“A SEVERE FLU PANDEMIC… could kill more than 33 million people worldwide in just 250 days.” – “Boy, do we not have our act together.” — Bill Gates”. (J)

“It’s never an easy business to predict which flu viruses will make people sick the following winter. And there’s reason to believe two of the four choices made last winter for this upcoming season’s vaccine could be off the mark.”

“Flu circulation “remains difficult to predict and flu viruses are constantly breaking rules that we try to establish for them,”..”

 “No battle plan survives contact with the enemy” * 

Worth reading:

The Next Plague Is Coming. Is America Ready?, by Ed Yong


ASSIGNMENT: Does your community have a seasonal flu EMERGENCY RESPONSE PLAN? Do your community’s hospitals have SURGE CAPACITY  and RAPID RESPONSE TEAMS? If not, develop a plan!


In July of 2009 the Mayor of Hoboken asked me to organize a H1N1 “Swine Flu” Task Force. We started with a set of questions based on reports from communities that had already experienced a Swine Flu surge:

Health Officer: Where vaccination sites should be established? Is there a special plan to monitor restaurants and food shops where flu-related safety guidelines need to be strictly enforced? Who will start preparing a Community Education plan?

Hospital: What is the back-up plan if hospital becomes “contaminated” and is closed to admissions, or if nursing staff is depleted by flu-related absenteeism, etc.? ICU triage? Availability of respirators?

OEM:  off-site screening centers if hospital ER is on overload

Hoboken Volunteer Ambulance Corps:  “mutual assist” plan

Hoboken Police Department & Hoboken Fire Department: back-up plan if the ranks get depleted by the flu

BOE: criteria in deciding whether or not to close schools

Stevens Institute of Technology: surveillance and plan for (college) students

“Field Manual” for the Mayor outlining all variabilities and options

Why was there no swine flu surge in NJ/ NYC metro area? maybe “herd” immunity” from prior year’s flu?

“Australia had an unusually early and fairly severe flu season this year. Since that may foretell a serious outbreak on its way in the United States, public health experts now are urging Americans to get their flu shots as soon as possible.

“It’s too early to tell for sure, because sometimes Australia is predictive and sometimes it’s not,” said Dr. Daniel B. Jernigan, director of the influenza division of the Centers for Disease Control and Prevention. “But the best move is to get the vaccine right now.”..

In 2017, Australia suffered its worst outbreak in the 20 years since modern surveillance techniques were adopted. The 2017-2018 flu season in the United States, which followed six months later as winter came to the Northern Hemisphere, was one of the worst in modern American memory, with an estimated 79,000 dead.” (A)

“Maryland health officials on Tuesday confirmed the first 11 influenza cases of the flu season. Officials urge Marylanders to get vaccinated.

“We don’t know yet whether flu activity this early indicates a particularly bad season on the horizon,” Maryland Department of Health Secretary Robert R. Neall said in a statement. “Still, we can’t emphasize strongly enough – get your flu shot now. Don’t put it off. The vaccine is widely available at grocery stores, pharmacies and local health clinics, in addition to your doctor’s office.”

Most of the 11 cases recorded since Sept. 1 have been subtyped as influenza A, with a few classified as influenza B. Though most influenza cases are mild, the virus can pose a serious risk for young children, seniors, pregnant women and people with compromised immune systems.

During last year’s flu season, 3,274 people were hospitalized and 82 died as a result of the flu in Maryland, according to state health officials.” (B)

“The first pediatric influenza-associated death of the 2019-20 flu season has been reported in California. According to a statement issued by Riverside University Health System a 4-year-old child who tested positive for the flu and had underlying health issues passed away from his illness.

According to the US Centers for Disease Control and Prevention (CDC) a total of 130 influenza-associated pediatric deaths were reported during the 2018-19 flu season. This number was a decrease from the 187 pediatric deaths reported during the 2017-18 season.

CDC investigators hypothesize that the real-world impact of the flu is being underreported. “Using mathematical modeling to account for under-detection, CDC estimates that the actual number of flu-related deaths in children during [the 2017-18] season was closer to 600—nearly 3 times what was reported through existing mechanisms,” the authors of a recent report wrote in a flu spotlight.

Cameron Kaiser, MD, public health officer of Riverside County, says that this early season death could be predictive of a severe flu season.” (C)

“The overall effectiveness of last flu season’s vaccine was only 29% because it didn’t protect against a flu virus that appeared later in the season, according to the U.S. Centers for Disease Control and Prevention.

It said the vaccine was 47% effective into February, but that dropped to just 9% after the late strain showed up, the Associated Press reported.

Flu vaccines are created each year to protect against flu strains predicted to be circulating in the upcoming season.

The effectiveness of last season’s vaccine was the second lowest since 2011. The vaccine for the 2014-15 flu season was only 19% effective, the AP reported.” (D)

It’s never an easy business to predict which flu viruses will make people sick the following winter. And there’s reason to believe two of the four choices made last winter for this upcoming season’s vaccine could be off the mark.

Twice a year influenza experts meet at the World Health Organization to pore over surveillance data provided by countries around the world to try to predict which strains are becoming the most dominant. The Northern Hemisphere strain selection meeting is held in late February; the Southern Hemisphere meeting occurs in late September.

The selections that officials made…for the next Southern Hemisphere vaccine suggest that two of four viruses in the Northern Hemisphere vaccine that doctors and pharmacies are now pressing people to get may not be optimally protective this winter. Those two are influenza A/H3N2 and the influenza B/Victoria virus…

Flu vaccine is a four-in-one or a three-in-one shot that protects against both influenza A viruses — H3N2 and H1N1 — and either both or one of the influenza B viruses, B/Victoria and B/Yamagata. Most flu vaccine is made with killed viruses, and most vaccine used in the United States is quadrivalent — four-in-one…

Flu circulation “remains difficult to predict and flu viruses are constantly breaking rules that we try to establish for them,” Hensley said, adding that flu vaccines “often protect against severe disease even when … mismatched.” (E)

“A shortage of high dose flu shots is concerning some older adults.

The Vanderburgh County Health Department says people older than 65 are recommended to take a high dose flu shot.

Director of Clinical Outreach, Lynn Herr, says there is an option rather than not getting the shot at all.

“Then we need to have a conversation with our primary caregiver saying go ahead and get the regular or go ahead and wait for the higher dose flu shot.”

According to the CDC, the high dose vaccine helps people 65 years or older have a better fight against the flu.

This shot contains four times the antigen than a regular flu shot.” (F)


 What Are “Emergencies”? Emergencies are incidents that threaten public safety, health and welfare.  If severe or prolonged, they can exceed the capacity of first responders, local fire fighters or law enforcement officials.  Such incidents range widely in size, location, cause, and effect, but nearly all have an environmental component.” (G) 

Medical surge capacity refers to the ability to evaluate and care for a markedly increased volume of patients—one that challenges or exceeds normal operating capacity. The surge requirements may extend beyond direct patient care to include such tasks as extensive laboratory studies or epidemiological investigations.

Because of its relation to patient volume, most current initiatives to address surge capacity focus on identifying adequate numbers of hospital beds, personnel, pharmaceuticals, supplies, and equipment. The problem with this approach is that the necessary standby quantity of each critical asset depends on the systems and processes that:

Identify the medical need

Identify the resources to address the need in a timely manner

Move the resources expeditiously to locations of patient need (as applicable)

Manage and support the resources to their absolute maximum capacity.

In other words, fewer standby resources are necessary if systems are in place to maximize the abilities of existing operational resources. Moreover, the integration of additional resources (whether standby, mutual aid, State or Federal aid) is difficult without adequate management systems. Thus, medical surge capacity is primarily about the systems and processes that influence specific asset quantity.

Basic example: If a hospital wishes to have the capacity to medically manage 10 additional patients on respirators, it could buy, store, and maintain 10 respirators. This would provide an important component of that capacity (other critical care equipment and staff would also be needed), but it would also be very expensive for the facility. If the hospital establishes a mutual aid and/or cooperative agreement with regional hospitals, it might be able to rely on neighboring hospitals to loan respirators and credentialed staff and, therefore, might need to invest in only a few standby items (e.g., extra critical care beds), minimizing purchase and maintenance of expensive equipment that generate no income except during rare emergency situations.”  (H)

Today, Rapid Response Teams (RRTs) are a crucial component of many hospitals.  Implementing a RRT was one of the six strategies that defined the Institute for Healthcare Improvement (IHI) 100,000 Lives campaign.  Most RRTs consist of critical care nurses, but they can also include respiratory therapists, pharmacists, and physicians.

Research consistently shows that patients exhibit signs and symptoms of deterioration for several hours prior to a code.  These symptoms include changes in vital signs, mental status, and lab markers. The goal of a RRT is to intervene upstream from a potential code.  They reach the patient before deterioration turns into crisis.  This is different than a code blue team that typically responds to a patient that has already decompensated to cardiac arrest.

Historically, most hospitals relied on busy bedside nurses to identify crashing patients and call for rapid response.  With 49 states having no limits on the number of patients assigned per nurse, many medical-surgical ward nurses are caring for 6 or more patients per shift.  Placing this additional responsibility on their already over-flowing plate is challenging at best.  Providing a RRT empowers bedside nurses to trigger an escalation of care earlier and faster. (I)

“… even the U.S. is disturbingly vulnerable—and in some respects is becoming quickly more so. It depends on a just-in-time medical economy, in which stockpiles are limited and even key items are made to order. Most of the intravenous bags used in the country are manufactured in Puerto Rico, so when Hurricane Maria devastated the island last September, the bags fell in short supply. Some hospitals were forced to inject saline with syringes—and so syringe supplies started running low too. The most common lifesaving drugs all depend on long supply chains that include India and China—chains that would likely break in a severe pandemic. “Each year, the system gets leaner and leaner,” says Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “It doesn’t take much of a hiccup anymore to challenge it.”” (J)

“One hundred years ago, in 1918, a strain of H1N1 flu swept the world. It might have originated in Haskell County, Kansas, or in France or China—but soon it was everywhere. In two years, it killed as many as 100 million people—5 percent of the world’s population, and far more than the number who died in World War I. It killed not just the very young, old, and sick, but also the strong and fit, bringing them down through their own violent immune responses. It killed so quickly that hospitals ran out of beds, cities ran out of coffins, and coroners could not meet the demand for death certificates. It lowered Americans’ life expectancy by more than a decade. “The flu resculpted human populations more radically than anything since the Black Death,” Laura Spinney wrote in Pale Rider, her 2017 book about the pandemic. It was one of the deadliest natural disasters in history—a potent reminder of the threat posed by disease.” (K)

To receive email updates about Seasonal Flu, enter your email address at:




Flu Near You https://flunearyou.org/#!/

Everyday Health Flu Map https://www.everydayhealth.com/flu/map/


PANDEMIC PREPAREDNESS. “It’s like a chain—one weak link and the whole thing falls apart. You need no weak links.”

Tomorrow morning’s Emergency Preparedness meeting (just scheduled for 8AM)

“We are arguably as vulnerable—or more vulnerable—to another (flu) pandemic as we were in 1918.”

“..in a severe (flu) pandemic, the U.S. healthcare system could be overwhelmed in just weeks.

“Think hospitals are under a strain now, from a slightly bad flu season? Wait until a really bad one hits.”

In the ICU at Massachusetts General Hospital, nurses use Gatorade to combat flu-related dehydration (due to shortages of intravenous fluids)

The CDC postponed its briefing on preparation for nuclear war and will focus on responding to severe influenza


* Helmuth von Moltke the Elder.

Share on LinkedInShare on Google+Share on FacebookTweet about this on Twitter

PART 4. New Jersey. “..heart transplant center, inflated survival rates to keep its funding — keeping a brain-dead patient on life support until he hit a one-year survival benchmark..”

When I started as President & CEO of Jersey City Medical Center in 1989, New Jersey had a comprehensive Certificate of Need process. When the state awarded a “CN” funding followed through the all payor reimbursement system then in place.

Over time JCMC was designated as: a Regional Perinatal Center; Level II Trauma Center; Teaching Hospital Cancer Program; a Children’s Hospital; and approved to start cardiac surgery/ interventional cardiology. With these programs JCMC became a major teaching affiliate of Mount Sinai School of Medicine and a total replacement hospital was opened on a new site in 2004.

The pediatric cardiac surgery problems at Johns Hopkins All Children’s Hospital and North Carolina Children’s Hospital are due, in part, to the disappearance of most state CON regulations resulting in hospitals opening “trophy” services that lead to low volume programs. Funding becomes a challenge.

ASSIGNMENT: What are the Lessons Learned from the Johns Hopkins All Children’s Hospital and North Carolina Children’s Hospital pediatric open cardiac surgery program failures? What are the regulatory implications?

Please contact me a jonathanmetsch@gmail.com if you would like to discuss preparation for this case.

After New PART 4 are excerpts from Parts 1-3, as well as an unabridged chronology.

PART 4. Johns Hopkins All Children’s Hospital and North Carolina Children’s Hospital pediatric cardiac surgery programs at “crossroads.”

“The hospital that calls itself New Jersey’s premier heart transplant center, Newark Beth Israel, inflated survival rates to keep its funding — in at least one instance by keeping a brain-dead patient on life support until he hit a one-year survival benchmark, startling new reporting revealed.

Family members were never told that Navy veteran Darryl Young was in an irreversible vegetative state after his heart transplant last year, and staff never offered hospice, other palliative care services or a Do Not Resuscitate directive, ProPublica revealed.

Meanwhile, behind the scenes, doctors were secretly recorded discussing how Young needed to be aggressively cared for despite their belief that he would never wake up or recover function, the ProPublica report said.” (H)

 “The North Carolina Children’s Hospital got a bit of good news last week from a state agency that sent a team of investigators on-site for 11 days of questioning and review of the pediatric heart surgery program.

The state Department of Health and Human Services says the program currently is in compliance with U.S. Centers for Medicare and Medicaid Services requirements…

An external review board was tapped to evaluate the program and new Quality and Safety reporting procedures were put in place.

The external review board has had one telephone conference meeting, according to Alan Wolf, a spokesman for the health care system, and has plans to meet in person soon.

Despite the state health department’s findings, the UNC Health Care system has no plans to schedule those types of surgeries before the external review is complete, according to Wolf.” (A)

“The families of two children who were paralyzed after heart surgeries at Johns Hopkins All Children’s Hospital will receive $26 million and $12.75 million in settlements with the hospital, state records show.

Although the identities of the children are not public, the records describing their cases match two of the patients featured in a Tampa Bay Times investigation into the hospital’s troubled heart unit. Both families were struggling with the costs of caring for a permanently disabled child with no relief in sight.

A third family that lost a child after heart surgery will receive $750,000…

In June, Johns Hopkins Health System CEO Kevin Sowers told the Times that he and hospital leaders had reached out to the families of children who died or were injured in the hospital’s heart surgery unit.

“We made a mistake, and we need to make sure we help support these families and make it right,” he said…  (B)

“UNC Hospitals in Chapel Hill is on probation after the system received preliminary denial of its accreditation.

Preliminary Denial of Accreditation is recommended when there’s an immediate threat to health and safety, a submission of falsified documents or misrepresented information, a lack of a required license, or significant noncompliance with Joint Commission standards, according to the Joint Commission..

“To be clear: There was no finding of any immediate threats to patient health and safety,” UNC Health Care spokesman Alan Wolf said in an email.

The Joint Commission recently conducted the triennial accreditation survey, when surveyors examined the main hospital in Chapel Hill.

UNC Health Care credited the slide in accreditation to new standards by the Joint Commission. The hospital will remain on preliminary denial of accreditation status until the hospital undergoes a new survey and satisfies the requirements.

The hospital network says it has already put plans in place to fix each problematic area…

UNC Health Care said the Joint Commission accepted its plans of correction, and expects the validation survey to take place next week.” (C)

UNC Hospitals is one step closer to regaining its clean reputation, but concerns remain.

After completing follow-up inspections, the Joint Commission lifted its preliminary denial of UNC Hospitals’ accreditation and upgraded the hospital to “accreditation with a follow-up survey.”

UNC Hospitals was originally placed on probation because it failed to meet the suicide prevention standards of the Joint Commission…

Most of the serious problems revolved around the treatment of mental health patients, particularly those at risk for suicide attempts or for being abused and exploited. The Joint Commission demanded better management of ligature risks — places where a patient could hang or choke themselves — and better identification of potential victims of abuse.

The Joint Commission only recommends Preliminary Denial of Accreditation when there’s an immediate threat to health and safety, a submission of falsified documents or misrepresented information, a lack of a required license, or significant noncompliance with Joint Commission standards…

The clean bill of accreditation means the Joint Commission is satisfied with UNC Hospitals’ response to its performance issues. But the hospitals will probably face added scrutiny.”  (D)

A North Carolina children’s hospital that stopped performing complex heart surgeries in recent months after high death rates were disclosed may now resume the procedures, according to an advisory board that was examining the hospital’s practices.

