COVID-19 – Page 2 – The Early Career Voice

Hopes for 2021

January 16, 2021January 14, 2021 Lina Ya'qoub, MD

As 2020 concluded with all of the unprecedented events, with the tragedies people had to suffer and are still suffering from, with all the good and bad, we enter the New Year of 2021 with some hope; hoping for better health, better strategies to combat what we are dealing with in this pandemic, and being more responsible for each other.

COVID-19 Pandemic

COVID-19 pandemic has changed how we live our lives, and the impact of this pandemic will likely last at least a few years, if not more after the pandemic is over. There are a lot of “unknowns” about COVID-19 infection, including the long-term effects of this infection and the effectiveness of some medications, that we will get to encounter and manage in the next several years.

COVID-19 Vaccine

With multiple effective vaccines discovered recently, healthcare workers were given priority to get the vaccine, followed by more vulnerable patients, including the elderly and those with significant comorbidities. The Centers of Disease Control and Prevention (CDC) website provides helpful information on the currently available vaccines in the United States (US), Pfizer, and Moderna, including their storage, preparation, and expected side effects (Link is provided below) [1]. The hope is that by the Spring of 2021, 75% of the population in the United States will be vaccinated. Moreover, efforts by international organizations, including the World Health Organization (WHO), to distribute the vaccine to all countries are ongoing [2].

COVID-19 New Strains

We have seen the discovery of new strains of COVID-19 infection in the United Kingdom and, most recently, the US. These new mutant strains of COVID-19 may not be covered by the available vaccines, as such, the vaccine is an additional layer of protection, with the other protection measures, including social distancing, masks, and hygiene, which may be the most important way to prevent the spread of these new strains at this point of time.

With all that being said, our hopes for a “normal 2021” depend on how we handle the COVID-19 pandemic, we may not see everything going back to normal in 2021, but we can work on making the initial right steps now so that we have less grief, less “loss,” fewer travel restrictions, with healthier and happier upcoming years!!

Special thank you to my sister, Rawan Ya’acoub, an assistant professor of Doctor of Pharmacy/Clinical Pharmacology at the University of Jordan in Amman, Jordan, who helped me write this blog, and for all of her support.

References

S. COVID-19 Vaccine Product Information: https://www.cdc.gov/vaccines/covid-19/info-by-product/index.html
COVID-19 vaccines: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines

“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.”

COVID Fatigue

January 14, 2021January 14, 2021 Aubrey J. Grant, MD

Anesthesia alert! This overhead call alerting pending intubation can be heard bellowing throughout the hallways of my medical center several times throughout the day and is seemingly the soundtrack of COVID-19. My typical routine is to pause, make sure it’s not sounding the alarm to my patient’s room, and then continue with my workday.

It has been 304 days since the WHO has declared COVID-19 a pandemic. COVID numbers at my medical center continue to rise, and although the vaccine is widely available to hospital staff, we are continuing to see some of our highest numbers since the beginning of the pandemic.

As a general cardiology fellow on the advanced heart failure service at a high volume mechanical circulatory support and transplant center, we really get to know our patients while taking care of them during their index hospitalizations. For the past two weeks, I’ve gotten to know one patient in particular. She presented in cardiogenic shock, was stabilized on inotropes and a balloon pump, with plans for upcoming destination therapy LVAD implantation.

Every day when we come to her bedside, she is on FaceTime with her partner. Today, the day before her LVAD implantation, we walked to her bedside, and once again she was on FaceTime with her devoted partner. She is obviously loved. Considering that she was going for LVAD the following day, we spent a bit more time explaining the procedure in-depth to the patient and her partner. After discussing all of the technical details, she timidly asked “Do you think my partner could come to spend the night with me tonight? I just need to see my love and it’s been so long.” You could see the tears begin to drop from her face and her partners.

Donning and doffing, wearing the N95, not knowing what anyone looks like without their mask; things have become routine. Health-care workers have adapted so well to the ever-demanding challenges of practicing medicine in the era of COVID-19. We’ve made guidelines, adjusted our practice, established routines, and found ways to provide quality medical care in the darkest of times. We’ve become oddly accustomed to these necessary rituals in order to protect ourselves, our loved ones, and the patients that we care for.

But none of this is normal.

At that moment, when we told our patient that the person who loved her the most in this world could not sit with her the night before a life-altering surgery, it became dramatically apparent to me that all of this is abnormal. The weight of 304 days of pandemic sat heavy in my heart and the sounds of endless anesthesia alerts echoed in my head.

Depression and burnout were prevalent in the healthcare field even before the pandemic. COVID-19 has undoubtedly placed an added burden on all healthcare providers. I implore people to take time off if you can, spend time with family if able, and be thoughtful of your mental well being because this past year has been anything but normal.

