May 2020


DenverCovid19HospRate

Valverde neighborhood has the highest rate of Covid-19 hospitalization in Denver. Image from Christie Mettenbrink for Denver Public Health

by George Taniwaki

Denver’s Valverde neighborhood is just a few miles from the Barnum West neighborhood where I grew up. The streets there are busier and noisier, with more industrial businesses lining Alameda Ave. and Federal Blvd. Studies show excessive car traffic can lead to stress and chronic respiratory ailments, especially when combined with smoking, which is more common among residents there.

The houses are smaller, with more families living in multigenerational arrangements. Residents are more likely to ride public transportation to get to work or school. They are also more likely to have jobs that are considered essential. Crowded living and working conditions increase the likelihood of contracting Covid-19.

Finally, adults in Valverde are less likely to speak English at home, meaning they have less access to healthcare information. They are less likely to have health insurance and less access to healthcare providers, even if they have insurance.

This isn’t an accident of history. Cities like Denver had long adopted policies (Colorado Trust, May 2018) that encouraged racial segregation and discrimination. From the 1920s until the 1970s, the city worked with banks, mortgage companies, and property insurers, to draw maps of neighborhoods that were safe, a practice called redlining. Similar maps were used by Denver Public Schools to plan the location of new buildings to ensure schools were kept racially segregated.

Even today, the impact of segregation is still visible. An excellent article in The Conversation (May 2020) looks at the distribution of Covid-19 hospitalization rates by neighborhood (see map at top). You can see more charts and an explanation at Denver Public Health (May 2020).

InfectionPreventionConversationCartoon

Staff need to encourage patients to speak up. Image from CDC

by George Taniwaki

While doing research on the role being played by the Center for Disease Control and Prevention (CDC) during the Covid-19 pandemic, I accidentally discovered a website full of information on infection prevention for dialysis patients.

The most effective way to prevent infection is for both the patients and staff to be trained on infection prevention and best practices. Further, they should both actively monitor the dialysis procedure to be aware of opportunities for infection. Finally, patients should feel free to speak up if something looks amiss, and staff should welcome feedback.

The CDC website contains videos, posters, a cartoon (see screenshot above), and other resources for training staff and patients. It also contains information about the Making Dialysis Safer for Patients Coalition. Good stuff.

Making Dialysis Safer Coalition

GGSC_Speakers

The presenters at the Greater Good Online Institute for Health Professionals, Eve Ekman, Dacher Keltner, Jamil Zaki, Elissa Epel, and Jyothi Marbin (not shown Liz Markle). Image from  Greater Good Science Center

by George Taniwaki

A couple weekends ago, I attended the Greater Good Online Institute for Health Professionals, May 2-3, 2020. The workshop was sponsored by the Greater Good Science Center at University of California, San Francisco. I was hoping to pick up some tips on how I can improve my ability to empathize with kidney patients and their family in order to help them find a donor.

It turns out the program was focused on a completely different set of topics related to reducing stress, improving self-care, and treating patients holistically. Not helpful for my goal, but an interesting weekend nonetheless.

Key take away

If you are interested in leading a happier life and connecting to others with empathy, then the GGSC has tools to help you. They have an online magazine, a Science of Happiness podcast, and videos. In addition to having classes for health professionals, they have online courses for the workplaceK-12 educators, and families.

After the workshop, one of the goals for participants is to commit to making one change in our lives to make us happier. A typical goal would be to regularly share with a colleague (a few times a week) three good things that you are grateful for. Reflecting on your day and picking out three good things is hard, especially during a pandemic. Striking up a conversation with a colleague simply to talk about one’s feelings is uncomfortable. But the practice sounds useful, I will endeavor to try.

Agenda and video recordings

The agenda along with links to the speaker’s video sessions are shown in the table below. After each speaker there was a breakout session (not shown) where small groups could reflect on the talk and discuss how it impacts them. Of course, you won’t be participate in the group discussion as an individual watching the YouTube recording, but perhaps you can try turning on your camera and talking to yourself.