The board noted “significant investment and progress” had been made at North Carolina Children’s Hospital while suggesting areas for improvement, including increasing the number of surgeries performed, a factor associated with better outcomes.

The external board made its recommendations in a six-page report released on Tuesday by UNC Health Care, which runs the hospital and is affiliated with the University of North Carolina…..

The advisory board did not seem to address conditions at the hospital when doctors voiced concerns several years ago, but noted that “team dynamics and interactions appear to be strong.” Recommendations it made to the hospital’s board of directors included continuing to publicly report mortality data; hiring a second full-time pediatric heart surgeon; and considering a joint venture with another hospital to increase the volume of surgeries.

Concerns about the quality of pediatric heart surgery programs have been disclosed at hospitals across the country, especially at institutions with a smaller number of surgeries. Several programs have been suspended or shut down; other hospitals have merged their programs with larger ones to achieve more consistent results.

The advisory board was composed of three doctors from outside institutions: Nationwide Children’s Hospital in Columbus, Ohio; the University of Michigan School of Medicine; and Children’s Hospital of Pittsburgh.

Two doctors leading UNC’s pediatric heart program previously worked at two of those institutions: Dr. Timothy Hoffman, chief of pediatric cardiology, came to UNC from Nationwide Children’s Hospital. Dr. Mahesh Sharma, chief pediatric cardiac surgeon, joined UNC from Children’s Hospital of Pittsburgh.” (E)

“The News & Observer reports the outside review board’s report was announced Tuesday. It noted ongoing improvements in the unit, though it advised the hospital to consider if patients with complex heart problems along with additional illnesses should be referred to other hospitals.” (F)

“Rumors floated around a children’s heart surgery unit in a major hospital of a major city. Babies operated on for complex heart problems were dying, and dying at rates far higher than those of comparable hospitals. Doctors and cardiologists feared, even avoided, referring young babies for surgery at the unit — a culture of silence surrounding it all…

But this is not UNC. And this is not 2019. This was thirty years ago at Bristol Royal Infirmary, the flagship hospital of Bristol, a city of about 500,000, in the United Kingdom.

“It would be reassuring to believe that it could not happen again,” wrote Sir Ian Kennedy, chair of the public inquiry into the tragedy that claimed the lives of dozens of babies at Bristol. But he didn’t sound particularly reassured, and sadly his doubt has been borne out. It has happened again.

The parallels between the two scandals are uncanny. At both hospitals, the cardiac surgery for very young babies was malfunctioning, and babies were dying at appalling rates. At both hospitals a culture of silence surrounded a growing sense among staff that something was going catastrophically wrong.

And at both hospitals it took outsiders to blow the whistle: at UNC someone leaked recordings of the conversations held by a group of concerned cardiologists (doctors who refer patients to cardiac surgery) in June 2016 to the New York Times. Dr Kevin Kelly, leader of the children’s hospital at UNC, had convened the meeting to discuss the “crisis.” “When you walk out of here,” he says in the recordings, “stop talking about it outside of this room.”

At Bristol thirty years ago, a young new anesthetist named Stephen Bolsin grew concerned about eight-hour operations instead taking twelve. He began to collect data on the outcomes of babies at the unit. When he sensed the numbers didn’t look good, he took his concerns to the head of the unit, surgeon James Wisheart, who shut him down.

When Bolsin went over his head to the hospital manager, Wisheart got wind of this breach in the strict medical hierarchy and said this amazing – and terrifyingly similar – thing: “If you wish to remain in Bristol you should not disclose the results of pediatric cardiac surgery to people outside the unit ever again.”” (G)

PART 1. Brand names don’t always signify the highest quality of care

 “Sandra Vázquez paced the heart unit at Johns Hopkins All Children’s Hospital.

Her 5-month-old son, Sebastián Vixtha, lay unconscious in his hospital crib, breathing faintly through a tube. Two surgeries to fix his heart had failed, even the one that was supposed to be straightforward.

Vázquez saw another mom in the room next door crying. Her baby was also in bad shape.

Down the hall, 4-month-old Leslie Lugo had developed a serious infection in the surgical incision that snaked down her chest. Her parents argued with the doctors. They didn’t believe the hospital room had been kept sterile.

By the end of the week, all three babies would die…

The internationally renowned Johns Hopkins had taken over the St. Petersburg All Children’s Hospital six years earlier and vowed to transform its pediatric heart surgery unit into one of the nation’s best.

Instead, the program got worse and worse until children were dying at a stunning rate, a Tampa Bay Times investigation has found.

Nearly one in 10 patients died last year. The mortality rate, suddenly the highest in Florida, had tripled since 2015…

Times reporters spent a year examining the All Children’s Heart Institute – a small, but important division of the larger hospital devoted to caring for children born with heart defects…

They discovered a program beset with problems that were whispered about in heart surgery circles but hidden from the public.

Among the findings:

All Children’s surgeons made serious mistakes, and their procedures went wrong in unusual ways. They lost needles in at least two infants’ chests. Sutures burst. Infections mounted. Patches designed to cover holes in tiny hearts failed.

Johns Hopkins’ handpicked administrators disregarded safety concerns the program’s staff had raised as early as 2015. It wasn’t until early 2017 that All Children’s stopped performing the most complex procedures. And it wasn’t until late that year that it pulled one of its main surgeons from the operating room.

Even after the hospital stopped the most complex procedures, children continued to suffer. A doctor told Cash Beni-King’s parents his operation would be easy. His mother and father imagined him growing up, playing football. Instead multiple surgeries failed, and he died.

In just a year and a half, at least 11 patients died after operations by the hospital’s two principal heart surgeons. The 2017 death rate was the highest any Florida pediatric heart program had seen in the last decade.

Parents were kept in the dark about the institute’s troubles, including some that affected their children’s care. Leslie Lugo’s family didn’t know she caught pneumonia in the hospital until they read her autopsy report. The parents of another child didn’t learn a surgical needle was left inside their baby until after she was sent home.

The Times presented its findings to hospital leaders in a series of memos early this month. They declined interview requests and did not make the institute’s doctors available to comment.

In a statement, All Children’s did not dispute the Times’ reporting. The hospital said it halted all pediatric heart surgeries in October and is conducting a review of the program.

“Johns Hopkins All Children’s Hospital is defined by our commitment to patient safety and providing the highest quality care possible to the children and families we serve,” the hospital wrote. “An important part of that commitment is a willingness to learn.” (G)

The top three leaders of Johns Hopkins All Children’s Hospital in Florida resigned Tuesday following a Tampa Bay Times investigation that revealed increasing mortality rates among heart surgery patients.

The resignations from the 259-bed teaching hospital in St. Petersburg included CEO Jonathan Ellen, M.D., and Vice President Jackie Crain, as well as Jeffrey Jacobs, M.D., who is the heart institute’s deputy director, the Tampa Bay Times reported. Paul Colombani, M.D., stepped down as chairman of the department of surgery but will continue working in a clinical capacity, a statement from the health system said…

Johns Hopkins, which owns and operates the hospital, said it would install Kevin Sowers, who is president of the Johns Hopkins Health System and executive vice president of Johns Hopkins Medicine, to lead the hospital in a temporary capacity while a plan for interim leadership is put into place.

Johns Hopkins’ board also said it commissioned an external review to examine the heart surgery program and said it would share its lessons from the review to help hospitals around the country avoid the same mistakes.

The moves come following the Tampa Bay Times investigation that highlighted a growing number of heart surgery deaths at the hospital amid warnings about safety from staffers that went unheeded. (H)

“Three additional senior administrators have left Johns Hopkins All Children’s Hospital in the wake of a Tampa Bay Times investigation into high mortality rates at the hospital’s Heart Institute, the hospital announced Wednesday.

A total of six senior officials have left since the Times report, including the hospital’s CEO, three vice presidents and two surgeons who held leadership roles at the Heart Institute. A seventh official stepped down as chairman of the surgery department but remained employed at the hospital as a doctor.

The resignations announced Wednesday included vice presidents Dr. Brigitta Mueller, the hospital’s chief patient safety officer, and Sylvia Ameen, who oversaw culture and employee engagement and served as the hospital’s chief spokeswoman.

The hospital also said Dr. Gerhard Ziemer, who started as the Heart Institute’s new director and chief of cardiovascular surgery in October, would leave the hospital. The hospital never publicly announced Ziemer had been hired, and he had not yet obtained his Florida medical license when the Times investigation was published at the end of November. At that point, the hospital said the Heart Institute   had already stopped performing surgeries.

Sowers also announced that Johns Hopkins had hired external experts to develop a plan to restart heart surgeries at All Children’s.

That is a separate effort from an external review of the problems in the Heart Institute, which Johns Hopkins announced its board had commissioned last month, spokeswoman Kim Hoppe said…

Johns Hopkins is one of the most prestigious brands in medicine and is internationally renowned for developing innovative patient safety protocols that are used at hospitals across the world. But last weekend, the Times published a story detailing a series of safety problems at hospitals across its network. In response, the health system pledged to “do better.” (I)

“The Johns Hopkins Medicine Board of Trustees has appointed a former federal prosecutor to lead its investigation into the Johns Hopkins All Children’s Hospital’s heart surgery unit, the health system announced late Tuesday.

F. Joseph Warin, of the global law firm Gibson Dunn, and his team will review the high mortality rates and other problems at the hospital’s Heart Institute and report back to a special committee of the board of trustees by May, the health system said.

Once the review is complete, the health system said it would also name an independent monitor at All Children’s to “make sure that the hospital is being held accountable for taking corrective action where necessary.”

The announcement was accompanied by a video of Johns Hopkins Health System president Kevin Sowers, who acknowledged for the first time that the hospital had been warned about problems by frontline workers.

“I know personally that many of you courageously spoke out when you had concerns but were ignored or turned away,” he said. “That behavior is unacceptable and will not be tolerated going forward.”

Sowers, who is also interim president at All Children’s, said he hoped to meet with the families of patients affected by problems in the Heart Institute in the coming days to share his “profound sadness for the failures of care they experienced.” (J)

 “State and federal inspectors descended on Johns Hopkins All Children’s Hospital this week, following sharp calls for an investigation into problems in the hospital’s heart surgery unit, the Tampa Bay Times has learned.

The scope of the inspection is unclear. But hospital regulators had been criticized in recent weeks for their lax response to early signs of an increase in mortality at the hospital’s Heart Institute…

State and federal regulators knew the institute was having problems months earlier. In April, the hospital’s CEO told the Times that the institute had “challenges” that led to an uptick in mortality, and acknowledged the hospital had left surgical needles inside two children.

In May, state regulators cited the hospital for not properly reporting two medical mistakes, which is required by state law. Days later, a spokeswoman for the federal agency told the Times that it would perform its own investigation.

But state regulators didn’t fine the hospital, and overlooked several subsequent warnings that its surgical results had been poor.

And federal inspectors later changed course and decided not to undertake a comprehensive review of the heart surgery program, the Times reported last month. One reason was that state inspectors hadn’t found any violations of federal rules, a spokeswoman said. Another was that a nonprofit hospital accreditor was due to perform a scheduled review.” (L)

 “.. experience showcases the promise of a much-touted but little understood collaboration in health care: alliances between community hospitals and some of the nation’s biggest and most respected institutions.

For prospective patients, it can be hard to assess what these relationships actually mean – and whether they matter.

Leah Binder, president and chief executive of the Leapfrog Group, a Washington-based patient safety organization that grades hospitals based on data involving medical errors and best practices, cautions that affiliation with a famous name is not a guarantee of quality.

Brand names don’t always signify the highest quality of care,” she said. “And hospitals are really complicated places.”..

To expand their reach, flagship hospitals including Mayo, the Cleveland Clinic and Houston’s MD Anderson Cancer Center have signed affiliation agreements with smaller hospitals around the country. These agreements, which can involve different levels of clinical integration, typically grant community hospitals access to experts and specialized services at the larger hospitals while allowing them to remain independently owned and operated. For community hospitals, a primary goal of the brand-name affiliation is stemming the loss of patients to local competitors…

In some cases, large hospital systems opt for a different approach, largely involving acquisition. Johns Hopkins acquired Sibley Memorial and Suburban hospitals in the Washington, D.C., area, along with All Children’s Hospital in St. Petersburg, Fla. The latter was re-christened Johns Hopkins All Children’s Hospital in 2016…

Although affiliation agreements differ, many involve payment of an annual fee by smaller hospitals. Officials at Mayo and MD Anderson declined to reveal the amount, as did executives at several affiliates. Contracts with Mayo must be renewed annually, while some with MD Anderson exceed five years…

“It is not the Mayo Clinic,” said Dr. David Hayes, medical director of the Mayo Clinic Care Network, which was launched in 2011. “It is a Mayo clinic affiliate.”

Of the 250 U.S. hospitals or health systems that have expressed serious interest in joining Mayo’s network, 34 have become members.

For patients considering a hospital that has such an affiliation, Binder advises checking ratings from a variety of sources, among them Leapfrog, Medicare and Consumer Reports, and not just relying on reputation.

“In theory, it can be very helpful,” Binder said of such alliances. “The problem is that theory and reality don’t always come together in health care.”

Case in point: Hopkins’ All Children’s has been besieged by recent reports of catastrophic surgical injuries and errors and a spike in deaths among pediatric heart patients since Hopkins took over. Hopkins’ chief executive has apologized, more than a half-dozen top executives resigned and Hopkins recently hired a former federal prosecutor to conduct a review of what went wrong.

“For me and my family, I always look at the data,” Binder said. “Nothing else matters if you’re not taken care of in a hospital, or you have the best surgeon in the world and die from an infection.” ” (Q)

PART 2. June 1, 2019. “The situation that the New York Times described in North Carolina parallels that at Johns Hopkins All Children’s Hospital in St. Petersburg, which stopped performing heart surgeries after the Tampa Bay Times reported on problems in the unit

 “Tasha and Thomas Jones sat beside their 2-year-old daughter as she lay in intensive care at North Carolina Children’s Hospital. Skylar had just come out of heart surgery and should recover well, her parents were told. But that night, she flatlined. Doctors and nurses swarmed around her, performing chest compressions for nearly an hour before putting the little girl on life support.

Five days later, in June 2016, the hospital’s pediatric cardiologists gathered one floor below for what became a wrenching discussion. Patients with complex conditions had been dying at higher-than-expected rates in past years, some of the doctors suspected. Now, even children like Skylar, undergoing less risky surgeries, seemed to fare poorly.

The cardiologists pressed their division chief about what was happening at the hospital, part of the respected University of North Carolina medical center in Chapel Hill, while struggling to decide if they should continue to send patients to UNC for heart surgery…

That March, a newborn had died after muscles supporting a valve in his heart appeared to have been damaged during surgery. At least two patients undergoing low-risk surgeries had recently experienced complications. In May, a baby girl with a complex heart condition died two weeks after her operation. Two days later, Skylar went in for surgery.

In the doctors’ meeting, the chief of pediatric cardiology, Dr. Timothy Hoffman, was blunt. “It’s a nightmare right now,” he said. “We are in crisis, and everyone is aware of that.”

That comment and others – captured in secret audio recordings provided to The New York Times – offer a rare, unfiltered look inside a medical institution as physicians weighed their ethical obligations to patients while their bosses also worried about harming the surgical program.

In meetings in 2016 and 2017, all nine cardiologists expressed concerns about the program’s performance. The head of the hospital and other leaders there were alarmed as well, according to the recordings. The cardiologists – who diagnose and treat heart conditions but don’t perform surgeries – could not pinpoint what might be going wrong in an intertwined system involving surgeons, anesthesiologists, intensive care doctors and support staff. But they discussed everything from inadequate resources to misgivings about the chief pediatric cardiac surgeon to whether the hospital was taking on patients it wasn’t equipped to handle. Several doctors began referring more children elsewhere for surgery.

The heart specialists had been asking to review the institution’s mortality statistics for cardiac surgery – information that most other hospitals make public – but said they had not been able to get it for several years. Last month, after repeated requests from The Times, UNC released limited data showing that for four years through June 2017, it had a higher death rate than nearly all of the 82 institutions nationwide that do publicly report…

The best option, Dr. Kelly said, was to combine UNC’s surgery program with Duke’s. For years, physicians at both children’s hospitals talked informally about joining forces, but nothing came of it. They were “basically destroying each other’s capacity to be great,” Dr. Kelly said, by running competing programs less than 15 miles apart. But even combining the programs wasn’t an instant fix: It would take at least a year and a half, he said… (D)

“The situation that the New York Times described in North Carolina parallels that at Johns Hopkins All Children’s Hospital in St. Petersburg, which stopped performing heart surgeries after the Tampa Bay Times reported on problems in the unit…

UNC Health Care only made some of its death rate data public to the New York Times after numerous requests from the newsroom. The statistics showed that UNC’s children’s heart surgery program had one of the highest four-year death rates in the country…

UNC Health Care told the New York Times that the physicians’ concerns had been handled appropriately.