Smallpox to COVID-19: We’ve come a long way!

January 13, 2021January 12, 2021 Amr Barakat, MD

The history of humankind has never witnessed an infectious agent deadlier than Smallpox. It is thought to have first appeared in Asia or Africa thousands of years ago, before spreading to the rest of the world. This virulent disease was causing hundreds of thousands of deaths each year during the 16^th, 17^th, and 18^th centuries in Europe alone; and when Europeans brought it to Mexico in the 16^th century, it killed nearly half of the previously unexposed Aztec and Inca population in less than 6 months.^1,2 In the early 1700s, Lady Mary Montague, the wife of the British Ambassador to Turkey, and a disfigured Smallpox survivor, was fascinated by the smooth skin of the ladies at the famous Turkish Baths. A face with no scars was a rare sight in Smallpox-devastated England at the time. “The small-pox, so fatal, and so general amongst us, is here entirely harmless, by the invention of engrafting”, she wrote home in her notable letter.³ She had witnessed the primitive form of vaccination, which was then called inoculation. Turkish mothers would gather their children at Smallpox parties, where an old lady would tear the skin of healthy kids and smear a small sample of the virus (typically from a recently infected child). The kids would then develop a mild form of illness that recovers with no scarring and gives them long term immunity. Lady Montague used this technique to protect her son and has been credited for bringing this historical discovery back to England and advocating for its widespread use despite major opposition from the British medical community at the time (Figure 1). Subsequently, in 1796, Edward Jenner developed the much safer technique of vaccination using Cowpox instead of the Smallpox virus.⁴ Two centuries later, Smallpox was completely eradicated!

Figure 1: The painting Lady Mary Wortley Montagu with her son, Edward Wortley Montagu, and attendants attributed to Jean Baptiste Vanmour (oil on canvas, circa 1717). © National Portrait Gallery, London: NPG 3924.

What is most remarkable about this story is that the practice of Smallpox inoculation was introduced in Europe only in 1721 by the relentless efforts of a concerned and enlightened mother, despite being successfully used in Oriental countries such as China, India, and Turkey for centuries. In other words, one half of the globe was deeply suffering from an illness that killed millions of people over the years, while the other half held the secret to its prevention. And it was only when knowledge was exchanged between the two halves that humanity finally defeated one of its deadliest historical enemies! There has never been a better moment to relive and celebrate the magnificent product of worldly human collaboration than these days, as people around the globe started receiving their first doses of COVID-19 vaccines. A deadly virus that took the world by surprise and killed more than 1.5 million people, now, only a year later, has more than one vaccine with proven efficacy. It is amazing how far we have come along since the times of Smallpox! The obvious difference is the power of science and research, yet, another big and equally important difference, is how well connected our world is right now. This unprecedented connection is what allowed us to have a global response to this pandemic and unite our efforts to create a solution (Figure 2). Two Turkish immigrants develop a technology in the labs of a Germany-based biotech company to be quickly adopted by an American Pharmaceutical giant, which tests it and subsequently mounts a large-scale distribution process around the world —among other fascinating stories. As much as we seem deeply divided nowadays, due to political and ideological differences, in fact, over the history of humankind, there has never been a time where the world population was more united! Maybe we clearly see our major differences simply because we have never been this close! And our closeness and continued collaboration are what will get us through this! It is too early to declare victory, and things are far from perfect, but it’s a good time to pause and appreciate our progress!

Figure 2: The global effort for COVID-19 vaccine development.
Image credit: Judith Kulich, Cody Powers, Amit Pangasa, Kristyn Feldman, Parul Rewari and Samaya Krishnan. COVID-19 vaccines: Who might win the race to the global market? Published May 13, 2020. Available online on: https://www.zs.com/insights/covid-19-vaccines-who-might-win-the-race-to-the-global-market

References:

Hopkins DR. The greatest killer: smallpox in history. vol. 793. University of Chicago Press; 2002.
Razzell P. The conquest of smallpox: the impact of inoculation on smallpox mortality in eighteenth century Britain. Caliban Books, 13 The Dock, Firle, Sussex BN8 6NY; 1977.
Lady Mary Wortley Montagu, “Lady Mary Wortley Montagu on Small Pox in Turkey [Letter],” in Children and Youth in History, Item #157. Available online: https://chnm.gmu.edu/cyh/items/show/157 (accessed December 27, 2020). Annotated by Lynda Payne
Lindemann, Mary. Medicine and Society in Early Modern Europe. Cambridge University Press. p. 77. ISBN 978-0521732567; 2013.

