chill down my spine.

But that’s exactly what this is. War. War against a common enemy. And when you’re going to war, you don’t make light of the prep.

Which brings to mind this brilliantly appropriate quote by Michael O. Leavitt, Secretary of the U.S. Department of Health and Human Services, 2007:

“Everything we do before a pandemic will seem alarmist. Everything we do after a pandemic will seem inadequate. This is the dilemma we face, but it should not stop us from doing what we can to prepare. We need to reach out to everyone with words that inform, but not inflame. We need to encourage everyone to prepare, but not panic.”

Unprecedented times call for unprecedented measures. In this global healthcare crisis and the ultimate test of our times, it is on all of us to be responsible.

References

Wu JT, Leung k, Leung GM. Nowcasting and forecasting the potential domestic and international spread of the 2019-nCoV outbreak originating in Wuhan, China: a modelling study. Lancet 2020; 395: 689–97
Stevens H. Why outbreaks like coronavirus spread exponentially, and how to “flatten the curve”. The Washington Post March 14, 2020. https://www.washingtonpost.com/graphics/2020/world/corona-simulator/?fbclid=IwAR1ALnyJWXEcBIIh1qFvz1a3JMCtAQP0_jvYIKIRqBnrKpjDKn-sEo1J39A
Centers for Disease Control & Prevention (CDC): Coronavirus Disease 2019 (COVID-19). Are You at Higher Risk for Severe Illness? https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html
WHO Director-General’s opening remarks at the media briefing on COVID-19 – 20 March 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—20-march-2020
The Korean Clusters. How coronavirus cases exploded in South Korean churches and hospitals. Via Reuters Graphics. Updated March 3, 2020. https://graphics.reuters.com/CHINA-HEALTH-SOUTHKOREA-CLUSTERS/0100B5G33SB/index.html

COVID-19; Patients with Congenital Heart Disease (CHD)

March 20, 2020March 20, 2020 Alyssa Vermeulen, DO, FAAP

This week, the ACHA (American Congenital Heart Association) hosted a webinar in regards to Coronavirus aka SARS-CoV-2, and the illness it causes, COVID-19, 3,000 attended (view the recording here.) CHD patients, parents of CHD patients and CHD providers had the same question, how does this virus affect this special population? Unfortunately, the data is lacking on coronavirus those with CHD and there is a lot we don’t know.

A recent study¹ in China looked at 2143 pediatric patients with COVID-19, the majority (94.1%) were asymptomatic or mild, more severe cases, were seen in infants (<1 year old) than older children, and there was only one death. This study lacks details, such as what other medical conditions they may have. Severe cases were 5.9% compared to 18.5% in adult population studies. Although reassuring for the general pediatric population, we still don’t know how this applies to pediatric patients in the United States and those with CHD.

What we do know.

There is a trend toward overgeneralization of “heart disease,” particularly in the media. It has been noted that the COVID-19 affects older adults and those with “heart disease,” meaning cardiovascular disease(CVD), such as coronary artery disease and hypertension, more severely.² This does not include Congenital Heart Disease.

The virus may also cause myocardial injury, with reports of myocarditis and arrhythmias in those with severe cases.^2-4 The effect is thought to be related to Angiotensin-converting enzyme 2(ACE2), which, in animal studies, has a role in the cardiovascular, and immune system and has been identified as a functional receptor for coronaviruses.^2,3

Many patients with CVD and CHD take a medication known as ACE inhibitors or an Angiotensin Receptor Blockers (ARBs). The use of these medications is common in both populations, but for different indications, as their “heart disease” is not the same. There are trials assessing the use of these medications and effect on COVID19 in adults, and varying theories on whether they are protective or not, with that said, the HFSA/ACC/AHA currently recommends continuing these medications as prescribed.⁵

Are patients with CHD considered high risk?

The answer is we don’t know. With a wide range of congenital heart disease, from repaired/“normal” hearts, to those with altered blood flow, lung abnormalities, and arrhythmias. As mentioned, the CDC places those with “heart disease,” meaning those with CVD, and older adults, at high risk of severe illness,⁶ this does not include CHD, however, CHD patients aren’t immune to CVD and if a patient has CVD and also CHD they are considered high risk.

With data lacking in many populations, it is important for those considered at high risk for other viruses, like influenza, such as CHD, asthma and those who are immunocompromised, to take appropriate precautions. It is better to be over prepared and over cautious.

Follow up and Communication.

CHD patients should keep in close contact with their medical team and stay updated with recommendations of their team and the CDC (found in detail here), like social distancing, good hand hygiene and staying home if you are sick. Concerning symptoms that require further evaluation include shortness of breath (or fast breathing in infants), chest pain, and palpitations.

As far as visiting your doctor, you will likely be asked to either re-schedule or have a telephone visit. You can ask your medical team about this option and even anticipate it for the next few months. Elective procedures, catheterizations and imaging will likely be delayed. If one good thing comes out of this pandemic, it may be better options and availability for telemedicine in the future.

Keep your Mind Healthy

Use this time to support your mental health— pay attention to the news and social media, but set timers so you don’t over-saturate yourself. Find the book you’ve had on your shelves that you’ve been too busy for and set aside time every day to read, call or FaceTime friends, and maybe even fill up your bathtub and relax!

Meditation and exercise are also great options, and many apps offer free trials. Calm and Headspace have some free mediation content and free trials. Peloton & DailyBurn offer free day trials with a variety of classes(Tip: If you do choose a free trial, be sure to set an alarm on your calendar before the free trial is over so you can choose if it’s worth continuing for a fee or not.) There are also options to support your local gyms and studies virtually with on demand classes, just check out their websites and/or Instagram.

There is so much unknown, which causes us to worry and discomfort, but we are learning more each day. Stay informed, stay safe, wash your hands and try to keep your mental health in check.

For more on coronavirus and heart health, read Noora Aljerhi’s blog (3/9/2020) on the early career voice.

Dong, Yuanyuan, et al. “Epidemiological Characteristics of 2143 Pediatric Patients with 2019 Coronavirus Disease in China.” Pediatrics, 2020, doi:10.1542/peds.2020-0702.
Hui, Hui, et al. “Clinical and Radiographic Features of Cardiac Injury in Patients with 2019 Novel Coronavirus Pneumonia.” 2020, doi:10.1101/2020.02.24.20027052.
Zheng, Ying-Ying, et al. “COVID-19 and the Cardiovascular System.” Nature News, Nature Publishing Group, 5 Mar. 2020, nature.com/articles/s41569-020-0360-5?code=85e25438-46d1-4753-bfdd-84496a98b564.
Hu, Hongde, et al. “Coronavirus Fulminant Myocarditis Saved with Glucocorticoid and Human Immunoglobulin.” European Heart Journal, 2020, doi:10.1093/eurheartj/ehaa190.HFS/ACC/AHA statement
“HFSA/ACC/AHA Statement Addresses Concerns Re: Using RAAS Antagonists in COVID-19.” American College of Cardiology, 17 Mar. 2020, acc.org/latest-in-cardiology/articles/2020/03/17/08/59/hfsa-acc-aha-statement-addresses-concerns-re-using-raas-antagonists-in-covid-19.
“If You Are at Higher Risk.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 12 Mar. 2020, www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html.