After the New York Times started reporting, the hospital ramped up efforts to find a temporary pediatric heart surgeon and reached out to families whose children had died or had unusual complications to discuss their cases…

The turmoil at UNC underscores concerns about the quality and consistency of care provided by dozens of pediatric heart surgery programs across the country. Each year in the United States about 40,000 babies are born with heart defects; about 10,000 are likely to need surgery or other procedures before their first birthday.

The best outcomes for patients with complex heart problems correlate with hospitals that perform a high volume of surgeries – several hundred a year – studies show. But a proliferation of the surgery programs has made it difficult for many institutions, including UNC, to reach those numbers: The North Carolina hospital does about 100 to 150 a year. Lower numbers can leave surgeons and staff at some hospitals with insufficient experience and resources to achieve better results, researchers have found.

“We can do better. And it’s not that hard to do better,” said Dr. Carl Backer, former president of the Congenital Heart Surgeons’ Society, who practices at Lurie Children’s Hospital of Chicago. “We don’t have to build new hospitals. We don’t have to build new ICUs. We just need to move patients to more appropriate centers.”

Studies show that the best outcomes for patients with complex heart problems correlate with hospitals that do a higher volume of surgeries – several hundred a year.

At least five pediatric heart surgery programs across the country were suspended or shut down in the last decade after questions were raised about their performance; a Florida institution run by the prestigious Johns Hopkins medical system stopped operations after reporting by The Tampa Bay Times in 2018. At least a half-dozen hospitals have merged their programs with larger ones to achieve more consistent results. And more institutions are considering such partnerships.” (E)

“North Carolina’s secretary of health on Friday called for an investigation into a hospital where doctors had suspected children with complex heart conditions had been dying at higher than expected rates after undergoing heart surgery.

Dr. Mandy Cohen, the secretary, said in a statement that a team from the state’s division of health service regulation would work with federal regulators to conduct a “thorough investigation” into events that occurred in 2016 and 2017 at North Carolina Children’s Hospital, part of the University of North Carolina medical center in Chapel Hill…

The investigation is in response to an article published by The New York Times on Thursday, which gave a detailed look inside the medical institution as cardiologists grappled with whether to keep sending their young patients there for surgery.” (H)

PART 3. Hopkins All Children’s Hospital/ North Carolina Children’s – pediatric cardiac surgery debacles.

“Johns Hopkins All Children’s Hospital has begun implementing some of the dozens of recommendations from a law firm hired to identify deficiencies at the hospital and its parent organization, Johns Hopkins Medicine, in the wake of high death rates in the St. Petersburg hospital’s pediatric cardiology program…

The recommendations focus on four key areas, said Dr. Kevin Sowers, president of Johns Hopkins Health System and executive vice president of Johns Hopkins Medicine.

He outlined those four areas in a video posted online. They are: strengthen the management and culture at Johns Hopkins All Children’s Hospital; improve processes for evaluating patient clinical quality and safety; clarify and streamline the reporting structure between the six Johns Hopkins Hospitals and the Johns Hopkins Health System; and review the ways in which the boards of Johns Hopkins All Children’s Hospital and Johns Hopkins Medicine should advance their governance responsibilities…

…In the coming weeks, the board of Johns Hopkins Medicine will appoint a monitor to track and report regularly back to them on the hospital’s progress.” (A)

“The recommendations for improvement include:

Prioritize a culture of absolute commitment to patient safety and of raising and addressing problems and concerns, including throughout the process of hiring and evaluating senior executives

Give physician leaders a stronger voice, create a more robust check-and-balance on the president

Better educate staff and faculty about JHM’s commitment to transparency and a culture of “see something, say something” and to improve channels to submit complaints and provide for independent review

Separate the medical staff office responsibilities from the patient safety and quality department responsibilities, which previously were overseen by a single vice president of medical affairs…

In the coming weeks, the board of Johns Hopkins medicine will appoint an external monitor to track and report back regularly to them on the hospital’s progress,” he said.

The initial focus will be on the St. Petersburg hospital, a team will go to the other five hospitals in the network to ensure the changes are taking place.” (B)

“The review recommended a commitment to patient safety and said the “see something, say something” culture is a vital part of that.

The hospital published the report on its website along with a video of Sowers talking about the results.

“Above all, we must work each and every day to support a culture in which each of us is supported and empowered to speak up and speak out,” Sowers said in the video.

He provided a toll free number where employees can anonymously report any issues: 1-844-SPEAK2US.” (C)

 “Children’s heart surgery departments across Florida will soon be subject to more oversight.

Gov. Ron DeSantis signed a bill late Tuesday that will let physician experts visit struggling programs and make recommendations for improvement…

The bill signed into law Tuesday makes significant changes.

It lets a committee called the Pediatric Cardiac Technical Advisory Panel appoint physician experts to visit Florida’s 10 children’s heart surgery programs. They will be able to examine surgical results, review death reports, inspect the facilities and interview employees.

Dr. David Nykanen, the chairman of the advisory panel and a pediatric cardiologist at Arnold Palmer Hospital for Children in Orlando, called site visits “crucially important,” especially when departments are having problems.

He said visits could start within the next six months…

The hospital has not yet resumed heart surgeries. The results of a review commissioned by the Johns Hopkins Medicine board are expected soon.” (E)

“A state regulatory process that limited the number of hospitals and some specialty services like transplant programs are going away on July 1.

Despite attempts by two hospitals, Central Florida doesn’t have a pediatric heart transplant program. But that could change in the coming years because a state regulatory process that limited the number of hospitals and some specialty services like transplants is going away on July 1.

For nearly five decades, the program known as certificate of need has required hospitals to get authorization from the state before building new facilities or offering new or expanded services — a complicated process that’s costly, includes reams of paperwork and potential challenges from competitors, and can take months or years…

Starting July 1, general hospitals are no longer required to obtain a certificate of need to build a facility or to start services such as pediatric and adult open heart surgery, organ transplant programs, neonatal intensive care units and rehab programs…

The second part of the bill goes into effect on July 1, 2021, when the certificate of need requirement will be eliminated for certain specialty hospitals such as children’s and women’s hospitals, rehab hospitals, psychiatric and substance abuse hospitals and hospitals that offer intensive residential treatment services for children.” (F)

“Cohen announced late last week that she had assembled a team from the state Division of Health Service Regulation, which licenses and oversees health care facilities, to “conduct a thorough investigation into these events.” They are coordinating with the U.S. Centers for Medicare & Medicaid Services, a federal oversight agency…

Kelly Haight Connor, a spokeswoman for the state health department, said Monday it’s difficult to know how long an investigation will take. In other DHHS investigations, a team often interviews a range of people, from caregivers, staff and those in their care.

Wesley Burks, CEO of UNC Health Care since December 2018 and dean of the UNC School of Medicine, sent a five-paragraph email to staff on May 30 at 10:16 a.m. and attached the Times’ article he described as “critical of UNC Medical Center’s pediatric congenital heart surgery program.”

 “While this program faced culture challenges in the 2016-2017 timeframe, we believe the Times’ criticism is overstated and does not consider the quality improvements we’ve made within this program over many years,” Burks wrote in the email. “As the State’s leading public hospital, UNC Medical Center often gets the most complex and serious cases in its pediatric congenital heart program. For many of these very sick children, we are often parents’ last hope…

On Monday, UNC Health Care spokesman Phil Bridges released a “timeline of Continuous Quality Improvement within the program over the past 10 years.”

The timeline mentions a four-month period from June to September in 2016 in which “concerns and allegations against specific individuals in the Congenital Heart Program” were “independently investigated and reviewed” by the dean’s office and the chief medical officer.

“Allegations of misconduct and concerns determined to be unfounded,” the document states, adding “allegations against specific individuals and results of the investigations constitute personnel records, which may not be disclosed,” citing public records law.

An ongoing initiative, according to the document, calls for a Department of Pediatrics review after every death in the Pediatric Intensive Care Unit, including pediatric cardiac patients, to assess the care provided and evaluate any opportunities for improvement.” (G)

“UNC Health Care officials announced Monday they are halting the most complex pediatric heart surgeries following a report that raised serious safety concerns over a number of child deaths at UNC Children’s Hospital…

Officials from UNC HealthCare said in a statement they plan to create an advisory board of external medical experts and “pause the most complex heart surgeries” until that board and regulatory agencies review the program.

The external advisory board, which is expected to have members from the University of Southern California, the University of Michigan, University of Pittsburgh Medical Center and Nationwide Children’s Hospital, will examine the efficacy of the UNC Children’s Hospital pediatric heart surgery program and make recommendations for improvement. The group will report to the UNC Health Care Board of Directors.

UNC Healthcare officials said they are also developing a new structure to support internal hospital reporting and plan to publicly release Society for Thoracic Surgeons’ (STS) patient outcome data, make a $10 million investment in new technology and bring in new specialists as part of their efforts to “restore confidence” in its pediatric heart program.

“Our pediatric heart program cares for very sick children with incredibly complex medical problems, and our clinical team works tirelessly to help those patients return to normal, healthy and productive lives,” Wesley Burks, M.D., CEO of UNC Health Care said in a statement. “We grieve with families anytime there is a negative outcome and we constantly push to learn from those tragic instances.

UNC Health Care’s board also endorsed the creation of a pediatric heart surgery family advisory council to provide a voice for patients, family members and staff directly to hospital leadership…

Most recently, Johns Hopkins’ All Children’s Hospital came under fire for increasing mortality rates among heart surgery patients at the 259-bed hospital following a Tampa Bay Times investigation. Top leaders of that hospital ultimately resigned and Johns Hopkins’ board also said it commissioned an external review to examine the heart surgery program.

In 2015, St. Mary’s Medical Center in Florida closed it’s pediatric heart surgery program after a CNN investigation revealed it had a mortality rate of more than three times the national average. In 2009, Massachusetts General Hospital suspended its pediatric surgery program in the wake of surgical errors.” (H)

 “UNC Children’s Hospital should merge its pediatric heart surgery program with the same work being done at Duke Health’s Children’s Hospital, just 10 miles away. A common program would greatly enhance the treatment of children and babies in need of complex heart surgery.

As it is, UNC Children’s does 100 to 150 pediatric heart surgeries a year, a rate considered low volume. That makes it harder to recruit and retain surgeons and limits surgeons ability to hone their skills. It also makes it harder to maintain the other parts of the program, cardiologists, anesthesiologists and staff for a pediatric heart intensive care unit.

East Carolina University’s hospital faced similar challenges as it provided pediatric heart surgery at a low-volume level of 50 to 75 surgeries a year. Eighteen months ago, ECU started sending all its pediatric heart surgery patients to Duke. The change helped boost Duke’s volume to where it has done more than 800 surgeries in 18 months. During the same period, Duke has posted a 1 percent mortality rate, despite a caseload in which a third of the operations are high risk.

Unfortunately, UNC Children’s Hospital appears uninterested in combining resources despite overtures from Duke. In a statement Thursday, the hospital said, “While there have been discussions with Duke Health over the years about ways to collaborate across various pediatric specialties, there are no plans to combine our programs. Patients in this region benefit from having two world-class medical institutions located so close together. Our clinicians frequently collaborate with colleagues at Duke. We sometimes transfer patients to them and vice versa.

UNC Children’s would prefer to run its own pediatric heart surgery program as a matter of institutional pride and money — the most complex operations can cost a half-million dollars. But pride and money aren’t — or shouldn’t be — the primary concerns. What matters most is how to get the best care for children in this highly specialized and high-stakes area of medicine. To do that, North Carolina’s best hospitals should combine their resources and expertise.” (J)

Typically, with complex medical procedures, outcomes are strongly correlated with volume. That means that if a program does more procedures, it has more expertise, the healthcare team has more experience working together — and as a result, patients have better results. Larger programs often have better equipment and more personnel. Sadly, the pediatric surgery program at North Carolina Children’s Hospital was a low-volume center…

Powerful forces stand in opposition to the closure of low-volume centers. Low-volume centers are attractive because they are geographically convenient; patients do not have to travel long distances for their care. Some insurance coverage is regionally-restricted, and families without resources are unable to access high-volume centers. Low-volume centers are often staffed by entrepreneurial physicians who don’t want restrictions on their right to practice medicine. And their goals are often closely aligned with those of local political officials, who would like to imagine that low-volume programs can replicate the results at large medical centers. Perhaps most importantly, hospital administrators at low-volume centers do not wish to see their revenues slashed — and their leadership positions eliminated.

So the problem of decentralized medicine and low-volume centers is getting worse, not better. To an increasing degree, a larger and larger proportion of specialized procedures in the United States are being done at low-volume centers…” (N)

For an unabridged chronology, click on

PART 3. Hopkins All Children’s Hospital/ North Carolina Children’s – pediatric cardiac surgery http://doctordidyouwashyourhands.com/2019/08/part-3-hopkins-all-childrens-hospital-north-carolina-childrens-pediatric-cardiac-surgery-debacles/



G.Johns Hopkins promised to elevate All Children’s Heart Institute, by KATHLEEN McGRORY and NEIL BEDI, http://www.tampabay.com/projects/2018/investigations/heartbroken/all-childrens-heart-institute/

H.Top officials at Johns Hopkins All Children’s Hospital resign following reports of heart surgery deaths, by Tina Reed, https://www.fiercehealthcare.com/hospitals-health-systems/top-officials-at-johns-hopkins-all-children-s-hospital-resign

I.Three more All Children’s officials resign following Times investigation, by By Kathleen McGrory and Neil Bedi, https://www.tampabay.com/investigations/2019/01/02/three-more-all-childrens-officials-resign-following-times-investigation/

J.Johns Hopkins hires former prosecutor to investigate All Children’s Heart Institute,by Kathleen McGrory and Neil Bedi , https://www.tampabay.com/investigations/2019/01/09/johns-hopkins-hires-former-prosecutor-to-investigate-all-childrens-heart-institute/

Q.Community Hospitals Link Arms With Prestigious Facilities To Raise Their Profiles, by Sandra G. Boodman, https://khn.org/news/community-hospitals-link-arms-with-prestigious-facilities-to-raise-their-profiles/


D.” Horrible complications are happening that you can’t explain.” ” We have to be honest with the patients.” ” It’s a nightmare right now.” Secret recordings captured physicians’ concerns that more children seemed to fare poorly after heart surgery. Their hospital kept doing the operations, by BY ELLEN GABLER, https://www.nytimes.com/interactive/2019/05/30/us/children-heart-surgery-cardiac.html?smid=nytcore-ios-share

E.In North Carolina, the New York Times reveals another heart surgery program in trouble, by Kathleen McGrory and Neil Bedi, https://www.tampabay.com/investigations/2019/05/30/in-north-carolina-the-new-york-times-reveals-another-heart-surgery-program-in-trouble/

H. Secretary Cohen calls for investigation into NC Children’s hospital, https://www.ncspin.com/secretary-cohen-calls-for-investigation-into-nc-childrens-hospital


A.Johns Hopkins All Children’s releases ‘lessons learned’ from review, by Margie Manning, https://stpetecatalyst.com/johns-hopkins-all-childrens-releases-lessons-learned-from-review/

B.Law firm recommends Johns Hopkins hospital to make administrative, patient safety changes, by  Veronica Brezina-Smith, https://www.bizjournals.com/tampabay/news/2019/07/01/law-firm-recommends-johns-hopkins-hospital-to.html

C.Johns Hopkins All Children’s Hospital Faces More Changes, by Julio Ochoa, https://wusfnews.wusf.usf.edu/post/johns-hopkins-all-childrens-hospital-faces-more-changes

E.Extra oversight for children’s heart surgery signed into law, by By Kathleen McGrory and Neil Bedi, http://www.tampabay.com/investigations/2019/06/26/extra-oversight-for-childrens-heart-surgery-signed-into-law/

F.Hospitals, transplant programs could multiply in Central Florida with law change, by Naseem S. Miller, https://www.orlandosentinel.com/health/os-ne-health-florida-certificate-of-need-repeal-20190701-tujobp6zofe7dorx7jxhfwc37q-story.html

G.No timeline for state investigation into NC Children’s Hospital, by Anne Blythe, http://www.tampabay.com/investigations/2019/06/26/extra-oversight-for-childrens-heart-surgery-signed-into-law/

H.UNC Children’s suspends complex heart surgeries after report raising safety concerns, by Tina Reed, | https://www.fiercehealthcare.com/hospitals-health-systems/unc-children-s-suspend-complex-heart-surgeries-after-report-raising-safety

J.UNC and Duke should unite on pediatric heart surgery, https://www.newsobserver.com/opinion/article231271418.html

N.Does Medicine Have a Wall of Silence?, by Milton Packer, https://www.medpagetoday.com/blogs/revolutionandrevelation/80256


Share on LinkedInShare on Google+Share on FacebookTweet about this on Twitter

EBOLA. PART 13. Ebola Treatment Centers are having difficulty maintaining their ability to respond to Ebola cases that may come again to the U.S.