COVID-19: Healthcare Workers vs The Vaccine

January 9, 2021January 8, 2021 Dapo Iluyomade, MD

The mid-December rollout of two FDA-approved COVID-19 vaccines coincided with a surge in US infections, as we surpassed 21 million cases and 300k deaths. Amidst the hope for a recovery from the virus, that has captivated the world for the past 10 months, the vaccine rollout was met with stiff resistance from many Americans. Of these, healthcare workers comprise the largest group of those refusing vaccination (albeit, healthcare workers also comprised the majority of people offered the early doses). This theme has persisted over the past few weeks. I will review some of the ideas behind the refusal of vaccine acceptance.

First, the headlines (taken from Forbes):

Last week, Ohio Gov. Mike DeWine said he was “troubled” by the relatively low numbers of nursing home workers who have elected to take the vaccine, with DeWine stating that approximately 60% of nursing home staff declined the shot.
Joseph Varon, chief of critical care at Houston’s United Memorial Medical Center, told NPR in December more than half of the nurses in his unit informed him they would not get the vaccine.
Roughly 55 percent of surveyed New York Fire Department firefighters said they would not get the coronavirus vaccine, the Firefighters Association president said last month.
The Los Angeles Times reported that hospital and public officials in Riverside, Calif., have been forced to figure out how best to allocate unused doses after an estimated 50% of frontline workers in the county refused the vaccine.
Fewer than half of the hospital workers at St. Elizabeth Community Hospital in Tehama County, Calif., were willing to be vaccinated, and around 20% to 40% of L.A. County’s frontline workers have reportedly declined an opportunity to take the vaccine.
Nikhila Juvvadi, the chief clinical officer at Chicago’s Loretto Hospital, said that a survey was administered in December, and 40% of the hospital staff said they would not get vaccinated.

Distrust For The Government Among Black/LatinX

Frontline workers in the United States are disproportionately Black and Hispanic. It is no surprise to my readers, as mentioned briefly in my AHA recap article(s), that structural racism is (and has been) a pervasive force within healthcare. “I’ve heard Tuskegee more times than I can count in the past month — and, you know, it’s a valid, valid concern,” said Dr. Juvvadi. This forms the crux of the argument made by minority frontline workers against receiving the vaccine. A recent survey by the Kaiser Family Foundation found that 29% of healthcare workers were hesitant to receive the vaccine, citing concerns related to potential side effects and a lack of faith in the government to ensure the vaccines were safe. Furthermore, dissenters question the involvement of Black/LatinX participants in the clinical trials that led to the development and deployment of at least two FDA-approved vaccines at the time of this article. Dr. Juvvadi told NPR that “there’s no transparency between pharmaceutical companies or research companies — or the government sometimes — on how many people from.” In an op-ed published in the New York Times last week, emergency physicians Benjamin Thomas and Monique Smith wrote that “vaccine reluctance is a direct consequence of the medical system’s mistreatment of Black people,” exemplified by the unethical surgeries performed by J. Marion Sims and the Tuskegee Syphilis Study, that highlight “the culture of medical exploitation, abuse, and neglect of Black Americans.”

Altruism and Others More Deserving

Medicine is an inherently altruistic field, one that requires a dedication to the service and betterment of others. This theme has largely affected the sentiment concerning the acceptance of the COVID-19 vaccines. In an op-ed published earlier this week by Marty Makary MD MPH, a professor of surgery and health policy at the Johns Hopkins University School of Medicine, the case for delaying vaccination is made. Dr. Makary states:

“After a summer of corporate statements pledging that Black Lives Matter, America’s vaccine rollout is creating inequities stemming from a ruling class making rules to favor themselves. In the first two weeks after the FDA authorized the life-saving vaccine, hospital board members, spouses of physicians, cosmetic surgery receptionists, and young firefighters have been getting the vaccine ahead of our society’s most vulnerable. Low-risk Americans with access and power are cutting in the vaccine line and, by doing so, are essentially telling our society’s most vulnerable members ‘your life matters less.’”

Dr. Makary shares his experience as a physician who performs surgeries on COVID-negative patients in a sterile environment with the highest infection control precautions accounted for. Furthermore, he weighs his personal risk of having a complicated course of COVID-19 infection versus that of his elderly patients, many of whom have multiple comorbid medical conditions. He argues that low-risk healthcare workers, including those who have already been infected, defer their vaccination in order to allow for higher-risk individuals to receive a potentially life-saving intervention. This highlights the chasm in Medicine between altruism and self-preservation. Is it possible to do both?