Schedule YouTube Description
Sat, 8:30 – 9:00 31:00 (no sound at start) Dacher Keltner and Eve Ekman — Welcoming remarks/grounding
Sat, 9:00 – 9:30 1:00:19 Dacher Keltner — Gratitude and Awe in Healthcare
Sat, 10:30 – 11:00 2:32:43 Jyothi Marbin — Diversity, Equity, and Inclusion in Healthcare
Sat, 12:30 – 1:00 4:31:53 Jamil Zaki — Neuroscience of Empathy in Medicine
Sun,8:30 – 9:00 28:29 Dacher Keltner and Eve Ekman — Welcoming remarks/grounding with review of themes from previous day
Sun, 9:00 – 9:30 1:0054 Liz Markle — Behavioral Health and the Community as Medicine
Sun, 10:30 – 11:00 2:29:33 Elissa Epel — Supporting Stress Resilience in Healthcare
Sun, 12:30 – 1:00 4:31:46 Eve Ekman — Emotion Awareness in Healthcare
Sun, 1:45 – 2:00 5:43:05 Eve Ekman and Dacher Keltner — Closing remarks and reflection

About the speakers

Short biographies of the six speakers are available at GGSC. Some additional speaker resources and links are shown below.

Speaker Resource
Eve Ekman, Ph.D., MSW Three-Day Online Immersive Emotional Balance Training in June; Atlas of Emotions Online and Eve Ekman trainings online; free Guided Meditations
Dacher Keltner, Ph.D. Born to be Good
Jyothi Marbin, M.D. UCSF
Jamil Zaki, Ph.D. The War for Kindness
Elizabeth Markle, Ph.D. Open Source Wellness, podcast conversation about Community as Medicine
Elissa Epel, Ph.D. UCSF Resources to Support Your Mental Health During Coronavirus, The Telomere Effect

GGSC_Logo

Nightingale-mortality

Example of polar area chart showing causes of mortality among soldiers by month during Crimean war. Image from Wikimedia

by George Taniwaki

May 12 is International Nurses Day to recognize the contribution nurses make and to celebrate the birth of Florence Nightingale. Today marks the 200th anniversary of her birth. The World Health Organization named this year the Year of the nurse and midwife in her honor. Certainly, with the Covid-19 pandemic in full force, 2020 will be remembered as the Year of the nurse for many years to come.

Ms Nightingale, who was born in Florence, Italy was the founder of the modern nursing profession. Prior to her efforts, nursing was a volunteer activity, most often undertaken by untrained family members, soldiers, or religious members. Ms Nightingale trained nurses during the Crimean War. She later founded the first secular nursing school and published many nursing textbooks.

In addition to advancing nursing in a clinical setting, Ms Nightingale was a social activist who advocated for more government spending on healthcare for the poor. She helped develop the field of public health nursing to reach patients who were poor and sick at home.

Finally, Ms Nightingale was an incredible statistician and a pioneer in data visualization. She kept thorough notes and documented which treatments worked and which did not, making it possible for others to replicate her results. She popularized a type of pie chart that she called a coxcomb (see image above) and is now known as a polar area chart. She was the first woman elected to the Royal Statistical Society and became an honorary member of the American Statistical Association.

SafeStartWashington

Washington will end its quarantine using a four-step plan. Image from WA governor office

by George Taniwaki

On May 4, the state of Washington announced a plan to end the quarantine (Medium May). The plan is called Safe Start and includes four phases. The state is currently in Phase 1.

For each later phase, the list of allowed social activities and businesses that can be open increases. The lists are a fascinating insight into the conflict between medical advice, business interests, and social pressures that have surfaced during the pandemic. For instance golfing is allowed during Phase 1, but social gatherings are not.

Flexibility at the county level

One of the problems that other states have had regarding social distancing compliance is that rural areas with smaller populations and lower population densities believe that quarantines are being imposed on them by big city politicians. Thus, any successful plan must include a method for them to open faster, if the medical conditions allow it. (That is, if the caseload is low enough to not overwhelm the local hospitals, testing levels and contact tracing efforts are high enough to catch nearly all cases, and social distancing and hygiene practices widespread enough to reduce infection rates.)

Washington’s plan allows counties with a population of less than 75,000 that have not had a new case of COVID-19 in the past three weeks to move into later phases earlier by petitioning the state Department of Health.

American microbiologist Dr Maurice Hilleman (1919 - 2005) (center, rear) talks with his research team as they study the flu virus in a lab at Walter Reed Army Institute of Research, Silver Springs, Maryland, 1957. Fellow microbiologist F Joseph Flatley is near left. (Photo by Ed Clark/The LIFE Picture Collection via Getty Images)

Maurice Hilleman (center, rear) talks with his research team as they study the flu virus in 1957. Photo by Ed Clark/The LIFE Picture Collection via Getty Images

by George Taniwaki

The fall 2019 issue of Univ Chicago Mag contains the incredible story of Maurice Hilleman, PhD’44, a microbiologist. I had never heard of him, but he is truly an unsung hero. He worked on 40 vaccines in his lifetime. In an obituary published upon his death in 2005, Mr Hilleman is credited with saving more lives than anyone else in medical or public health history. That praise comes from Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (Wash Post, Nov 2005).