In 2016 The World Health Organization identified the top 8 emerging diseases that were likely to cause severe outbreaks in the near future: Crimean-Congo haemorrhagic fever; Ebola; Marburg; Lassa Fever; MERS; SARS;  Nipah; and Rift Valley fever. (Q)

The Ebola epidemic in the Democratic Republic of Congo is breaching its contiguous borders with South Sudan, Uganda, and Tanzinia; it also borders four other countries.

 “…If the purse strings tighten, however, and the WHO cannot continue its work, the outbreak will almost certainly pick up speed. It’s only a matter of time until the virus crosses borders…

There are a few possible explanations for this (funding) shortcoming. The first is unspoken, but (is) true of the world’s largest outbreak of the disease in West Africa — Ebola has not yet spread to rich countries…”

Are we ready?

ASSIGNMENT: As Ebola spreads from Congo to contiguous countries In Africa, is the United States prepared for Ebola and other known and unknown emerging viruses?

“It sounds like an improbable fiction: a virulent flu pandemic, source unknown, spreads across the world in 36 hours, killing up to 80 million people, sparking panic, destabilising national security and slicing chunks off the world’s economy.

But a group of prominent international experts has issued a stark warning: such a scenario is entirely plausible and efforts by governments to prepare for it are “grossly insufficient”.

The first annual report by the Global Preparedness Monitoring Board, an independent group of 15 experts convened by the World Bank and WHO after the first Ebola crisis, describes the threat of a pandemic spreading around the world, potentially killing tens of millions of people, as “a real one”.

There are “increasingly dire risks” of epidemics, yet the world remained unprepared, the report said. It warned epidemic-prone diseases such as Ebola, influenza and Sars are increasingly difficult to manage in the face of increasing conflict, fragile states and rising migration…

 “Ebola, cholera, measles – the most severe disease outbreaks usually occur in the places with the weakest health systems,”.. “As leaders of nations, communities and international agencies, we must take responsibility for emergency preparedness, and heed the lessons these outbreaks are teaching us. We have to ‘fix the roof before the rain comes.’” (A)

“On Wednesday (July 17), the World Health Organization declared the Ebola outbreak in Democratic Republic of Congo a global health emergency…

A WHO committee that decided the outbreak would be a PHEIC lays out specific recommendations in a statement, including keeping borders open and not placing restrictions on trade and travel. The members call for a “coordinated international response” and for neighboring countries to work with partners to prepare for detecting and managing imported cases.

The emergency committee writes that, nearly a year into the outbreak, “there are worrying signs of possible extension of the epidemic.” Robert Steffen, who chaired the group, tells STAT that WHO is now declaring a PHEIC in part because disease transmission in the DRC city of Beni has increased, there is a risk to response workers’ safety, and that the disease is still actively transmitted in large geographical areas of the country.” (B)

“South Sudan has stepped up surveillance along its porous southern border after an Ebola case was detected just inside DR Congo, an health official in Juba told AFP Wednesday…

It is the closest Ebola is known to have come to South Sudan since a major outbreak began in Congo last August.

Dr Pinyi Nyimol, the director general of South Sudan’s Disease Control and Emergency Response Centre, said a team of reinforcements had been sent to the region to bolster surveillance after the case was confirmed.

“We are very worried because it is coming nearer, and people are on the move so contact (with Ebola) could cross to South Sudan,” he told AFP.”  (C)

“Uganda’s ministry of health announced late on Thursday a second Ebola outbreak in the western district of Kasese, about 472 km from the capital Kampala, following an imported case from the neighboring Democratic Republic of the Congo (DRC).

Joyce Moriku Kaducu, minister of state for primary health care, said in a statement that a 9 year-old female Congolese who entered the country with her mother on Wednesday through the Mpondwe border to seek medical care at Bwera Hospital has tested positive of the deadly virus.

The minister said the child was identified by the point of entry screening team with symptoms of high fever, body weakness, rash, and unexplained mouth bleeding…

“Since the child was identified in Uganda at the point of entry, there are no contacts in Uganda,” she said…

In June, Uganda confirmed three index cases of the highly contagious disease who visited the neighboring DRC. The outbreak was declared finished after 42 days of close monitoring.” (D)

“A  nine-year-old Congolese girl who tested positive for Ebola in neighbouring Uganda has died of the disease, as the World Health Organisation (WHO) warned that the current outbreak was approaching the grim milestone of 3,000 cases and 2,000 deaths.

Her death makes her the fourth case to cross into Uganda amid the continuing struggle to contain the deadly outbreak.” (E)

The World Health Organization issued an extraordinary statement Saturday raising concerns about possible unreported Ebola cases in Tanzania and urging the country to provide patient samples for testing at an outside laboratory.

The statement relates to a Tanzanian doctor who died Sept. 8 after returning to her country from Uganda; she reportedly had Ebola-like symptoms. Several contacts of the woman became sick, though Tanzanian authorities have insisted they tested negative for Ebola.

But the country has not shared the tests so they can be validated at an outside laboratory, as suggested under the International Health Regulations, a treaty designed to protect the world from spread of infectious diseases.

It is highly unusual for the WHO, which normally operates through more diplomatic means, to publicly reveal that a member country is stymying an important disease investigation.

 “The presumption is that if all the tests really have been negative, then there is no reason for Tanzania not to submit those samples for secondary testing and verification,” Dr. Ashish Jha, director of the Harvard Global Health Institute, told STAT…” (F)

“The statement comes hard on the heels of similar remarks by the US health secretary, Alex Azar, last week amid mounting concern that Tanzania may be in breach of its international commitments to share critical data relating to global health security.

Although Tanzania has insisted that its own tests showed negative for the Ebola virus, international health organisations have raised the alarm about not being given access to samples.

According to unconfirmed reports, the woman, in her mid-30s, had been conducting health research and had visited several health facilities in central Uganda before her death, after showing symptoms of a serious febrile illness.

The patient, who died on 8 September, had not been to the Democratic Republic of the Congo or had contact with Ebola cases, leading international health monitoring organisations to initially rule out the Ebola virus.

However, as several more reported cases emerged, including the initial patient’s sister, Tanzania’s response to the issue has prompted alarm about the country’s willingness to share either its test results or allow secondary testing of samples.

Azar voiced his own criticism during a visit to Uganda, telling reporters that he and others are “very concerned” as he urged Tanzania’s government to share laboratory results regarding the case.” (G)

A team of specialists at Emory University will never forget Aug. 2, 2014. That’s the day Kent Brantley, an American missionary based in Liberia, became the first of four patients with the Ebola virus to arrive at its Atlanta facility.

The eyes of the world watched as the Serious Communicable Diseases Unit ⁠— in hazmat suits, successfully treated Brantley and three other patients with the highly infectious disease.

The team at Emory is innovating on what they learned five years ago to help treat the disease now. “ (H)

“This fall, the University of Nebraska Medical Center is scheduled to open a cutting-edge center for training, simulation and quarantine to prepare federal workers to address highly infectious diseases. Creation of the National Center for Health Security and Biopreparedness is timely and important, given the troubling new Ebola outbreak in Africa.

As a result, the infectious disease initiative at UNMC and clinical partner Nebraska Medicine is taking on particular importance. UNMC received a $19.8 million federal grant for creation of the new biopreparedness center. A team of infectious disease experts from UNMC and Nebraska Medicine was in Uganda last year to train local health care workers in infection response and control…

During 2014-15, the med center treated three Ebola patients and monitored several others who were exposed but did not develop the disease. On Dec. 29 last year, an American doctor who had been treating patients in the Democratic Republic of Congo arrived in Omaha, where he completed the last 14 days of a 21-day monitoring period in UNMC’s biocontainment unit.” (I)

“During the outbreak five years ago, 56 hospitals across the U.S. were designated Ebola treatment centers, or ETCs. The idea was to increase national capacity to care for patients who contracted this highly infectious disease. These hospitals are mostly clustered around major airports where travelers from West Africa are likely to arrive, including Chicago’s O’Hare International Airport. They were initially equipped with dedicated clinical care resources, specialized infrastructure and trained staff to safely manage and treat patients suspected or confirmed to have Ebola. Since its inception in 2014, fewer resources have been allocated to this hospital network. As a result, the ETCs are having difficulty maintaining their ability to respond to Ebola cases that may come again to the U.S., and other infectious diseases that may follow.

Outbreaks are costly. Public health responses to Ebola, Zika, MERS, SARS and other diseases cost tens of billions of dollars, much of which can be avoided by taking preventive action. Congress can wait until Ebola or some equally deadly infectious disease arrives in our country, overwhelms state, local, tribal and territorial health care and public health capacity, and threatens lives and then provide billions in emergency supplemental funding. Or Congress can now recognize that these significant disease events will continue to occur and proactively take steps to ensure we can respond by creating a standing response fund.” (J)

“… In the past two years, the Trump administration has dissolved the federal government’s biosecurity directorate, scaled back its infectious disease prevention efforts, restricted development aid for countries like Congo, made several attempts to rescind foreign aid, including for global health, and pulled C.D.C. workers from Congo’s outbreak zones without a clear plan to send them back.

The administration has also announced policies meant to scare legal immigrants off public assistance programs, including for health care, to which they are legally entitled. Such policies imperil everyone: The more people who don’t have access to vaccines or antibiotics, the greater the risk that an infectious disease will spread. That applies to diseases like Ebola that might arrive on American shores from other countries, but it also applies to diseases that are already here, like flu and measles. The only reliable way for a country to protect itself from these threats is for it to help other countries do the same.

The new medications for Ebola and tuberculosis are the product of years of investment and careful work. That investment could continue to pay off, but only if the United States and its partners around the world increase their global health efforts, instead of shrinking away from them.” (K)

“As the Ebola epidemic in the DRC has become a global health emergency, we must not relent in our efforts to fight back. There are Ebola vaccines available today (pending licensing) thanks to the research and development and vaccine trials conducted during the West Africa Ebola epidemic. But the public health community needs a greater supply of those vaccines, and we need coordinated action on behalf of the public, philanthropic and private sectors to arrest the outbreak in the DRC. Stopping outbreaks at the source protects America. Infectious, deadly diseases such as Ebola do not recognize or respect borders.” (L)

“I’m not a social scientist. I have zero data on which to lean here. Someone who actually does this sort of research may conclude that donor fatigue, or the financial straits some countries and most media outlets currently face, or the turning inward that has accompanied the rise of populism can explain why this Ebola outbreak isn’t as front burner an issue as it would have been a decade ago, why organizations struggling to stop it are finding fewer donors writing smaller checks.

But in the meantime I am left wondering if we have learned to fear this virus less. And in the process, if we have let Ebola drift toward the column of bad diseases — things like cholera and yellow fever, Guinea worm and malaria — that we’re not so concerned about. Sure, they sicken and kill lots of people. But they don’t do it here.” (M)

“…If the purse strings tighten, however, and the WHO cannot continue its work, the outbreak will almost certainly pick up speed. It’s only a matter of time until the virus crosses borders…

There are a few possible explanations for this shortcoming. The first is unspoken, but was true of the world’s largest outbreak of the disease in West Africa — Ebola has not yet spread to rich countries…

At last month’s G20 summit in Japan, high-income countries, including the United States, declared their full support for the Ebola response. They must now make good on that promise to the WHO. If countries procrastinate, the world risks a repeat of the 2014–16 Ebola outbreak, in which a slow response contributed to the loss of more than 11,300 lives in Africa and a cost to taxpayers of more than $3 billion. The WHO needs just a fraction of this to prevent a horrific repeat of history.” (N)

“A dispute between two major players in the epidemic response — Doctors Without Borders and the W.H.O. — erupted on Monday, just as the W.H.O. announced that a new vaccine, the second to be deployed, would be introduced into the region.

On Monday, Doctors Without Borders accused the World Health Organization of “rationing Ebola vaccines and hampering efforts to make them quickly available to all who are at risk of infection.”

The W.H.O. quickly fired back, saying it was “not limiting access to vaccine but rather implementing a strategy recommended by an independent advisory body of experts and as agreed with the government of the D.R.C. and partners.”..

The approach so far has relied on a traditional strategy called ring vaccination that has been used successfully against other diseases. It involves vaccinating everyone who has had contact with an infected person, and all the contacts of those people, as well.

Officials from Doctors Without Borders say the strategy has not worked in Congo, in part because it has not been possible to track down every person who has come into contact with someone infected with Ebola, and because some contacts have refused to cooperate. The group has urged more widespread vaccination in regions where the disease is spreading, whether people are known contacts or not.

But it says that instead the W.H.O. has doled out limited amounts of vaccine. About 225,000 people have been vaccinated, but Doctors Without Borders says 450,000 to 600,000 should have received the vaccine by now.” (O)

“The United States has warned its citizens to take extra care when visiting Tanzania amid concerns over Ebola, adding to calls for the East African country to share information about suspected cases of the deadly disease there…

U.S. travelers should “exercise increased caution”, the State Department said on Friday in an updated travel advisory that cited reports of “a probable Ebola-related death in Dar es Salaam”.” (P)

“The medical response to an Ebola infection is markedly more challenging than many other diseases. It is one of the most deadly viruses with a 60% – 90% mortality rate compared to 2% for measles.

The Ebola virus is extremely infectious and highly communicable. Treating the disease is resource intensive. Patients must be kept in isolation in specialised, well-designed treatment centres. Health care workers are at high risk of exposure and must take extreme precautions to examine patients. Breakdown in personal protection and infrastructure can be fatal. In fact, approximately 6% of the victims have been involved in looking after patients.” (R)

“Today (June 12, 2019) the U.S. Centers for Disease Control and Prevention (CDC) is announcing activation of its Emergency Operations Center (EOC) on Thursday, June 13, 2019, to support the inter-agency response to the current Ebola outbreak in eastern Democratic Republic of the Congo (DRC). The DRC outbreak is the second largest outbreak of Ebola ever recorded and the largest outbreak in DRC’s history. The confirmation this week of three travel-associated cases in Uganda further emphasizes the ongoing threat of this outbreak. As part of the Administration’s whole-of-government effort, CDC subject matter experts are working with the USAID Disaster Assistance Response Team (DART) on the ground in the DRC and the American Embassy in Kinshasa to support the Congolese and international response. The CDC’s EOC staff will further enhance this effort.

CDC’s activation of the EOC at Level 3, the lowest level of activation, allows the agency to provide increased operational support for the response to meet the outbreak’s evolving challenges. CDC subject matter experts will continue to lead the CDC response with enhanced support from other CDC and EOC staff.” (S)

“…if we want to prevent Ebola cases evolving into wider outbreaks, then we’ll need to move beyond reactionary responses and address the factors that pave the way for epidemics.”..

To prevent future outbreaks, and to support the health of local communities in the poorest parts of the world, we need to invest in strengthening primary care and medical education. Otherwise, we will be here again in another five years, once again having failed to learn from our mistakes.” (T)


May 15, 2017

Lesson Learned from recent EBOLA and ZIKA episodes. We need to designate REGIONAL EMERGING VIRUSES REFERRAL CENTERS (REVRCs).

1. There should not be an automatic default to just designating Ebola Centers as REVRCs although there is likely to be significant overlap.

2. REVRCs should be academic medical centers with respected, comprehensive infectious disease diagnostic/ treatment and research capabilities, and rigorous infection control programs. They should also offer robust, comprehensive perinatology, neonatology, and pediatric neurology services, with the most sophisticated imaging capabilities (and emerging viruses “reading” expertise).

3. National leadership in clinical trials.

4. A track record of successful, large scale clinical Rapid Response.

5. Organizational wherewithal to address intensive resource absorption.

  • Faculty might want to scan the following unabridged Ebola chronology

PART 1. May 15, 2017. EBOLA is back in Africa. Is ZIKA next? Are we prepared?

PART 2. May 9, 2018. New Ebola outbreak declared in Democratic Republic of the Congo

PART 3. May 18, 2018 . As ZIKA and EBOLA reemerge, Trump administration cuts funding to halt international epidemics

PART 4. June 11, 2018 . “With an outbreak like this, it’s a race against time, as one Ebola patient with symptoms can infect several people every day.”

PART 5. June 16, 2018. EBOLA, ZIKA. EMERGING VIRUSES. ” All too often with infectious diseases, it is only when people start to die that necessary action is taken.”

PART 6. June 17, 2018. ANDEMIC PREPAREDNESS. “It’s like a chain-one weak link and the whole thing falls apart. You need no weak links.”

PART 7. June 21, 2018. Democratic Republic of Congo’s Ebola outbreak has been “largely contained”…

PART 8. June 24, 2018. “Slightly over a month into the response, further spread of [Ebola Virus Disease] has largely been contained,” WHO announced on June 20.