I end with a quote from Dr. Makary, expressing his views on the matter:

“I’m not criticizing clinicians who get the vaccine — my personal decision might be different if I spent more time in the ICU, took more ER calls, or was at high risk of being a silent carrier of the virus, putting my patients at risk. But that’s not me. Given my very low personal risk of mortality and my very low risk of getting the virus in my clinical work, I have joined a growing chorus of healthcare workers who have taken a pledge to not get the vaccine until every high-risk American has been offered it first.”

Thank you for reading, and please feel free to reach out to me with comments or questions on Twitter @DrDapo.

The Inequity of the COVID19 Vaccine Distribution: The rich countries hoard vaccines while the poor countries struggle to get them

December 28, 2020December 17, 2020 Miguel Quintero-Consuegra, MD

Last week at Cedars-Sinai, we received an email asking its employees interested in getting the vaccine against COVID19. I was very excited about this since it means a lot of things at once. The development of safe mRNA vaccines in a short period shows how much technology has advanced and highlights the importance of working together as the companies that manufactured the vaccines were not in a race against each other but against the virus. On the other hand, getting a notification that I was soon going to get vaccinated against this virus that has changed our world was pure joy, that sadly faded away.

As I told my friends and family the excitement that I was having because I would be vaccinated soon, all they did was ask me, but when are we going to get the vaccination for us? For our healthcare workers, grandparents, and grandmothers? We have heard in the USA with optimism how the government has secured millions of doses for its people, and it only makes sense that a government wants to put their citizens first but, at what cost? Where does the solidarity with other nations reside? These questions made me dig deeper into an issue that gets shadow by the hype of us getting vaccinated.

The People Vaccine Alliance, an international watchdog that includes Amnesty International, has warned that some countries have bought enough COVID vaccine to immunize their populations more than once. It highlights Canada as the top country on this matter that has reported over 400.000 cases of COVID19 has secured enough vaccinations to immunize its population at least five times. In contrast, poorer countries will only be able to vaccinate one in ten people. The Alliance data also showed that the deals that have been done between the governments and the eight leading vaccine candidates’ risk of leaving behind middle-low and low-income countries, as rich nations hoard on vaccine deals.¹

A clear example of the disparity between the rich and the poor has been the Moderna and Pfizer vaccines’ inequitable deals, which have shown on their preliminary data to have the highest efficacy rate. Due to their promising results, the vaccine lots have been bought in a staggering 96% for Pfizer and 100% for Moderna by rich nations. With those impressive figures, the gap between the have and the have nots will stretch even further. The Director-General of the World Health Organization, Tedros Adhanom, warned during a press conference “Every government rightly wants to do everything to protect its people, but there is now a real risk that the poorest and most vulnerable will be trampled in the stampede for vaccines”.²

Nonetheless, international efforts have been made to achieve global vaccination, such as COVAX. This compact, composed of 189 countries, amongst which the USA and Russia resonate for their absence, has high and middle-income countries committing to provide funding to ensure access to vaccination and equitably manufacturing them. In contrast, poorer countries have signed to secure vaccines for their population. This effort will also be backed up by agencies such as the Bill and Melinda Gates Foundation.³ Efforts by the Oxford/Aztreneca are also of great importance to allow developing nations to get the vaccine, as they have pledged to five more than half of its doses to developing nations. Unfortunately, this would only reach 18% of the world’s population.⁴

I concur with Melinda Gates’s denomination of this phenomenon as vaccine nationalism, with the populist premise of “our citizens first,” that suffice its purpose of improving the polls for political gains. However, these actions go against one of the most powerful lessons this pandemic has taught us, the sense of community and working towards the benefit of all.

I firmly believe that vaccine allocation for a health crisis like this should prioritize global immunization for healthcare workers and elderly patients, rather than prioritizing country of residence or origin. It is not acceptable to have an effective vaccine, not reaching healthcare providers on the frontlines of developing countries fighting this virus without this indispensable weapon. In contrast, rich countries rely on an excess of vaccines and immunize low-risk citizens first.

This pandemic has shown us how fragile humanity. Now more than ever, the rich countries and their economic capacity must set an example of global leadership and outline a sensible policy that focuses on a global perspective rather than an exclusive, nationalistic one because this crisis won’t be over until everyone gets vaccinated.

References

COVID-19 Vaccine: What We Need To Know

December 23, 2020December 16, 2020 Lina Ya'qoub, MD

While we are living in the third peak of COVID-19 pandemic, we have been delighted to hear about the recent food and drug administration (FDA) approval of the COVID-19 vaccine, after trials involving hundreds or more of patients showed the vaccine safety and efficacy [1,2]. However, the COVID-19 vaccine is associated with some side effects, which in fact might be more common than the flu vaccine. Healthcare workers and first responders will have the priority to get the vaccine at many institutions given their high-risk work environment. So, I decided to share some knowledge about some of the side effects of the vaccine I recently read about and how institutions are planning to stagger the vaccines among their employees.

