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Physicians Shouldn’t Be Heard Only During a Pandemic

Adham Karim, MD

I know that COVID-19 has dominated the headlines for quite some time, and I’m sorry in advance, but yeah, this is another COVID-19 article. I’m not an infectious disease expert, and I’m not here to talk about the possible health benefits of black seed oil, vitamin C, or Alex Jones’s anti-covid toothpaste.

The anti-vaxxer movement and the virulent spread of e-cigarettes helped highlight what happens when physicians and scientists are silent on social media – pseudoscience and flat out bad advice rise to fill the void. Of course both of these movements have swung in the other direction as more knowledgeable voices found prominence, but that’s not without many unfortunate cases of measles and vape induced lung injury first causing people to second guess the misinformation.

With our current situation, there are a LOT of learning points. Chief amongst them is what happens when doctors stay out of (or get involved in) public policy. The national stockpiles were woefully understocked. The pandemic response team was dismantled (in 2018). The CDC lost huge amounts of funding. The list goes on and on. On the other hand, having an experienced physician in the room where decisions are made has had a significantly positive impact. Of course, like vaccines, statins, and social distancing, it’s difficult to quantify the impact of something when all you’re left with is the absence of a bad outcome.

What’s not difficult, is to learn from what happened with this outbreak. We’ve seen a rapid shift towards telemedicine adoption, and a lag in the deployment of testing kits. We’ve also seen that rapid adoption of a potential wonder drug treatment (hello Hydroxychloroquine) might actually result in MORE deaths, and make it difficult for people with lupus and rheumatoid arthritis to get refills on their HCQ prescriptions. Society as a whole has come to realize.

As a trainee, I’ve read heart wrenching stories about people in my position forced to work with inadequate PPE, and ultimately succumbing to this virus. I agree that medicine is a field that demands sacrifice, but I disagree that someone who signed up for this job should accept improper protection at the risk of their own life. In my own program, residents have come down with the coronavirus despite adequate PPE; so I can only imagine how those with less equipment must feel like. Having spent time on the Covid unit myself, I got a taste of what my friends in New York and Chicago were dealing with on a larger scale, and an every day basis for the past several weeks. Of course, I’m fortunate enough to work in a state that was not in the top 3 hit by coronavirus, and whose leadership includes a pro-active governor and an experienced physician.

We need to be more vocal on the policy level – and while it may not be as sexy as deploying a stent into a thrombosed LAD or as intellectually titillating as making a breakthrough in the science of atherosclerosis, it is arguably just as necessary. We don’t need to be running for office, but it certainly wouldn’t hurt to write to one’s Congress representative (https://www.house.gov/representatives/find-your-representative), and sign with your name and job title. Let them know how many people’s lives you impact, and tell them to provide you with aid. I’m not just talking about masks and gowns. I’m talking about hazard pay and disability benefits. If I suffer complications related to coronavirus, I most likely got it because of my job, not because I went to the grocery store one time last week. I want to know my family won’t get sacked with a huge bill because of that. As a physician, I’m fortunate enough to expect an increase in pay when I finish training, but I work alongside many other healthcare providers who are not so fortunate – they shouldn’t have to worry about financial calamity just for doing their job and helping their fellow countrymen.

Several iterations of coronavirus relief aid have been put out by Congress, and trillions of dollars have been disbursed. I’m glad to know that Shake Shack was able to secure 10 million dollars to pay its employees, but I’d like to know what has been done for the residents in NY who died from complications relating to Covid. What’s more is that we are now starting to see the consequences of the Covid scare – the dramatic down tick in strokes, STEMI activations and other acute illnesses doesn’t mean America suddenly got healthier – it means that a lot of these people were staying home, and our hospitals will need to be prepared to deal with the sequelae of these conditions as people start to come out of the woodwork.

In a climate where the aid given to businesses and Wallstreet far outweighs that given to the front line providers, I can only say that we physicians are not blameless. Ultimately, these are just the frustrated ramblings of another trainee who has seen so many of his colleagues impacted negatively one way or another, all while the public is more concerned with being able to mow their lawn than the wellbeing of those on the front line. As Dr. Fauci (who, by the way, might be getting nominated to be Vanity Fair’s Sexiest Man Alive) once said: “you just have a job to do. Even when somebody’s acting ridiculous, you can’t chide them for it. You’ve got to deal with them. Because if you don’t deal with them, then you’re out of the picture.”

Sources

https://www.ama-assn.org/delivering-care/public-health/residency-pandemic-how-covid-19-affecting-trainees

http://www.onlinejacc.org/content/early/2020/04/07/j.jacc.2020.04.011

https://www.medscape.com/viewarticle/928337

“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.”