PART 9. August 10, 2018. After Ebola scare, Denver Health wishes it notified public of potential deadly virus sooner

PART 10. August 20, 2018. At least 10 health-care workers have been infected with the deadly Ebola virus as they battle an outbreak in an eastern province of Congo

PART 11. August 30, 2018. “…(WHO) reports the next seven to 10 days are critical in controlling the spread of the Ebola virus in eastern Democratic Republic of Congo.” http://doctordidyouwashyourhands.com/2018/08/who-reports-the-next-seven-to-10-days-are-critical-in-controlling-the-spread-of-the-ebola-virus-in-eastern-democratic-republic-of-congo/

PART 12. June17, 2019. “Three cases of EBOLA have emerged in Uganda, a neighboring country to the Democratic Republic of the Congo.” http://doctordidyouwashyourhands.com/2019/06/part-12-june17-2019-three-cases-of-ebola-have-emerged-in-uganda-a-neighboring-country-to-the-democratic-republic-of-the-congo/

Share on LinkedInShare on Google+Share on FacebookTweet about this on Twitter

“Walmart’s (health care) strategy is based on price competition. Patients know what services will cost before they walk into the physician’s office. Prices are rock-bottom.”

Health care “disruption” is well underway with most attention focused on paradigm-challenging players like: Amazon, Berkshire Hathaway and JPMorgan Chase forming an independent health care company for their employees; and the CVS Health Aetna Acquisition.

In the meantime, under-the-radar, Walmart’s strategy has been “based on the hospital inefficiency in innovation and the business theory of bundling and unbundling services.”

Now Walmart is leveraging its 1.5 million employees and 4,769 stores throughout the United States (90% of Americans live within 10 miles of a Walmart store) to launch its major health care initiatives.

“Walmart, the world’s biggest retailer, is moving deeper into the primary care and mental health market, opening a new clinic called Walmart Health in Georgia.

The company recently updated its website with a link to Walmart Health, describing its “newest location in Dallas, GA.” It also went online with the site “Walmarthealth.com,” where patients can set up appointments. Walmart is testing the concept with the initial clinic and could open more in the future, according to people familiar with the matter who asked not to be named because the plans are confidential.

The website indicates that first appointments are available on Sept. 13, and the company will offer primary care, dental, counseling, labs, X-rays and audiology, among other services…

The new clinic will have on-site health providers, including nurses, to offer consultations, immunizations and lab tests, people familiar with the matter said. Added services include hearing tests, 60-minute counseling sessions and vision tests.” (A)

“Walmart’s new Georgia location opening comes as rivals CVS Health and Walgreens Boots Alliance push further into outpatient healthcare services through various models. The retailers see 10,000 baby boomers aging into Medicare coverage each day and are also looking to fill emptying space in their brick and mortar stores in the face of changing consumer shopping habits driven by online retail giant Amazon, which is also exploring new ways to get into the healthcare business but has yet to offer face-to-face personalized healthcare services for customers.

This year, CVS has said its new health hub concept store will reach four U.S. metropolitan areas and 50 locations by the end of this year as part of a major expansion. CVS said the HealthHub rollout will grow to 1,500 locations by the end of 2021, or about 500 HealthHubs a year…

Walgreens has a joint venture with the big health insurer Humana, opening senior clinics in certain markets and the drugstore chain has a partnership with UnitedHealth Group’s MedExpress urgent care subsidiary that has opened centers that include X-rays and are staffed by physicians with a door connecting to an adjacent Walgreens store.

But Walmart says the new Walmart Health centers aren’t designed to increase foot traffic and customer volume into their stores… Walmart has a different approach.

“We are trying to solve problems for our customers,”… “We already have the volume. We have the locations and the right people.” (B)

“Here we see two rival strategies to marketing healthcare services. Walmart’s strategy is based on price competition. Patients know what services will cost before they walk into the physician’s office. Prices are rock-bottom. This directly benefits patients, who will come again. Word will get out. In contrast, the hospital’s strategy is based on billing insurance companies for services whose prices are not revealed to patients in advance. Patients have no economic incentive to seek lower-cost services elsewhere.

These two strategies reflect different organizational legal structures. Walmart is a profit-seeking corporation. Profit-seeking enterprises whose business plans seek a growing market, as Walmart’s business plan always has, are forced by price-sensitive consumers to compete by cutting costs and then lowering prices. In contrast, the hospital is a non-profit enterprise. By law, non-profit enterprises have no owners. Employees may not profit directly from innovations that lead to higher profits. In non-profits, everyone is salaried. There is therefore far less incentive to cut costs and reduce prices.” (C)

“As Walmart moves deeper into primary care, the retail giant wants to ensure there is a skilled healthcare workforce to fill critical roles in its 20 care clinics…

Walmart announced Tuesday its 1.5 million associates will be able to apply for one of seven bachelor’s degrees and two career diplomas in health-related fields for $1 a day through Live Better U, Walmart’s education benefit program…

The new degrees and certificate programs will provide Walmart employees with a path to higher-paying careers in the growing healthcare field, Walmart executives said..

The health and wellness courses include career diploma programs for pharmacy technicians and opticians through Penn Foster and seven bachelor’s degrees in health science, health and wellness and healthcare management/administration offered through Purdue University Global, Southern New Hampshire University, Bellevue University and Wilmington University.

The education program will arm employees with training to fill critical healthcare roles across Walmart and Sam’s Club, which includes more than 5,000 retail pharmacies, 3,000 vision centers and 400 hearing centers, the retailer said in a release. The upskilled workforce will help the retailer make quality healthcare more affordable and accessible to customers in the communities it serves.” (D) 

“What is health care’s allure for Walmart? Medical services typically have higher margins than store products. Since they are often provided in person, there is more opportunity for consumers to pick up other items while visiting the store. And usage is growing, especially as the United States’ population ages.

In particular, Walmart is eyeing both the Medicare and Medicaid markets since many of its customers are senior citizens and lower-income Americans. Its prices are generally lower than at pharmacy chains, such as CVS.

As Walmart expands its health care menu, it builds even more ties with its shoppers. Its deal with Anthem, for instance, lets the insurer’s Medicare Advantage customers use their plan benefits to purchase over-the-counter medicine, first aid supplies, support braces and pain relievers from a store.

And Walmart can market its healthy grocery items to certain Medicare Advantage enrollees since the federal government recently allowed insurers to cover such products as a supplemental benefit. This has given the company another advantage over pharmacy chains, which have much more limited food selections.

Also, the retailer’s locations blanket the nation. Many are in rural areas where there are few other health care options. Walmart often operates as a community center, with customers dropping in a few times a week. And it serves as a one-stop shop, where people could access medical services and pick up whatever other items they need.”  (E)

“On the heels of Walmart offering health clinics in certain locations, the big-box retailer is adding on a digital healthcare site—WalmartHealth.com—so consumers can make doctor, dentist, and behaviorial health medical appointments, in addition to scheduling hearing tests and immunizations…

There are some true loyalty-generating opportunities in extending your ambulatory offerings with select regional retail clinics, utilizing technology to improve your digital front door and provide real-time patient obligations.” (F)

Walmart’s Centers of Excellence program gives associates access to world-class specialists for:

Certain heart surgeries, like cardiac bypass and valve replacements. Certain spine surgeries, like spinal fusions and removal of spinal discs (discectomy). Hip and knee joint replacements. Breast, lung, colorectal, prostate, and blood cancers (including myeloma, lymphoma, and leukemia). Certain weight loss surgeries, like gastric bypass and gastric sleeve procedures. Organ and tissue transplants (except kidney, cornea, and intestinal), ventricular assist devices (VADs) and total artificial hearts, and CAR-T cell therapy. Outpatient radiology, which will be reviewed automatically through the pre-authorization program

Walmart has partnered with several world-class health systems across the country to serve the Centers of Excellence program, and a few of these include: Cleveland Clinic, in Cleveland, Ohio, for cardiac surgery. Johns Hopkins Hospital, in Baltimore, Maryland, for joint replacement surgery. Mayo Clinic in Minnesota, Florida and Arizona, for transplants and cancer care. Geisinger Medical Center, in Danville, Pennsylvania, for weight loss surgery. Mercy Springfield, in Springfield, Missouri, for spine surgery..

In addition to the full cost of treatment for many conditions, the benefit includes travel and lodging expenses for both the patient and a companion caregiver. Travel and lodging are not included for the weight-loss-surgery benefit.” (G)

“Geisinger has earned designation as a Radiology Center of Excellence by Covera Health, a New York City-based company that uses advanced clinical analytics to objectively measure quality in radiology.

With its new distinction, Geisinger joins a national program that integrates with self-funded insurers’ existing health networks to steer community members toward local radiology providers based on their diagnostic accuracy — not price — to curb misdiagnoses. Danville, Pa.-based Geisinger is also a member of Covera Health’s Quality Care Collaborative, in which participants receive practical, actionable feedback to improve their clinical practice.”  (H)

“Walmart’s retail strategy in health care is based on the hospital inefficiency in innovation and the business theory of bundling and unbundling services. The vast majority of hospital revenue is rooted in the fee-for-service business model: rather than make money for improving health (a reimbursement model that is much harder to design than it sounds), providers are paid more for the number of services provided — hampering incentives for innovation. Providers are thus incentivized to provide a high-volume, high-cost standard of care, squeezing money from insurance companies. In turn, those costs are passed down to consumers in the form of higher premiums. However, as hospital operational costs ballooned, health systems began to treat their departments like a public investment portfolio. They unbundled (divested from) low-end services that required all the same operating expenses but didn’t turn a profit.

Outpatient primary care is a prime unit to be unbundled from traditional health care delivery systems, i.e. hospitals, for two reasons:

Most patients that visit primary care physicians don’t need the resources of an expensive medical center on-hand for each visit, and would be better served by an experience that emphasized price, convenience, and attention.

Reimbursement rates for most primary care services, e.g. a blood pressure checkup or physical exam, are much lower than specialty care (imaging, biopsies, intensive procedures, etc) and thus provide a lower short-term return on invested capital…

This brings us to the biggest loser of Walmart’s foray into health care: traditional health systems. Walmart’s strategy notably doesn’t utilize any ownership of inpatient hospitals; all incentives are aligned to provide the highest value care at the lowest possible cost in outpatient settings, ultimately decreasing utilization of expensive health care services like inpatient hospitalizations. (I)

“After more than a decade of transforming health care for its roughly 1 million workers and huge and loyal customer base, Walmart plans to play an even larger role. Marcus Osborne, vice president of transformation and wellness for the retail giant, made that point clear in a recent talk with the Health Care Council of Chicago.

Osborne said Walmart will continue to expand its health care services for customers and employees until or unless the company “hits a third rail” by entering a space in which it can’t compete effectively. To date, he emphasized that every significant initiative the company has undertaken to address its customers’ top three health care concerns — cost, convenience and access — has delivered value for employees and customers and a return for the company.

He also reported that all projects that Wal-Mart Stores Inc. undertook over the last two years, including a pilot with its Boston-based partner Beacon Health to bring affordable, behavioral health care to customers, performed better than expected. He said Walmart’s most successful venture recently has been its partnership with Quest Diagnostics to provide in-store testing services to customers, providing a level of convenience that has increased patient compliance with their physicians’ directives by 50 percent or more.

Other topics Osborne addressed include: Access to care; Variation in clinical practice; Solving obesity; Scaling success. (J)

Sam’s Club, a retail warehouse club operated by Walmart, is teaming up with healthcare companies to offer four bundled healthcare service offerings for its members, ranging from $50 to $240 per year.

The pilot, called Care Accelerator, is in tandem with payer Humana and on-demand primary care app 98point6. Bundles vary in included services, but each offers free prescriptions on some generic medications, low-cost dental and vision services, prepaid health debit cards for use within the network and unlimited telehealth for $1 a visit.

The company stressed that Care Accelerator is not a health insurance plan. Participating Sam’s Club members will still have to pay their healthcare provider at the point of service, though it will be at a discounted rate.

The family bundle, for example, costs $240 a year and covers up to six family members. It includes access to preventive lab screenings for early detection of heart disease and diabetes, a 10% discount on hearing aids and up to a 30% discount on chiropractic, massage and acupuncture services.

By comparison, the “Starter A” bundle only includes free select generic medications, $1 telehealth visits, $60 eye exams and a $5 prepaid health debit card. Medications must be filled at Sam’s Club pharmacies and eye exams must be done at Sam’s Club, guaranteeing business for the retailer and its 566 pharmacy locations.” (K)


“Back in 2005, a memo from Walmart’s then-Vice President of Benefits, Susan Chambers, outlined a strategy for how the company could remove sick workers from the payrolls and avoid paying healthcare benefits. More recently, premiums on Walmart’s health plans have soared, and the company has cut eligibility considerably.

Starting in 2015, Walmart cut coverage for anyone working less than 30 hours per week.

In the last five years, the cost of Walmart’s cheapest healthcare plan has more than doubled.

Hundreds of thousands of Walmart workers and their family members qualify for publicly funded health insurance.

Walmart’s health care plans fail to cover hundreds of thousands of associates. In 2009, Walmart claimed that 52% of associates were covered under its healthcare plan. The company has refused to disclose coverage rates for its 1.5 million U.S. employees since then.

In recent years, Walmart has made it even more difficult for associates to get quality health care for themselves and their families. The company stopped offering health insurance to part-time employees working less than 24 hours per week in 2012, and starting in 2015, it cut coverage for anyone working less than 30 hours per week, including those who had previously been grandfathered in. In the last five years, the cost of Walmart’s cheapest healthcare plan has more than doubled. The cost of many of the company’s family plans has more than quadrupled over that time period.

For employees earning Walmart’s starting rate of $9.00/hour working an average of 34 hours per week, the deductible alone on Walmart’s cheapest plan for workers with children is over a third of the employee’s annual gross income.”  (L)



You are the CEO of a suburban community hospital, the only one in town, two block away from a big Walmart store that just opened a Walmart Health clinic.

Last year the hospital purchased a second MRI and started an interventional cardiology program. University Medical School, 50 miles away, has just opened a local cancer program satellite.

The Board is in a panic as Walmart is hiring your biggest physician admitters and senior technical staff. Admissions are falling.

There is a Board meeting next week.

Where do you start?


Compare WalmartCare with CVSCare, AppleCare, GoogleCare, MicrosoftCare, AmazonCare, and other nontraditional models.

Analysis: Impact of CVS, Walgreens, Walmart Retail Healthcare Expansion Strategies by Ethan Chernofsky  https://hitconsultant.net/2019/09/27/cvs-walgreens-walmart-retail-healthcare-expansion/#.XY-HDEZKhlA

If you want to discuss other ways of organizing this case for class discussion please contact me at jonathanmetsch@gmail.com

Some Resources For Faculty Preparation

Project Management. The hardest part of getting started….is getting started

“…what would it look like if Amazon CEO Jeff Bezos took the helm of a major integrated (health care) delivery system?”

Apple, Amazon, Google and Microsoft trajectories for healthcare http://doctordidyouwashyourhands.com/2018/07/apple-amazon-google-and-microsoft-trajectories-for-healthcare/

Share on LinkedInShare on Google+Share on FacebookTweet about this on Twitter

PART 3. SURPRISE MEDICAL BILLS. “I was never in a position to preselect who (would) perform my heart transplant,” (and if the physicians and surgeons were in network)….because I did not know when a new heart would become available.


Going forward all new cases will be shorter and for ongoing cases new and previous posts will be thoughtfully edited.

On continuing cases do you prefer that new posts be shown first or last?

Reminder. You can edit these cases for classroom use with attribution to Doctor, Did You Wash Your Hands? ®      http://doctordidyouwashyourhands.com/

Why not “test drive” a case in the classroom?

Please post your comments, feedback and suggestions and/ or email me at jonathanmetsch@gmail.com

thanx! for your interest


Jonathan Metsch, Dr.P.H.


PART 1: January 31, 2019. “If you’re shot, stabbed, hit by a car, fall off a roof or suffer any other major injury in San Francisco, you’ll be whisked to San Francisco General Hospital, the only trauma center in the city “

PART 2: February 20, 2019. A new bill would outlaw the big, surprise bills that Zuckerberg San Francisco General Hospital has sent to hundreds of patients.

PART 3: April 18, 2019. “Zuckerberg San Francisco General Hospital announced Tuesday it has overhauled its billing policies…

PART 4: August 20, 2019. Hospitals kept ER fees secret

ASSIGNMENT: How do other states address financial sustainability for their “safety-net” hospitals?