What are the side effects of the vaccine?

Side effects seem to be more common than the annual flu vaccine, with arm pain at the injection site, generalized fatigue and malaise, headaches, dizziness, fever, chills, nausea, vomiting, and diarrhea. Rare side effects include Bell’s palsy and temporary facial muscle paralysis. Most of these side effects are mild and resolve in a few days. These side effects occur more frequently after the second dose of the vaccine. These side effects actually suggest reactogenicity and that the immune system is responding to the vaccine [1,2].

Are there long-term adverse events of the COVID-19 vaccine?

This is still unknown and under close monitoring by FDA [1].

How will the vaccine change things from now on?

The COVID-19 vaccine is an additional protection layer, but it does not substitute the other protection measures we have been following; that means we should still conform to social distancing and follow hygienic instructions wherever we go till the pandemic is over. This pandemic has taught us all, as a healthcare professional and as members of the community, to be responsible for our actions toward each other and persist despite all the obstacles. The vaccine could be the first step that leads us back to “normal life” as long as we stay responsible for each other.

REFERENCES

[1] Walsh EE, Frenck RW Jr, Falsey AR, et al. Safety and Immunogenicity of Two RNA-Based Covid-19 Vaccine Candidates [published online ahead of print, 2020 Oct 14]. N Engl J Med. 2020;NEJMoa2027906. doi:10.1056/NEJMoa2027906

[2] Yuan P, Ai P, Liu Y, Ai Z, Wang Y, Cao W, Xia X, Zheng JC. Safety, Tolerability, and Immunogenicity of COVID-19 Vaccines: A Systematic Review and Meta-Analysis. medRxiv [Preprint]. 2020 Nov 4:2020.11.03.20224998. doi: 10.1101/2020.11.03.20224998. PMID: 33173896; PMCID: PMC7654888.

COVID-19 Vaccine & Cardiovascular Disease: What We Know So Far

December 22, 2020December 17, 2020 Barinder Hansra, MD

It’s hard to believe the majority of 2020 was spent in a pandemic. The world came to a screeching halt and the entire scientific community worked tirelessly to find ways to keep each other safe. However, we all have experienced highs and lows due to COVID-19. But we were fortunate to have Operation Warp Speed to help produce and deliver millions of doses of safe and effective vaccines against the COID-19 virus.¹

It is well known that traditional risk factors such as hyperlipidemia, hypertension, diabetes, and obesity are modifiable risk factors for coronary artery disease. Through the evolution of research, inflammation and infection were also discovered to play a role in developing an acute myocardial infarction (MI).^2,3 After the epidemics of influenza in Europe and the US in the early 1900s, it was speculated that there is a relationship between influenza and MI. This was on the basis that excess mortality was due to other causes than influenza, such as heart disease.⁴Mechanistically, influenza causes platelet aggregation leading to MI. This finding (along with others) led the American Heart Association and American College of Cardiology in 2006 to recommend influenza immunization as a part of comprehensive secondary prevention in persons with coronary and other atherosclerotic vascular diseases (class I, level B).⁵

Based on our past experiences of viral infections and the current pandemic-state, what emerged was that on November 20, 2020, Pfizer and BioNTech (the sponsor) submitted an Emergency Use Authorization (EUA) request to the FDA for an investigational COVID-19 vaccine. The purposed use under a EUA is for active immunization for the prevention of COIVD-19 caused by SARS-CoV-2 in individuals 16 years of age and older; with a 2 doses regimen, administered 21 days apart.¹

There are many safety and side effects to discuss regarding the vaccine (any vaccine for that matter) but I’ll be focusing on the cardiovascular risk profile. The most frequent comorbidities were obesity (35.1%), diabetes (8.4%), and pulmonary disease (7.8%)^.1 Other baseline characteristics included: myocardial infarction (1%), peripheral vascular disease (0.6%), congestive heart failure (0.4%), and hypertension (24.5%).¹

Of the serious adverse events, a total of 6 deaths (2 vaccines, 4 placeboes) from the total 43,448 participants occurred. Both vaccine recipients were >55, one experienced a cardiac arrest 62 days after the second vaccination dose and the other died from arteriosclerosis 3 days after the first dose. From the placebo group, only 1 patient died from an MI. Interestingly, 1 patient had ventricular arrhythmia but was known to have cardiac disease. Overall, there was no imbalance in severe adverse cardiovascular events. In general, serious adverse events were uncommon and represented medical events that occurred at a similar frequency in the general population.¹

Some of the gaps from the safety reporting of the COVID-19 vaccine includes; duration of protection – as the participants are not more than 2 months out from initially receiving the vaccine, the et of immunocompromised individuals is too small to evaluate efficacy (i.e. heart transplant recipients ), children <16, and pregnant/lactating individuals.