Mr Hilleman was one of the discoverers of the two types of genetic changes (called shift and drift) that cause humans to get repeated infections of the flu. His work guides the selection of which flu viruses that should be included in the annual flu vaccine and to predict which flu strains are likely to cause a pandemic.

In 1957, he was one of the  first people to realize an emerging 1957 flu virus could become a pandemic and sweep across the world. However, neither the US Public Health Service nor the Influenza Commission took the threat seriously. Hilleman approached six vaccine manufacturers directly. Forty million doses of vaccines were prepared and distributed. Although 69,000 Americans died, the pandemic could have resulted in many more deaths. Hilleman was awarded the Distinguished Service Medal for his work.

In addition to flu vaccines, Mr Hilleman was involved in the creation of vaccines for measles, mumps, rubella (and the combined MMR vaccine), hepatitis B, and chicken pox (varicella). Overall, he worked on 40 vaccines, including 9 of the 14 diseases that now have pediatric vaccines.

Cow_pock

The cow pock or the wonderful effects of the new inoculation! – the publication of ye Anti-Vaccine Society. Image from Wikimedia

by George Taniwaki

Today marks the 40th anniversary of eradication of smallpox. You probably don’t fear smallpox. That’s because it is believed to be the first, and so far only, infectious disease of humans to be eradicated.

About smallpox

It wasn’t that long ago that smallpox was the most feared disease on earth. The disease is highly contagious and has a mortality rate of 30%. It could make whole cities uninhabitable. Those who survived it may have had scarring and blindness. The origin of the smallpox virus (Orthopoxvirus variola) is unknown. Based on gene clock dating, it may have first appeared in Africa about 30,000 years ago after jumping from rodents.

The disease may be the source of many of the plagues that have been recorded in history and is estimated to have caused 300 million deaths in the 20th century alone.

Prevention

Long before the development of modern vaccines, people realized that taking the small bits of the scabs and pus from a person infected with smallpox and inhaling it could result in a milder form of the disease. The mortality rate for this inoculation therapy was about 2 to 3%, but many felt it was a reasonable risk during an epidemic outbreak.

In 1796, Edward Jenner noticed that dairy farmers were less likely to get infected by smallpox. He guessed correctly that inoculation with the scabs and pus from a person infected with the O. cowpox virus would confer immunity to smallpox . Cowpox is a milder disease than smallpox, so the mortality risk from inoculation was lower as well. The name of his invention, vaccine, is derived from the Latin root vacca for cow. Not everyone was enthusiastic about his invention and anti-vaccine societies took root (see image at top).

The current smallpox vaccine is based on a third virus, O. vaccinia, which is closely related to horsepox and is believed to cause an even milder disease. The vaccine is about 95% effective while causing side-effects in about 2% of patients.

Newer vaccines have also been developed but not deployed. One, based on O. vaccinia Ankara uses a version of the vaccinia virus that has been modified so that it does not replicate, so cannot cause disease. Another contains recombinant DNA that express genes for the antigens, so does not contain any virus and does not need live animal cultures to manufacture.

Eradication

In 1959, the World Health Organization (WHO) proposed a plan to eliminate smallpox. However, funding did not appear until 1967, with the launch of the  Intensified Eradication Program. Cases of smallpox dwindled and one at a time, continents were declared disease-free. The last known case of smallpox occurred in October 1977 and the WHO certified the global eradication of smallpox on May 8, 1980.

As the disease became eradicated in developed countries, it became clear that while the number of hospitalizations and deaths were zero, the injuries caused by side effects of the vaccine were quite high. Thus, all nations began eliminating vaccination of their populations for smallpox. The exception is the U.S. military, which vaccinates all service members.

Today, the biggest controversy surrounding smallpox is whether to destroy the last remaining stocks of live O. variola virus (WHO 2008, CDC 2011). They are not needed to produce the current vaccine and are considered a high risk for an accident or intentional release as a bioweapon (NCBI 1999).

Vaccines work

It may seem ironic that we are “celebrating” the eradication of smallpox while sheltering at home waiting for tests, treatments, and preventatives for Covid-19. But it truly is a public health milestone. I hope this story helps convince you that vaccines work. They save lives. And we need one for Covid-19 as quickly as possible.

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