PART 1: January 31, 2019. “If you’re shot, stabbed, hit by a car, fall off …

“If you’re shot, stabbed, hit by a car, fall off a roof or suffer any other major injury in San Francisco, you’ll be whisked to San Francisco General Hospital, the only trauma center in the city. …But you may leave with a very unpleasant side-effect: a shockingly high bill. …That’s because S.F. General – whose patients are overwhelmingly poor and are on Medicare or Medi-Cal, or have no insurance at all – lacks a good way to deal with patients who are actually insured.” (A)

“Under a new state law, if you visit an in-network facility – such as a hospital, lab or imaging center – you will only be responsible for your in-network share of the cost, even if you’re seen by an out-of-network provider…

The new law covers Californians with private health insurance plans that are regulated by the state Department of Managed Health Care, or DMHC, and the state Department of Insurance, which includes roughly 70 percent of the state’s private insurance market, according to the California Health Care Foundation.

It does not cover some 5.7 million people whose employer-sponsored insurance plans are regulated by the U.S. Department of Labor…

The key point to remember is that you shouldn’t pay more than your in-network copayment, coinsurance or deductible, as long as you visited an in-network facility for non-emergency services.” (B)

“The trauma center has no contracts with private insurance companies. If it did, there would be agreements with those insurers on how much a particular drug or a particular procedure costs.

Instead, the hospital charges the highest rates approved by the Board of Supervisors and the mayor, receives whatever amount the patient’s insurance company decides to pay, and bills the patient for the rest.” (C)

On April 3, Nina Dang, 24, found herself in a position like so many San Francisco bike riders – on the pavement with a broken arm.

A bystander saw her fall and called an ambulance. She was semi-lucid for that ride, awake but unable to answer basic questions about where she lived. Paramedics took her to the emergency room at Zuckerberg San Francisco General Hospital, where doctors X-rayed her arm and took a CT scan of her brain and spine. She left with her arm in a splint, on pain medication, and with a recommendation to follow up with an orthopedist.

A few months later, Dang got a bill for $24,074.50. Premera Blue Cross, her health insurer, would only cover $3,830.79 of that – an amount that it thought was fair for the services provided. That left Dang with $20,243.71 to pay, which the hospital threatened to send to collections in mid-December…

Most big hospital ERs negotiate prices for care with major health insurance providers and are considered “in-network.” Zuckerberg San Francisco General has not done that bargaining with private plans, making them “out-of-network.” That leaves many insured patients footing big bills.

The problem is especially acute for patients like Dang: those who are brought to the hospital by ambulance, still recovering from a trauma and with little ability to research or choose an in-network facility.

A spokesperson for the hospital confirmed that ZSFG does not accept any private health insurance, describing this as a normal billing practice. He said the hospital’s focus is on serving those with public health coverage – even if that means offsetting those costs with high bills for the privately insured.

“It’s a pretty common thing,” said Brent Andrew, the hospital spokesperson. “We’re the trauma center for the whole city. Our mission is to serve people who are underserved because of their financial needs. We have to be attuned to that population.”

But most medical billing experts say it is rare for major emergency rooms to be out-of-network with all private health plans. (D)

On its web site, ZSFG declares that “everyone is welcome here” regardless of their financial situation or immigration status:

Everyone is welcome here, no matter your ability to pay, lack of insurance, or immigration status. We’re much more than a medical facility; we’re a health care community promoting good health for all San Franciscans.

We’re part of a large group of neighborhood clinics and healthcare providers, the San Francisco Health Network. In partnership, we provide primary care for all ages, specialty care, dentistry, emergency and trauma care, and acute care for the people of San Francisco…

“Our mission is to serve people who are underserved because of their financial needs,” the spokesperson also stated. “We have to be attuned to that population.” (E)

“More than half of U.S. adults “have been surprised by a medical bill that they thought would have been covered by insurance,” according to a new survey from research group NORC at the University of Chicago…

The big picture: Drug prices have been in the crosshairs of lawmakers, and health insurers have always been a punching bag. But hospitals and doctors aren’t attracting any large-scale movement to rein in pricing and billing tactics.

“There’s a huge amount of trust in the providers people choose to go to,” said Caroline Pearson, senior fellow at NORC. “I think we’ve got a long way to go until we have backlash against those providers. But as insurance gets more complicated and out-of-pocket costs rise, we’re going to see more and more surprise bills.”  (F))

“U.S. Sen. Bill Cassidy, R-La., said federal lawmakers on both sides of the aisle are moving closer to an agreement on legislation to prevent surprise medical bills, according to a Bloomberg Government report…

Republicans and Democrats have been working to address the issue, and bipartisan legislation is predicted for early 2019, Mr. Cassidy told Bloomberg Government…

There have been legislative efforts related to surprise medical bills. In September, a bipartisan group of senators unveiled the Protecting Patients from Surprise Medical Bills Act. Then on Oct. 11, Democrat Sen. Maggie Hassan of New Hampshire introduced the No More Surprise Medical Bills Act of 2018. The first draft bill focuses on preventing out-of-network providers from charging patients more for emergency care than what they would pay using insurance. The second bars healthcare providers from out-of-network billing for emergency services, according to the report.

Meanwhile, Bloomberg Government notes, insurers and hospitals are pointing the finger at each other over who is at fault for the problem.

Mr. Cassidy told the publication there are “bad apples with both groups” and anticipates both sides “are going to have to give a little bit” when it comes to changes.” (G)

“Payer groups, including America’s Health Insurance Plans, are joining forces with employers, consumers and other stakeholders in support of a plan they say will tackle surprise billing.

The groups signed on to a set of guiding principles aimed at protecting consumers from the practice. The guidelines are: inform patients when care is out of network, support federal policy that protects consumers while restraining costs and ensuring quality networks and pay out-of-network doctors based on a federal standard.

Meanwhile, the American Hospital Association and the Federation of American Hospitals released a joint statement saying hospitals and health systems also support patient protections from surprise billing but place blame on insurers, not providers…

AHIP said surprise billing happens because providers aren’t participating in certain networks. “When doctors, hospitals or care specialists choose not to participate in networks – or if they do not meet the standards for inclusion in a network – they charge whatever rates they like,” the group wrote.

In their statement, the hospital groups also backed consumer protections, but pointed the finger at payers for the issue. “Inadequate health plan provider networks that limit patient access to emergency care is one of the root causes of surprise bills. Patients should be confident that they can seek immediate lifesaving care at any hospital. The hospital community wants to ensure that patients are protected from surprise gaps in coverage that result in surprise bills, and we look forward to working with policymakers to achieve this goal,” they wrote…”  (H)

“I’ve read emergency room bills from all 50 states and the District of Columbia. I’ve looked at bills from big cities and from rural areas, from patients who are babies and patients who are elderly. I’ve even submitted one of my own emergency room bills for an unexpected visit this past summer.

Some of the patients I read about come in for the reasons you’d expect: a car accident, pains that could indicate appendicitis or a heart attack, or because the ER was the only place open that night or weekend….

I’ll stop collecting emergency room bills on December 31. But before I do that, I wanted to share the five key things I’ve learned in my year-long stint as a medical bills collector.

1) The prices are high – even for things you can buy in a drugstore

2) Going to an in-network hospital doesn’t mean you’ll be seen by in-network doctors

3) You can be charged just for sitting in a waiting room

4) It is really hard for patients to advocate for themselves in an emergency room setting

5) Congress wants to do something about the issue.. (I)

“Zuckerberg General’s emergency room fees are also higher, on average, than ERs nationally, in the state of California, and in the city of San Francisco. In the city, they’ve charged up to five times as much. The fees are set by the San Francisco Board of Supervisors, which has voted for steady increases, doubling the charge since 2010.

When asked about the fees, board members admitted that they hadn’t kept a close eye on the prices and said they plan to hold hearings on the issue.

“It turns out we should have been monitoring this much more closely,” says Aaron Peskin, a supervisor who has previously voted in favor of the hospital prices and who is now calling for the hearings…

The city of San Francisco manages Zuckerberg General and sets the prices the hospital charges.

The task falls to the San Francisco Board of Supervisors, an 11-member board that oversees city policies and budgets. Every year or two, they approve a lengthy document that lists hospital prices for everything from an emergency room fee to a day in the obstetrics unit to a primary care exam. The document describes the fees as “proper reasonable amounts.”

The current prices were approved at a board a meeting in July 2017. A video recording of that meeting shows there was no debate or discussion of the prices. Instead, the board of supervisors unanimously approved the ZSFG charges in a voice vote that latest less than a minute…

But there is little record of public discussion or debate over that increase. Meeting records for each vote on the hospital prices since 2010 show that the fees have always been approved unanimously.

“I cannot recall there ever being any discussion of them,” says Peskin, a board member who has served on and off since 2001. “I don’t think there has ever been a split vote, and that’s been true as long as I’ve been on the board of supervisors. But that will probably change now.”..

The San Francisco Board of Supervisors now plans to bring greater scrutiny to the hospital’s billing practices in light of Vox’s reporting.” (J)

“Zuckerberg San Francisco General Hospital is reducing a bike crash patient’s $20,243 bill down to $200 – only after the case drew national attention to the hospital’s surprising policy of being out-of-network with all private health insurance…

The San Francisco Board of Supervisors, which oversees the hospital, now plans to hold hearings on Zuckerberg General’s billing practices as well.”  (K)

“Momentum is building for action to prevent patients from receiving massive unexpected medical bills, aided by President Trump, who is vowing to take on the issue…

Trump gave a boost to efforts on Wednesday.

“[People] go in, they have a procedure and then all of a sudden they can’t afford it, they had no idea it was so bad,” Trump said at a roundtable with patients about the issue.

“We’re going to stop all of it, and it’s very important to me,” he added.

But the effort still faces obstacles from powerful health care industry groups – including hospitals, insurers and doctors. Those groups are jockeying to ensure that they avoid a financial hit from whatever solution lawmakers and the White House back.” (L)

 “There are 141 million visits to the emergency room each year, and nearly all of them.. have a charge for something called a facility fee. This is the price of walking through the door and seeking service. It does not include any care provided.

Emergency rooms argue that these fees are necessary to keep their doors open, so they can be ready 24/7 to treat anything from a sore back to a gunshot wound. But there is also wide variation in how much hospitals charge for these fees, raising questions about how they are set and how closely they are tethered to overhead costs.

Most hospitals do not make these fees public. Patients typically learn what their emergency room facility fee is when they receive a bill weeks later. The fees can be hundreds or thousands of dollars. That’s why Vox has launched a year-long investigation into emergency room facility fees, to better understand how much they cost and how they affect patients…

We found that the price of these fees rose 89 percent between 2009 and 2015 – rising twice as fast as the price of outpatient health care, and four times as fast as overall health care spending.” (M)

 “San Francisco, CA -Today Mayor London N. Breed, Supervisor Aaron Peskin, the Department of Public Health and Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) announced immediate steps to improve billing practices at ZSFG for patients who have gotten stuck in the middle of disputes between the hospital and their insurance provider, including a temporary halt to the practice of balance billing…

Immediate Changes.

Temporarily halt all balance billing of patients

Effective immediately until a better plan is determined

Make financial assistance easier to get

Proactively begin the process of assessing a patient’s eligibility for assistance, rather than waiting for them to apply

Improve patient communications

Proactively reach out to patients who are receiving large bills to explain the situation, remove the element of surprise, and offer to help

Create a Frequently Asked Questions document to clear up many of the routine questions about billing and financial assistance

Publicize the patient financial services hotline, (415) 206-8448, so that people know where to go for help

Increase communication with patients and provide information about financial assistance opportunities

Additional elements of a comprehensive plan to be developed within 90 days

Make financial assistance easier to get

Adjust charity care and sliding scale policies to expand the number of people who are eligible

Revise ZSFG catastrophic high medical expense program to support more patients who are faced with high, unexpected bills for catastrophic events

Streamline the process of applying for assistance

Protect patients’ financial health

Establish an out-of-pocket maximum for patient payments to ZSFG

Pursue agreements with private insurance companies

Work with state partners to explore additional efforts to improve insurance payments

Ensure ZSFG prices and practices are fair

Undertake a study of hospital charges regionally, comparing trauma centers, academic medical centers, San Francisco and Bay Area hospitals

Research billing and financial assistance practices of California public hospitals to identify opportunities for improvement

Conduct financial analysis of impact on the City of proposed changes (N)

(A)San Francisco General Hospital Lacks A Good Way To Deal With Patients Who Are Actually Insured, https://californiahealthline.org/morning-breakout/san-francisco-general-hospital-lacks-a-good-way-to-deal-with-patients-who-are-actually-insured/

(B)Nasty surprise bills prohibited by new California law when people visit facilities in their insurance network , by Emily Bazar, https://www.sacbee.com/news/local/health-and-medicine/article157970259.html

(C)SF General’s insured patients suffer further trauma when bill arrives, by Heather Knight, https://www.sfchronicle.com/bayarea/heatherknight/article/SF-General-s-insured-patients-suffer-further-13543542.php

(D)A $20,243 bike crash: Zuckerberg hospital’s aggressive tactics leave patients with big bills, by Sarah Kliffsarah, https://www.vox.com/policy-and-politics/2019/1/7/18137967/er-bills-zuckerberg-san-francisco-general-hospital

(E)Report: Zuckerberg Hospital Gouges Paying Patients to Pay For Illegals, by Kit Daniels, https://www.infowars.com/zuckerberg-hospital-offsets-healthcare-costs-of-illegals-by-gouging-privately-insured/

(F)A Fainting Spell After A Flu Shot Leads To $4,692 ER Visit, http://health.wusf.usf.edu/post/fainting-spell-after-flu-shot-leads-4692-er-visit#stream/0

(G)Report: Zuckerberg Hospital Gouges Paying Patients to Pay For Illegals, by Kit Daniels, https://www.infowars.com/zuckerberg-hospital-offsets-healthcare-costs-of-illegals-by-gouging-privately-insured/

(H) Payer, hospital groups trade blame on surprise billing, by Les Masterson, https://www.healthcaredive.com/news/payer-hospital-groups-trade-blame-on-surprise-billing/544064/

(I)Taking Surprise Medical Bills To Court, by Julie Appleby, https://khn.org/news/taking-surprise-medical-bills-to-court/

(J)Prices at Zuckerberg hospital’s emergency room are higher than anywhere else in San Francisco, by Sarah Kliff, https://www.vox.com/2019/1/22/18183534/zuckerberg-san-francisco-general-hospital-er-prices

(K)After Vox story, Zuckerberg hospital rolls back $20,243 emergency room bill, by Sarah Kiff, https://www.vox.com/health-care/2019/1/24/18195686/vox-zuckerberg-hospital-emergency-room-bill

(L)Trump boosts fight against surprise medical bills, by PETER SULLIVAN, https://thehill.com/policy/healthcare/427066-trump-boosts-fight-against-surprise-medical-bills

(M)Emergency rooms are monopolies. Patients pay the price, by Sarah Kliff, https://www.vox.com/health-care/2017/12/4/16679686/emergency-room-facility-fee-monopolies

(N)Zuckerberg hospital puts balance billing on hold, General Hospital Until Plan to Improve Long-Term Billing Practices is Implemented, https://sfmayor.org/article/mayor-london-breed-and-supervisor-aaron-peskin-announce-halt-balance-billing-zuckerberg-san

PART 2:  February 20, 2019. A new bill would outlaw the big, surprise bills that Zuckerberg San Francisco General Hospital has sent to hundreds of patients.

“California lawmakers will introduce legislation Monday to end surprise emergency room bills like those that left one patient with a $20,000 treatment bill after a minor bike crash – a move they say was inspired by Vox’s reporting on the issue.

The new bill, introduced by Assemblyman David Chiu and Sen. Scott Wiener, would bar California hospitals from pursuing charges beyond a patient’s regular co-payment or deductible. The ban would apply even if a hospital was out-of-network with a patient’s health insurance…

California actually has some of the country’s strongest protections against surprise medical bills – but the state’s laws never anticipated a hospital with billing practices like Zuckerberg San Francisco General.

In 2016, California passed a law that protected patients from surprise bills from out-of-network doctors they didn’t choose.

This might happen if, for example, a patient went to an in-network hospital and then received a bill from an out-of-network anesthesiologist or radiologist they never even met.

That law covered patients receiving scheduled care like surgery or delivering a baby. Separately, a decade-old California Supreme Court ruling provided similar protections for emergency room patients.

Neither the court ruling nor the 2016 law anticipated a situation like Zuckerberg San Francisco General, where the entire hospital is “out of network” with all private health insurance.”..

This new legislation would tackle that rarer situation where a hospital is not in network, and then sends the patient a bill for whatever balance their insurer won’t pay.

There are two key parts to the proposal. First, the bill would prohibit hospitals from pursuing any balance that the patient owed beyond their regular co-payment or contributions to the health plan’s deductible.

Second, the bill would regulate the prices that the hospital could charge for its care, limiting the fees to 150 percent of the Medicare price or the average contracted rate in the area, whichever is greater.”  (A)

“Publicity over “balance billing,” a practice that at Zuckerberg San Francisco General Hospital has left some patients with insurance on the hook for thousands of dollars in bills, has prompted San Francisco lawmakers to call for a ban.

SF General made headlines recently for being out of network with all private insurance companies and charging its insured patients high bills — in one case $20,000 for a broken arm — without informing them first of the practice.