Where does this leave us as leaders in the health community? We can recognize that the benefits do outweigh the risks and continued efforts will be made to monitor the health of Americans. At this point, I believe we can clearly communicate potential cardiovascular outcomes with our patients to help them make an informed decision.

References

Vaccines and related biological products advisory committee meeting. FDA briefing documents. Pfizer-BioNTech COVID-19 vaccine.
Epstein SE, Zhou YF, Zhu J. Infection and atherosclerosis: emerging mechanistic paradigms. Circulation. 1999;100:20-28
Syrjanen J. Infection as a risk factor for cerebral infacrtion. Eur Heart J. 1993;14:17-19.
Collins SD. Excess mortality from causes other than influenza and pneumonia during influenza epidemics. Public Health Rep. 1932;47:2159-2168.
Smith SC Jr, Allen J, Blair Sn, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update. Circulation 2006;113:2363-72

COVID-19 and Historical Distrust

December 18, 2020December 16, 2020 Aubrey J. Grant, MD

As a member of the AHA FIT programming subcommittee, I could not have been more excited about the upcoming scientific sessions meeting. The planning for this meeting began many months in advance with lots of zoom sessions, emails, and organizing to help lay the groundwork for a successful event. As a new member of the committee, I was excited to facilitate the preventative cardiology fireside chat and the racism in medicine discussion.

However, two days prior to the session, I woke up with a terrible headache and I generally felt unwell. Considering the ongoing pandemic, I was concerned that I may be infected with COVID-19. Over the next twenty-four hours, my symptoms worsened and the following morning I tested positive for the virus.

As my illness progressed, I experienced all of the common reported symptoms: myalgias, headaches, cough, shortness of breath, and fevers. The fatigue persisted despite adequate rest. The barking cough was painful, and the constant fevers were so agonizing. The onslaught of symptoms persisted throughout my time in quarantine, and the experience was extremely debilitating. Moreover, Instead of conversing with amazing and thoughtful leaders in the field of cardiology as previously planned, the virus forced me to focus on my own physical well-being.

One of the more insidious, yet profound effects, of the COVID-19 infection, is the effect it has on your mental wellbeing. As a physician who manages COVID patients, I am uniquely sensitive to the dramatic and acute trajectory the disease may take. Being isolated in quarantine for 10-14 days, while intimately perceiving every symptom in fear, was a distinctly stressful symptom of COVID that I could have never predicted. I was confronted with my most crippling fear of progressing to critical condition and needing to be hospitalized. Regardless of the fact that I am a physician, I stared in the face of the reality that as a black man, I have a greater chance of worse outcomes.

The pandemic has further highlighted the disparity in care that exists in this country among different racial and ethnic groups. A recent publication reviewed the American Heart Association (AHA) COVID-19 registry of race and ethnicity data, which included 7,868 hospitalized patients across 88 registry sites from Jan 1 to July 22, 2020, revealed an over-representation of Non-Hispanic Black and Hispanic patients, which accounted for >50% of hospitalizations [1]. Further, these minority patients were significantly younger than patients of other ethnicities at the time of hospitalization [1]. The disproportionate rates of COVID-19 illness, hospitalizations, and death in Black and Hispanic communities are linked to several structural risk factors including living in crowded housing conditions, working in essential fields, Inconsistent access to health care, chronic health conditions, and chronic stress.

This specific health disparity is just one example of the striking effects of structural racism, years of distrust in healthcare, and lack of physical representation in the medical field on healthcare outcomes in this country. What is more alarming, is that even with the availability of a safe and effective vaccine, the historical pretext of racism in healthcare will delay and prohibit mass vaccination among many vulnerable minority populations. In a recent Kaiser Family Foundation poll, half of Non-Hispanic Black adults are not planning to take a coronavirus vaccine once one becomes available, even if scientists declare it safe and if it is available free of cost [2]. Among Non-Hispanic Black adults who say they are not planning to get a vaccine, nearly 40% cite safety concerns, including that it will be too new and assume insufficient testing [2]. Another 35% attributed their concerns to a general lack of trust or have doubts about the government or the health care system [2].

If we ever hope to get back to some sense of normalcy, herd immunity secondary to general vaccination needs to be the utmost priority among healthcare professionals. Overcoming the understandable barriers of distrust that exist in the minority community will not happen overnight. However, consistent efforts to understand, relate, and effectively communicate with patients of color can slowly help to assuage fears about vaccinations and create positive relationships between the healthcare system and the most vulnerable communities that are often ignored.