 
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RNA, DNA, and COVID-19

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

  1. Hadfield et al., Nextstrain: real-time tracking of pathogen evolution, Bioinformatics(2018).
  2. 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

“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.”
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How Coronavirus (COVID-19) can affect your heart health?

Noora Alhajri, MD, MPH

The rapid spread of the coronavirus (now known as COVID-19) has sparked a global alarm. The World Health Organization (WHO) has declared a state of public health emergency of international concern (PHEIC), as many countries are grappling with a rise in the number of confirmed cases. As of March 5th 2020, data from WHO have shown that more than 95,499 confirmed cases have been identified in 84 countries/territories with more than > 99% of the cases emerging from China1. In the United States, the Centers for Disease Control and Prevention (CDC) have increased the risk from Coronavirus spread to level 3 and advised against non-essential travels to China, Iran, Italy, and South Korea. “It is not so much a questions of if this will happen anymore, but rather more a question of exactly when this will happen and how many people in this country will have severe illness” said Dr. Nancy Messonier, director of the National Center for Immunization and Respiratory Disease at the Center for Disease Control and Prevention in the United States.

What is coronavirus?

Coronavirus (CoV) are a large family of viruses that causes illness ranging from the common cold to more severe diseases such as the Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-Cov). A novel coronavirus (nCov) is a new strain that has not been previously identified in humans. Coronavirus are zoonotic, meaning they can transmit between animals (such as bats, cats, camel, and cattle) and human.

What is the clinical profile of COVID-19 infection?

 Coronavirus infection is spread from human-to-human via droplets or direct contact. The infection is estimated to have a mean incubation period of 6.4 days (0-27 days), and a basic reproduction number of 2.24-3.58. Fever was the most common clinical feature followed by cough, shortness of breath, body ache, headache, and sore throat. There have been reports of gastrointestinal symptoms (nausea, vomiting, or diarrhea) before respiratory symptoms occur, but this is largely a respiratory virus. Those who have the virus may not have obvious symptoms (asymptomatic), or may have symptoms ranging from mild to severe. In some cases, the virus could be life-threatening. Older adults are less likely to present with fever, thus close assessment of these group of patients with other symptoms such as cough and shortness of breath is critical.

What are the cardiac Implications of COVID-19?

Early reports show that 50% of hospitalized COVID-19 patients had an underlying chronic medical illness, 80% of which are cardiovascular and cerebrovascular disease. The American College of Cardiology (ACC) issued a bulletin recently to warn patients with heart disease about their potential risk for complications if they contracted the disease. This does not mean that patients with cardiovascular disease or with cerebrovascular disease are at increased risk of getting coronavirus. However, they should practice additional precautions, since they are at great risk for complications. Nearly 20% of people developed Acute Respiratory Distress Syndrome (ARDS) according to a case report of Wuhan hospitalized patients. In addition, 7.2% of patients developed acute cardiac injury, 8.7% shock, 3.6% developed acute kidney injury, and 16.7% developed arrhythmia. Several unpublished first-hand reports suggest at least some patients develop myocarditis. Therefore, it would be reasonable to triage patients with COVID-19 infection according to the presence of underlying cardiovascular disease, renal disease, respiratory and other chronic diseases for prioritized treatment.

Several experts suggested rigorous use of guideline-directed plaque stabilizers (such as ACE-inhibitors, Statin, Beta-blockers, Aspirin) as it could protect cardiovascular patients during wide-spread outbreak of the virus. Furthermore, it is important for patients with cardiovascular disease to remain up to date with vaccination, including pneumococcal vaccine given the risk of secondary bacterial infection. It would be also crucial to receive the influenza vaccine to prevent any other sources of fever which could be initially confused with coronavirus infection.

The outbreak of COVID-19 has become a global clinical and public health threat. Knowledge about this novel virus remains limited. What we can do now is aggressively implement infection control measures to prevent the spread of COVID-19 via human- to- human transmission.

References:

  1. World Health Organization declares Global Emergency: A review of the 2019 Novel Coronavirus (COVID-19), International Journal of Surgery, (March 2020)
  2. Travel Health Notices: https://wwwnc.cdc.gov/travel/notices#travel-notice-definitions
  3. Chen H, Zhou M, Dong X, et al. Epidemiological and Clinical Characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020; published online January 29. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930211-7
  4. Wang D, Hu B, Hu C, et al.Clinical Characteristics of 138 Hospitalized Patients with2019 Novel Coronavirus- Infected Pneumonia in Wuhan, China. JAMA. Published online February 07, 2020. doi:10.1001/jama.2020.1585
  5. Cardiac Implications of Novel Coronavirus (COVID-19): https://www.acc.org/~/media/665AFA1E710B4B3293138D14BE8D1213.pdf

 

“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.”