Assembly Bill 1161, introduced by Assemblymember David Chiu and state Sen. Scott Wiener, would mandate that insured patients across the state owe the same copayment or deductible they would normally pay for their in-network emergency care.

The ban would apply regardless of whether or not the emergency room is in-network or out-of-network with a patient’s insurer.

Patients receiving non-emergency care already benefit from protections of a similar state law. However, the law does not apply to Preferred Provider Organization (PPO) patients.

Some 6 million people across the state have federally regulated self-insured plans, and some 1 million have plans regulated by the California Department of Insurance who don’t benefit from this protection, per the bill…

He said that the bill is a response “in regard to what we learned is happening at [ZSFGH] — but also across California — this is the situation of patients who get a surprise bill after visiting an emergency room.” (B)

Dear Congressional and Committee Leadership: (C)

On behalf of our member hospitals, health systems and other health care organizations, we are fully committed to protecting patients from “surprise bills” that result from unexpected gaps in coverage or medical emergencies. We appreciate your leadership on this issue and look forward to continuing to work with you on a federal legislative solution.

Surprise bills can cause patients stress and financial burden at a time of particular vulnerability: when they are in need of medical care. Patients are at risk of incurring such bills during emergencies, as well as when they schedule care at an in-network facility without knowing the network status of all of the providers who may be involved in their care. We must work together to protect patients from surprise bills.

As you debate a legislative solution, we believe it is critical to:

Define “surprise bills.” Surprise bills may occur when a patient receives care from an out-of-network provider or when their health plan fails to pay for covered services. The three most typical scenarios are when: (1) a patient accesses emergency services outside of their insurance network, including from providers while they are away from home; (2) a patient receives care from an out-of-network physician providing services in an in-network hospital; or (3) a health plan denies coverage for emergency services saying they were unnecessary.

Protect the patient financially…

Ensure patient access to emergency care…

Preserve the role of private negotiation…

Remove the patient from health plan/provider negotiations…

Educate patients about their health care coverage…

Ensure patients have access to comprehensive provider networks and accurate network information…

Support state laws that work…


American Hospital Association, America’s Essential Hospitals, Association of American Medical Colleges, Catholic Health Association of the United States, Children’s Hospital Association, Federation of American Hospitals

A.After Vox story, California lawmakers introduce plan to end surprise ER bills, by Sarah Kliff, https://www.vox.com/2019/2/24/18236482/zuckerberg-hospital-surprise-bills-california

B.Controversial ZSFGH billing practice that left privately-insured owing thousands could be banned, by Laura Waxmann, http://www.sfexaminer.com/controversial-zsfgh-billing-practice-left-privately-insured-owing-thousands-banned/

(C) Joint Surprise Billing Letter to Congress and Committee Leadership, https://www.aha.org/letter/2019-02-20-joint-surprise-billing-letter-congress-and-committee-leadership

PART 3. April 18, 2019. “Zuckerberg San Francisco General Hospital announced Tuesday it has overhauled its billing policies…

The hospital has for years made the rare decision to be out of network with all private health insurance plans. This created an acute problem for patients like like Nina Dang, 24, who made an unexpected trip to the hospital’s emergency room, the largest in San Francisco. An ambulance took Dang to the trauma center after a bike accident last April. She is insured by a Blue Cross plan, but she didn’t know that the ER does not accept insurance. She received a bill for $20,243.

After the Vox story ran, the hospital reduced Dang’s bill to $200, the copay listed on her insurance card.

Now, Zuckerberg San Francisco General Hospital (ZSFG) is essentially making the same change for all future patients: Its new billing policies will no longer charge those with private coverage “any more than they would have paid out of pocket for the same care at in-network facilities, based on their insurance coverage.”

This will put an end to the hospital’s use of a controversial practice call “balance billing,” when a hospital sends a patient a bill for the balance that an insurer won’t pay.

ZSFG will also create a new out-of-pocket maximum on what patients could end up owing for their treatment. The maximum is tethered to a patient’s income and ranges from zero dollars for the lowest earners to a $4,800 maximum for those with the highest incomes (1,000 percent of the poverty line, or $251,400 for a family of four).” (A)

“The changes are aimed at shielding patients from large bills by removing them from payment disputes between the hospital and the insurance company, said Rachael Kagan, director of communications with the department.

“We don’t have a large number of privately insured patients at Zuckerberg San Francisco General Hospital, but some of those who have been in that situation in the past have had a terrible experience and we want to rectify that,” said Ms. Kagan.

“We don’t want that to happen in the future. We know that it’s very stressful to get a large bill and we consider our responsibility to the patients to care for them in all ways. They will have gotten excellent medical care from us, and we want to protect their financial well-being also,” she added.

The hospital estimated that up to 1,700 of its 104,000 patients a year may have received a balance bill…

Zuckerberg hospital will also set a maximum out-of-pocket cost for patients at all income levels, with any insurance status, and this maximum will be income-based. No one will be charged more than 5 percent of their income…

Additionally, the hospital will make its patient financial assistance programs easier to qualify for so more people will get financial assistance. This involves increasing the threshold to qualify for the hospital’s charity care program. The threshold to qualify will increase from 350 percent of the federal poverty level to 500 percent of the federal poverty level.

The hospital is also adjusting the “sliding scale” financial assistance program for San Francisco residents. Previously, Zuckerberg hospital assessed eligibility for the program based on income and assets but will now only take income into account…

Overall, she said she’s pleased the hospital is taking these steps to better align its billing with its values and mission.” (B)

A.After Vox stories, Zuckerberg Hospital is overhauling its aggressive billing tactics, by Sarah Kliff, https://www.vox.com/2019/4/16/18410905/zuckerberg-san-francisco-hospital-bills

B.Publicity spurs billing revamp at Zuckerberg hospital, by Kelly Gooch, https://www.beckershospitalreview.com/finance/publicity-spurs-billing-revamp-at-zuckerberg-hospital.html

PART 4: August 18, 20129. Hospitals kept ER fees secret.

Zuckerberg San Francisco General and the University of California San Francisco are two of the city’s busiest hospitals, about 4 miles apart. But if you have private insurance and visit Zuckerberg General, you could end up paying a lot more for the same treatment.

For an especially serious visit, Zuckerberg General charges a facility fee of $11,176, 46 percent more than UCSF, which charges an average of $7,635.

The hospital is also out-of-network with all private insurance, leaving patients responsible for the fee and the cost of treatment. UC San Francisco, meanwhile, accepts insurance from most big providers. Insurers generally negotiate lower prices for patients, and many plans cover ER visits in part or in full…

When asked about the fees, board members admitted that they hadn’t kept a close eye on the prices and said they plan to hold hearings on the issue.

“It turns out we should have been monitoring this much more closely,” says Aaron Peskin, a supervisor who has previously voted in favor of the hospital prices and who is now calling for the hearings…

 “I cannot recall there ever being any discussion of them,” says Peskin, a board member who has served on and off since 2001. “I don’t think there has ever been a split vote, and that’s been true as long as I’ve been on the board of supervisors. But that will probably change now.” (A)

“Frustrated by waiting for federal lawmakers to act, states have been trying to solve this issue. As of December 2018, 25 states offered some protection against surprise billing, and the protections in nine of those states were considered “comprehensive,” according to the Commonwealth Fund. California, New York, Florida, Illinois and Connecticut are among the nine.

New state laws also have been adopted since, including in Nevada, which will limit how much out-of-network providers, including hospitals, can charge patients for emergency care, starting next year.

In California, a 2009 state Supreme Court ruling protects some patients against surprise billing for emergency care, and a state law that took effect in 2017 protects some who receive non-emergency care.

But millions remain vulnerable, largely because California’s protections don’t cover all insurance plans. The California Supreme Court ruling applies to people with plans regulated by the state Department of Managed Health Care. That leaves out the roughly 1 million Californians with plans regulated by the state Department of Insurance and the nearly 6 million people with federally regulated plans, most of whom have employer-sponsored insurance.

The state law governing non-emergency care also doesn’t apply to the millions of residents with health plans regulated by the federal government…

The California Hospital Association opposes the measure, which would limit the amount hospitals could charge insurance plans to a certain rate for each service, varying by region…

 “We fully support the provision of the bill that protects patients. It is the rate-setting piece that is our concern,” she said.”  (B)

“Legislation to prohibit California hospitals from sticking patients with huge emergency room bills that their insurers won’t cover has cleared a crucial hurdle in the state Capitol.

Lawmakers in the Assembly voted 48-9 on Thursday to approve AB1611, which would prohibit hospitals from “balance billing” patients if their insurance won’t cover the full cost for care.

Assemblyman David Chiu and state Sen. Scott Wiener, both Democrats from San Francisco, co-wrote the legislation. The bill now moves to the Senate…

AB1611 would prohibit hospitals from billing patients for any cost beyond their insurance deductible and co-payment. It also spells out rules for how hospitals and insurers resolve cost disputes.” (C)

 “Hospitals focused their opposition on a provision of the bill that would have limited charges for out-of-network emergency services.

The proposal would have required hospitals to work directly with health plans on billing, leaving the patients responsible only for their in-network copayments, coinsurance and deductibles.

Citing fierce pushback from hospitals, California lawmakers sidelined a bill Wednesday that would have protected some patients from surprise medical bills by limiting how much hospitals could charge them for emergency care.” (D)

The legislation, which contributed to the intense national conversation about surprise medical billing, was scheduled to be debated Wednesday in the state Senate Health Committee.

Instead, the bill’s author pulled it from consideration, vowing to bring it back next year.

“We are going after a practice that has generated billions of dollars for hospitals, so this is high-level,” said Assemblyman David Chiu (D-San Francisco). “This certainly does not mean we’re done.” (E)

 “California hospitals want you to know that they’re fully on board with the idea that emergency room patients shouldn’t be hit with thousands of dollars in surprise billings because the ER isn’t in their insurance plan’s network.

You should also know, however, that the hospitals just killed a measure in Sacramento that would have accomplished that goal, and that the reason they did so was to protect their own revenues….

The state’s hospitals went to the mattresses over the payment provision, cursing it as “government rate setting” that they would never accept.

Hospital executives inundated legislators with warnings that rate-setting would force their institutions to shut down.

We have 450 hospitals in California,” says Anthony Wright, executive director of Health Access, “and every hospital CEO has the cellphone number of his state senator and assemblyman. A hospital saying it would close would give pause to any lawmaker.”

The proponents were aware that they were poking a stick into a tiger’s cage. “We’re going after a practice that has generated billions of dollars in profits for hospitals, Chiu told me, “and hospital CEOs around the state waged very aggressive lobbying to protect those profits.”” (F)

“San Francisco’s health network has finalized its first contract with a private health insurer, Canopy Health Canopy — meaning Zuckerberg San Francisco General Hospital, long perceived as the hospital of last resort, is now in the business of wooing expectant mothers to choose to deliver at its Family Birth Center…

Department of Public Health staff said the signing of this contract was not a reaction to billing controversies at ZSFGH that erupted earlier this year, when it was revealed that even insured patients were being hit with crippling debts through the practice of “balance billing.” Because the hospital was out-of-network for private insurance companies, there was often a great divergence between what ZSFGH billed the insurance and what the insurance company would deign to pay — leaving individuals responsible for the “balance.”

This situation, however, did highlight the hospital’s unhealthy and precarious “payer mix.” With few privately insured patients, ZSFGH ministers mostly to Medi-Cal recipients or the marginally insured. Deals like the one initiated July 15 with Canopy would begin to change that mix, however.”  (G)

A.Prices at Zuckerberg hospital’s emergency room are higher than anywhere else in San Francisco, by Sarah Kliff, https://www.vox.com/2019/1/22/18183534/zuckerberg-san-francisco-general-hospital-er-prices

B.Lawmakers Push To Stop Surprise ER Billing, by Ana B. Ibarra, Lawmakers Push To Stop Surprise ER Billing, by Ana B. Ibarra, https://www.google.com/search?q=lawmakers+push+to+stop+surprise+er+billingby+ana+b.+ibarra&ie=&oe=

C.Legislation prompted by huge SF General bills passes California Assembly, by Dustin Gardiner, https://www.sfchronicle.com/politics/article/Legislation-prompted-by-huge-SF-General-bills-13908291.php

D.Hospitals block California’s balance-billing legislation, By Ana B. Ibarra, https://www.benefitspro.com/2019/07/11/hospitals-block-californias-balance-billing-legislation/

E.Lawmakers Push To Stop Surprise ER Billing, by Ana B. Ibarra, https://californiahealthline.org/news/lawmakers-push-to-stop-surprise-er-billing/

F.Column: How the hospital lobby derailed legislation to protect you from surprise hospital bills, by MICHAEL HILTZIK, https://www.latimes.com/business/story/2019-08-01/hospital-lobby-surprise-billing-legislation

G.San Francisco inks first contract with private health insurer, by Joe Eskenazi, https://missionlocal.org/2019/07/san-francisco-inks-first-contract-with-private-health-insurer/

Prequel ((still unabridged))

Share on LinkedInShare on Google+Share on FacebookTweet about this on Twitter


Please note you can get new an updated cases by free email after subscribing using the SUBSCRIPTION function in the middle of the right column of this post or at http://doctordidyouwashyourhands.com/2019/09/9808/

This is a two step process. Log in using the subscription function, then you will get an email to click on to activate your subscription.




Jonathan M. Metsch, Dr.P.H.

Clinical Professor, Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai

Adjunct Professor, Management, Zicklin School of Business, Baruch College, C.U.N.Y.

Adjunct Professor, Rutgers School of Public Affairs and Administration & Rutgers School of Public Health


President & CEO, LibertyHealth/ Jersey City Medical Center (1989-2006)

Share on LinkedInShare on Google+Share on FacebookTweet about this on Twitter

PART 4. CANDIDA AURIS. “.. nursing facilities, and long-term hospitals, are…continuously cycling infected patients, or those who carry the germ, into hospitals and back again.”

New PART 4 after PARTS 1, 2, and 3

PART 1. April16, 2019. Is it ethical for the public not to be notified about new “super bugs” in hospitals so they can decide whether or not to go to affected hospitals?

PART 2. May 13, 2019. CANDIDA AURIS. “In 30 years, I’ve never faced so tough a reporting challenge – and one so unexpected. Who wouldn’t want to talk about a fungus?…

PART 3. June 6, 2019. CANDIDA AURIS. “Antibiotic-resistant superbugs are everywhere. If your hospital claims it doesn’t have them, it isn’t looking hard enough.”

PART 1. April16, 2019.  Is it ethical for the public not be notified about new “super bugs” in hospitals so they can decide whether or not to go to affected hospitals?

“Last May, an elderly man was admitted to the Brooklyn branch of Mount Sinai Hospital for abdominal surgery. A blood test revealed that he was infected with a newly discovered germ as deadly as it was mysterious. Doctors swiftly isolated him in the intensive care unit.

The germ, a fungus called Candida auris, preys on people with weakened immune systems, and it is quietly spreading across the globe. Over the last five years, it has hit a neonatal unit in Venezuela, swept through a hospital in Spain, forced a prestigious British medical center to shut down its intensive care unit, and taken root in India, Pakistan and South Africa.

Recently C. auris reached New York, New Jersey and Illinois, leading the federal Centers for Disease Control and Prevention to add it to a list of germs deemed “urgent threats.”

The man at Mount Sinai died after 90 days in the hospital, but C. auris did not. Tests showed it was everywhere in his room, so invasive that the hospital needed special cleaning equipment and had to rip out some of the ceiling and floor tiles to eradicate it.

“Everything was positive – the walls, the bed, the doors, the curtains, the phones, the sink, the whiteboard, the poles, the pump,” said Dr. Scott Lorin, the hospital’s president. “The mattress, the bed rails, the canister holes, the window shades, the ceiling, everything in the room was positive.”” (A)

“Back in 2009, a 70-year-old Japanese woman’s ear infection puzzled doctors. It turned out to be the first in a series of hard-to-contain infections around the globe, and the beginning of an ongoing scientific and medical mystery.

The fungus that infected the Japanese woman, Candida auris, kills more than 1 in 3 people who get an infection that spreads to their blood or organs. It hits people who have weakened immune systems, and is most often found in places like care homes and hospitals. Once it shows up, it’s hard to get rid of: unlike most species of fungi, Candida auris spreads from person to person and can live outside the body for long periods of time.

Mount Sinai wasn’t the first hospital to face this task: a London hospital found itself with an outbreak in 2016, and the only way to stop it was to rip out fixtures…

Scientists still aren’t sure exactly where this happened or when. That’s one of the things they’re working on now, says Cuomo, because figuring out how the fungus evolved could help researchers develop treatments for it…

Although the “superbug” moniker might sound alarmist, Candida auris qualifies for two reasons, says Cuomo. First, all strains of the yeast are resistant to antifungals. There are three major kinds of antifungals used to treat humans, and some strains of Candida auris are resistant to all of them, while other strains are resistant to one or two. That limits the treatment options for someone who has been infected-someone who is probably already in poor health. The other reason is “this really scary property of not being able to get rid of it,” Cuomo says.” (B)

“Superbugs are a terrifying prospect because of their resistance to treatment, and one superbug that is sweeping all over the world is the Candida auris.