So I ask the question, what can you do as a healthcare provider to better understand and address these hurdles and to help encourage acceptance of the COVID-19 vaccination?

References

Rodriguez F, Solomon N, de Lemos JA, Das SR, Morrow DA, Bradley Smet al. Racial and Ethnic Differences in Presentation and Outcomes for Patients Hospitalized with COVID-19: Findings from the American Heart Association’s COVID-19 Cardiovascular Disease Registry. Circulation. 2020 Nov 17. Doi: 10.1161/CIRCULATIONAHA.120.052278. Epub ahead of print.
Hamel, L., Muñana, C., Artiga, S. and Brodie, M., 2020. KFF/The Undefeated Survey On Race And Health. [online] Kaiser Family Foundation. Available at: <https://www.kff.org/racial-equity-and-health-policy/report/kff-the-undefeated-survey-on-race-and-health/> [Accessed 16 December 2020].

Gratitude on Our Worst Days

December 9, 2020December 9, 2020 Nasrien E. Ibrahim, MD

My dad desperately tried to get a hold of me on the morning of December 1, 2020 but for some reason, I hadn’t seen that he called me and so I found out my aunt, Dr. Somaya Saad Zaghloul, succumbed to COVID-19 via my mom and aunt’s medical school classmate on Facebook Messenger. Exactly what my dad was trying to prevent. I called my parents immediately and the tragic news was confirmed. We were desperately praying since her admission to the hospital that she would be one of the lucky ones, but that morning, God had other plans. I in turn desperately called my brothers and sister so that they wouldn’t find out through social media as I had and in comforting them through my tears, I reminded them that Aunt Somaya was diagnosed with rheumatoid arthritis at age 17 and that during the last several years her pain was debilitating. She needed a wheelchair to get around when her legs couldn’t carry her very far, but despite that, she was teaching her medical school courses up until she was diagnosed with the cruel virus; now, she was no longer in pain. The epitome of grace, of resilience, of living life to the absolute fullest, of smiling through your struggle, of generosity, of welcoming everyone into your home, of always looking like a million bucks (bright red lipstick and all) even if you weren’t feeling like it, of loving deeply, and of being grateful for every blessing. She was legendary.

Another cruel reminder to be grateful for everything we’re blessed with, the big things, the small things, and everything in between; the things we take for granted every day like waking up with a roof over our head, food on our table, clothes on our back, a sound mind, legs that carry us, and the ability to go to work. Every morning I wake up with a routine that includes prayer and meditation, exercise, listening to the previous day’s The Breakfast Club episode, setting my intention for the day, and importantly, writing down at least 1 thing I am grateful for and I make it something specific. My morning power hour gets me through the toughest days and makes the best ones even more fabulous, it keeps me grounded. Gratitude, when practiced regularly improves mental wellness, increases empathy, reduces anger, increases happiness and satisfaction, improves self-esteem, and best of all, helps you sleep better. I highly recommend including it in your daily routine either every morning or before you sleep at night. The practice has changed the way I view the world and how I deal with its curveballs.

Every Christmas, I request to be on call on the inpatient Heart Failure and Transplant service to honor the death of my uncle, Dr. Ali Saad Zaghloul, from a massive heart attack on December 25, 2016, a tragic death I first found out about ironically via social media. Now, I will be honoring both my aunt and uncle every December for the entire month by feeding the less fortunate, by working the holidays so others who celebrate can spend time with their families, by remembering to always be kind and forgiving, by living each day like it were my very last, and most important, being there for patients who need the most support during their most vulnerable moments.

I hope we take the lessons 2020 taught us into 2021. My biggest lesson remains that human connections are the most important thing in this world. I wish you a safe, socially distanced, and serene holiday season. The light at the end of the tunnel is not so far away anymore, we’re almost there. I’m sending an overabundance of love and light to everyone who needs it right now. The souls who’ve departed us far too soon will live on forever through all those they touched.

Drs. Ali and Somaya Saad Zaghloul

#AHA20 and#COVID-19: Late-breaking science insights from the AHA COVID-19 registry

November 20, 2020November 20, 2020 Aaysha Cader, MD, MRCP

The American Heart Association (AHA) COVID-19 registry, leveraging the existing AHA Get With The Guideline (GWTG) platform, was developed to better understand hospital outcomes and adverse cardiovascular complications for patients with COVID-19.

The registry was formulated to accelerate the pace of COVID-19 research and quality improvement, where granular data were collected and analyzed at an unprecedented pace, shortening time to discovery and dissemination of results. As of November 9, 109 sites across the United States had enrolled over 22,500 patients in the registry. Data derived from the registry provided for some interesting results, presented at the late-breaking science session 7 at AHA Scientific Sessions.

Cardiovascular risk factors: The vast majority of hospitalized COVID-19 patients had cardiovascular risk factors, with only fewer than 15% having no traditional risk factors. Hypertension predominated (~60%), followed by diabetes (35%) and notably, obesity (45%).

In-hospital cardiac complications: The registry predominantly found that in-hospital cardiac complications occurred less frequently than initially feared, with the cardiovascular (CV) composite of complications (including CV death, myocardial infarction [MI], stroke, heart failure and shock) occurring in approximately 8.8%. Individual CV complications occurred as follows: MI ~3%; stroke, heart failure, and shock ~2%. Myocarditis was uncommon, occurring in 0.3%. Deep vein thrombosis (DVT) and pulmonary embolism (PE) occurred in 3.8%, substantially lower than those reported in prior single center reports.

The death occurred in ~19.5% in total, with respiratory causes predominating (72%) and only 10% being attributed to a cardiac cause. 18% had other causes, commonly sepsis. The need for mechanical ventilation was ~20%.

Racial and Ethnic Differences in Presentation and Outcomes for Patients Hospitalized with COVID-19 [1]

Race and ethnicity data of 7,868 hospitalized patients across 88 registry sites from Jan 1 to July 22, 2020 revealed an over-representation of Black and Hispanic patients, who accounted for >50% of hospitalizations. They were significantly younger than patients of other ethnicities at the time of hospitalization. Hispanics were more likely to be uninsured.

The longest duration from symptom onset to hospital arrival and a diagnosis of COVID was observed in Asian patients, who also had the highest cardiorespiratory disease severity at presentation.

There was a significant burden of CV risk factors among black patients with obesity (49.3%), diabetes (45.2%), and hypertension (69.9%) being the highest reported prevalence across ethnic groups.

Mortality: The overall mortality in this dataset was 18.4% with a total of 1,447 deaths, among which, 53% occurred among Hispanic and Black patients. However, after adjusting for sociodemographic, clinical, and presentation features, mortality and major adverse cardiovascular or cerebrovascular events did not differ by race/ethnicity.

Nevertheless, given the greater burden of mortality and morbidity of Black and Hispanic patients, the authors recommended that interventions to reduce disparities in COVID-19 be focused upstream from hospitalizations.

Association of Body Mass Index (BMI) with Death, Mechanical Ventilation, and Cardiovascular Outcomes in COVID-19 [2]

In an important analysis looking at the association of BMI with COVID-19 outcomes, this study found that obesity, and particularly class III obesity, is over-represented in the registry among patients of COVID19, with the largest differences observed among adults < 50 years. Higher obesity class associated with younger age. Higher BMI class was also associated with a higher prevalence of the black race.

Among 7606 patients, the composite primary endpoint of in-hospital death or mechanical ventilation occurred in 2109 (27.7%) patients. After multivariable adjustment, classes I to III obesity were associated with progressively higher risks of in-hospital death or mechanical ventilation. Significant BMI by age interactions was seen for all primary endpoints. There was no association between obesity class and major adverse cardiac events (MACE). As for venous thromboembolism, Class II obesity was associated with a composite higher risk of venous thromboembolism.

Severe obesity (BMI ≥40 kg/m2) was associated with an increased risk of in-hospital death only in those ≤50 years (hazard ratio, 1.36 [1.01–1.84]). In light of these findings, the authors underscored the importance of clear public health messaging and a rigorous adherence to COVID-19 prevention strategies in all obese individuals regardless of age, but especially those <50 years who may underestimate their risk for COVID-19.

The entire session can be viewed on-demand until the 4^th of January 2020: AHA Goes Viral: COVID-19, Influenza Vaccines, and Cardiovascular Disease. Both the above studies were also simultaneously published in Circulation.

References:

Rodriguez F, Solomon N, de Lemos JA, Das SR, Morrow DA, Bradley Smet al. Racial and Ethnic Differences in Presentation and Outcomes for Patients Hospitalized with COVID-19: Findings from the American Heart Association’s COVID-19 Cardiovascular Disease Registry. Circulation. 2020 Nov 17. doi: 10.1161/CIRCULATIONAHA.120.052278. Epub ahead of print.
Hendren NS, de Lemos JA, Ayers C, Das SR, Rao A, Carter S. Association of Body Mass Index and Age With Morbidity and Mortality in Patients Hospitalized With COVID-19: Results From the American Heart Association COVID-19 Cardiovascular Disease Registry. Circulation. 2020 Nov 17. doi: 10.1161/CIRCULATIONAHA.120.051936. Epub ahead of print.