C. auris is a fungus that causes serious infections in various parts of the body, including the bloodstream and the ear.

While its discovery has been relatively recent in 2009, this fungus has already wreaked havoc in hospitals in more than 20 different countries, including the United States, United Kingdom, and Spain, among others.

In the United States, CDC reports a total of 587 clinical cases of C. auris infections as of February. Most of it occurred in the areas of New York City, New Jersey, and Chicago.” (C)

“The CDC issued a public alert in January about a drug-resistant bacteria that a dozen Americans contracted after undergoing elective surgeries at Grand View Hospital in Tijuana, Mexico. Yet when similar outbreaks occur at U.S. hospitals, the agency does not issue a public warning. This is due to an agreement with states that prohibits the CDC from publicly disclosing hospitals undergoing outbreaks of drug-resistant infections, according to NYT.

Patient advocates are pushing for more transparency into hospital-based infection outbreaks, saying the lack of warning could put patients at risk of harm.

“They might not get up and go to another hospital, but patients and their families have the right to know when they are at a hospital where an outbreak is occurring,” Lisa McGiffert, an advocate with the Patient Safety Action Network, told NYT. “That said, if you’re going to have hip replacement surgery, you may choose to go elsewhere.”..

The CDC declined NYT’s request for comment. Agency officials have previously told the publication the confidentiality surrounding outbreaks is necessary to encourage hospitals to report the drug-resistant infections.” (D)

“New Jersey is among the states worst affected by an increasing incidence of the potentially deadly fungus Candida auris, whose resistance to drugs is causing headaches for hospitals, state and federal health officials said on Monday.

There were 104 confirmed and 22 probable cases of people infected by the fungus in New Jersey by the end of February, according to the federal Centers for Disease Control and Prevention, up sharply from a handful when the fungus was first identified in the state about two years ago.

The state’s number of cases – now the third-highest after New York and Illinois – has risen in tandem with an increase, first overseas, and now in the United States, in a trend that some doctors attribute to the overuse of drugs to treat infections, prompting the mutation of infection sources, in this case, a fungus.

The fungus mostly affects people who have existing illnesses, and may already be hospitalized with compromised immune systems, health officials said.

Nicole Kirgan, a spokeswoman for the New Jersey Department of Health, said she didn’t know whether any of the state’s cases have been fatal, and couldn’t say which hospitals are treating people with the fungus because they have not, so far, been required to report their cases to state officials…

But Dr. Ted Louie, an infectious disease specialist at Robert Wood Johnson University Hospital in New Brunswick, said many hospitals don’t know how to eradicate the fungus once it has occurred.

Some disinfectants commonly used in hospitals have proved ineffective in removing the fungus, Dr. Louie said, so hospitals have been urged to use other disinfecting agents, although it’s not yet clear which of them work, if any.

“This is a fairly new occurrence and we are still learning how to deal with it,” he said. “We have to figure out which disinfectant procedures may be best to try to eradicate the infection, so at this point, I don’t think we have good enough information to advise.” (E)

“Adding to the difficulty of treating candida auris is finding it in the first place. The infection is often asymptomatic, showing few to no immediate symptoms, said Chauhan. The symptoms that do appear, such as fever, are often confused for bacterial infections, he said.

“Most routine diagnostic tests don’t work very well for candida auris,” he said. “They’re often misidenfitied as other species.”

The best way to identify candida auris is by looking under a microscope, which often takes time because it requires doctors to grow the fungus, Chauhan said.

As with most infectious diseases, the best course of action is good hygiene and sterilization protocol. Washing your hands and using hand sanitizer after helps to prevent transmission and infection, Chauhan said.

Doctors and healthcare workers should use protective gear, and people visiting loved ones in hospitals and long-term care centers should take proper precautions, he said.

The Center for Disease Control recommends using a special disinfectant that is used to treat clostridium difficile spores. The disinfectant has been effective in wiping out clostridium difficile, known as c. diff, and disinfects surfaces contaminated with candida auris, as well.” (F)

“Hospitals and nursing homes in California and Illinois are testing a surprisingly simple strategy against the dangerous, antibiotic-resistant superbugs that kill thousands of people each year: washing patients with a special soap.

The efforts – funded with roughly $8 million from the federal government’s Centers for Disease Control and Prevention – are taking place at 50 facilities in those two states.

This novel approach recognizes that superbugs don’t remain isolated in one hospital or nursing home but move quickly through a community, said Dr. John Jernigan, who directs the CDC’s office on health care-acquired infection research.

“No health care facility is an island,” Jernigan said. “We all are in this complicated network.”

At least 2 million people in the U.S. become infected with an antibiotic-resistant bacterium each year, and about 23,000 die from those infections, according to the CDC…

Containing the dangerous bacteria has been a challenge for hospitals and nursing homes. As part of the CDC effort, doctors and health care workers in Chicago and Southern California are using the antimicrobial soap chlorhexidine, which has been shown to reduce infections when patients bathe with it. Though chlorhexidine is frequently used for bathing in hospital intensive care units and as a mouthwash for dental infections, it is used less commonly for bathing in nursing homes…

The infection-control work was new to many nursing homes, which don’t have the same resources as hospitals, Lin said.

In fact, three-quarters of nursing homes in the U.S. received citations for infection-control problems over a four-year period, according to a Kaiser Health News analysis, and the facilities with repeat citations almost never were fined. Nursing home residents often are sent back to hospitals because of infections.” (G)

“The C.D.C. declined to comment, but in the past officials have said their approach to confidentiality is necessary to encourage the cooperation of hospitals and nursing homes, which might otherwise seek to conceal infectious outbreaks.

Those pushing for increased transparency say they are up against powerful medical institutions eager to protect their reputations, as well as state health officials who also shield hospitals from public scrutiny…

Hospital administrators and public health officials say the emphasis on greater transparency is misguided. Dr. Tina Tan, the top epidemiologist at the New Jersey Department of Health, said that alerting the public about hospitals where cases of Candida auris have been reported would not be useful because most people were at low risk for exposure and public disclosure could scare people away from seeking medical care.

“That could pose greater health risks than that of the organism itself,” she said.

Nancy Foster, the vice president for quality and patient safety at the American Hospital Association, agreed, saying that publicly identifying health care facilities as the source of an infectious outbreak was an imperfect science.

“That’s a lot of information to throw at people,” she said, “and many hospitals are big places so if an outbreak occurs in a small unit, a patient coming to an ambulatory surgical center might not be at risk.”

Still, hospitals and local health officials sometimes hide outbreaks even when disclosure could save lives. Between 2012 and 2014, more than three dozen people at a Seattle hospital were infected with a drug-resistant organism they got from a contaminated medical scope. Eighteen of them died, but the hospital, Virginia Mason Medical Center, did not disclose the outbreak, saying at the time that it did not see the need to do so.” (H)

“Many have heard of the rise of drug-resistant infections. But few know about an issue that’s making this threat even scarier in the United States: the shortage of specialists capable of diagnosing and treating those infections. Infectious diseases is one of just two medicine subspecialties that routinely do not fill all of their training spots every year in the National Resident Matching Program (the other is nephrology). Between 2009 and 2017, the number of programs filling all of their adult-infectious-disease training positions dropped by more than 40 percent…

Everyone who works in health care agrees that we need more infectious-disease doctors, yet very few actually want the job. What’s going on?

The problem is that infectious-disease specialists care for some of the most complicated patients in the health care system, yet they are among the lowest paid. It is one of the only specialties in medicine that sometimes pays worse than being a general practitioner. At many medical centers, a board-certified internist accepts a pay cut of 30 percent to 40 percent to become an infectious-disease specialist.

This has to do with the way our insurance system reimburses doctors. Medicare assigns relative value units to the thousands of services that doctors provide, and these units largely determine how much physicians are paid. The formula prioritizes invasive procedures over intellectual expertise.

The problem is that infectious-disease doctors don’t really do procedures. It is a cognitive specialty, providing expert consultation, and insurance doesn’t pay much for that…

Infectious-disease specialists are often the only health care providers in a hospital – or an entire town – who know when to use all of the new antibiotics (and when to withhold them). These experts serve as an indispensable cog in the health care machine, but if trends continue, we won’t have enough of them to go around. The terrifying part is that most patients won’t even know about the deficit. Your doctor won’t ask a specialist for help because in some parts of the country, the service simply won’t be available. She’ll just have to wing it…

We must hurry. Superbugs are coming for us. We need experts who know how to treat them.” (I)

People visiting patients at the hospital, and most hospitalized patients, have little to fear from a novel fungal disease that has struck more than 150 people in Illinois – all in the Chicago area – a Memorial Medical Center official said Friday.

“For normal, healthy people, this is not a concern,” Gina Carnduff, Memorial Health System director of infection prevention, said in reference to Candida auris infections.

Carnduff, who is based at Memorial Medical Center, said only the “sickest of the sick” patients are at risk of catching or spreading the C. auris infection or dying from it.

Those patients, she said, include people who have stayed for long periods at health care facilities – such as skilled-care nursing homes or long-term acute-care hospitals – and who are on ventilators or have central venous catheter lines or feeding tubes…

Officials from both Memorial Medical Center and HSHS St. John’s Hospital said their institutions already are using the bleach-based cleaning solutions known to prevent the spread of C. auris and other infections.

The Illinois Department of Public Health’s website says more than one in every three people with “invasive C. auris infection” affecting the blood, heart or brain will die…

The state health department says 154 confirmed cases of C. auris and four probable cases have been identified, all in the Chicago area. Ninety-five cases were in Chicago, 56 were in Cook County outside of Chicago, and seven were spread among the counties of DuPage, Lake and Will.

Eighty-five of the 158 people making up the confirmed and probable cases have died, but only one death was “directly attributed” to the infection, Arnold said. It’s not known whether C. auris played a role in the deaths of the other 84 people, she said. (J)

“There is also the fact that some lab tests will not identify the superbug as the source of an illness, which means that some patients will receive the wrong treatment, increasing the duration of the infection and the chance to transmit the fungus to another person.” (K)

“Hospitals, state health departments and the Centers for Disease Control and Prevention are putting up a wall of silence to keep the public from knowing which hospitals harbor Candida auris.

New York health officials publish a yearly report on infection rates in each hospital. They disclose rates for infections like MRSA and C. Diff. But for several years, the same officials have been mum about the far deadlier Candida auris. That’s like posting “Wanted” pictures for pickpockets but not serial murderers.

Health officials say they’ll disclose the information in their next yearly report. That could be many months from now. Too late. Patients need information in real time about where the risks are…

Dr. Eleanor Adams, a state Health Department researcher, examined all the facilities in New York City affected by Candida auris over a four-year period. Adams found serious flaws, including “inadequate disinfection of shared equipment” to take vital signs, hasty cleaning and careless compliance with rules to keep infected patients isolated…” (L)

“Remedies for curtailing the advance of C. auris are familiar. Health care facilities must undergo stringent infection controls, test for new cases and quickly identify any sources passing it along. Visitors and medical workers must wash their hands after touching patients or surfaces. The yeast spreads widely throughout patients’ rooms. Some cleanups have reportedly required removing ceiling and floor tiles.

C. auris isn’t simply an opportunistic infection. Its rise is additional evidence that becoming too reliant on certain types of drugs may have unintended consequences. Exhibit A is the overuse of antibiotics in doctors’ offices and on farms that encourages the development of drug-resistant bacteria. Researchers suspect a similar situation involving C. auris and agricultural fungicides used on crops. So far the origins of C. auris are unclear, with different clusters arising in different areas of the world.

There’s no need to panic. But vigilance is required to track C. auris and raise awareness in order to combat it. Officials typically are eager to spread the word about potential health crises, from measles to MRSA. In this case, the CDC issued alerts about fungus to health care facilities, but the New York Times encountered an unusual wall of silence while investigating superbugs such as C. auris. Medical facilities didn’t want to scare off patients.

Any attempts to hide the spread of a communicable disease are irresponsible. Knowledge leads to faster prevention and treatment. Patients and their families have a right to know how hospitals and government agencies are responding to a new threat. Medical workers also deserve to be informed of the risks they encounter on the job.

Battling the superbugs requires aggressive responses and, ultimately, scientific advancements. Downplaying outbreaks won’t stop their rise.” (M)

“The rise of C. auris, which may have lurked unnoticed for millennia, owes entirely to human intervention – the massive use of fungicides in agriculture and on farm animals which winnowed away more vulnerable species, giving the last bug standing a free run. Sensitised to clinical fungicides, C. auris has proved to be difficult to extirpate, and culls infected humans who cannot fight diseases very effectively – infants, the old, diabetics, people with immune suppression, either because of diseases like HIV or the use of steroids. The new superfungus has the makings of a future plague, one of several which may cumulatively surpass cancer as a leading killer in a few decades.

The origin of C. auris is known because it broke out in the 21st century, but the plagues from antiquity lack origin stories. Even their spread was understood only retrospectively, in the light of modern science. The father of all plagues, the Black Death, originated in China in the early 14th century and ravaged most of the local population before it began its long journey westwards down the Silk Route, via Samarkand. At the time, the chain of hosts that carried it would have been incomprehensible – the afflicting organism Yersinia pestis, the fleas which it infested, the rats which the fleas in turn infested, which carried it into the homes of humans….” (N)

“WebMD: Most of us know candida from common yeast infections that you might get on your skin or mucous membranes. What makes this one different?

Chiller: It’s not acting like your typical candida. We’re used to seeing those.

Candida – the regular ones – are already a major cause of bloodstream infection in hospitalized patients. When we get invasive infections, for example, bloodstream infections, we think that you sort of auto-infect yourself. You come in with the candida already living in your gut. You’re in the ICU, you’re on a broad spectrum antibiotic. You’re killing off bad bacteria, you’re killing off good bacteria, so what are you left with? Yeast, and it takes over.

What’s new with Candida auris is that it doesn’t act like the typical candida that comes from our gut. This seems to be more of a skin organism. It’s very happy on the skin and on surfaces.

It can survive on surfaces for long periods of time, weeks to months. We know of patients that are colonized [meaning the Candida auris lives on their skin without making them sick] for over a year now.

It is spreading in health care settings, more like bacteria would, so it’s yeast that’s acting like bacteria” (O).

  1. A.A Mysterious Infection, Spanning the Globe in a Climate of Secrecy, by Matt Richtel and Andrew Jacobs, https://www.nytimes.com/2019/04/06/health/drug-resistant-candida-auris.html?smid=nytcore-ios-share
  2. B.There’s a new fungal superbug, and it’s probably humanity’s fault, by Kat Eschner, https://www.popsci.com/candida-fungus-superbug-infection
  3. C.Candida Auris: Signs And Symptoms If You’re Infected By The Deadly Superbug, by Naia Carlos, https://www.techtimes.com/articles/241233/20190411/candida-auris-signs-and-symptoms-if-youre-infected-by-the-deadly-superbug.htm
  4. D.CDC’s secrecy of drug-resistant outbreaks in hospitals sparks patient safety debate, by Mackenzie Bean, https://www.beckershospitalreview.com/quality/cdc-s-secrecy-of-drug-resistant-outbreaks-in-hospitals-sparks-patient-safety-debate.html
  5. E.CDC SAYS NJ HAS THIRD-MOST HOSPITALIZATIONS WITH DRUG-RESISTANT FUNGUS, by JON HURDLE, https://www.njspotlight.com/stories/19/04/08/cdc-says-nj-has-third-most-hospitalizations-with-drug-resistant-fungus/
  6. F.Candida Auris: Here’s why it’s a superbug and what that means, by Rodrigo Torrejon, https://www.northjersey.com/story/news/health/2019/04/12/candida-auris-superbug-what-does-mean/3445299002/
  7. G.How To Fight ‘Scary’ Superbugs? Cooperation – And A Special Soap, by Anna Gorman, https://khn.org/news/how-to-fight-scary-superbugs-cooperation-and-a-special-soap/
  8. H.Culture of Secrecy Shields Hospitals With Outbreaks of Drug-Resistant Infections, by Andrew Jacobs and Matt Richtel, https://www.nytimes.com/2019/04/08/health/candida-auris-hospitals-drug-resistant.html?smid=nytcore-ios-share
  9. I.The Scary Shortage of Infectious-Disease Doctors, by Matt McCarthy, https://www.nytimes.com/2019/04/09/opinion/doctors-drug-resistant-infections.html?smid=nytcore-ios-share
  10. J.Healthy people not at risk of catching fungal disease, Memorial official says, by Dean Olsen, https://www.sj-r.com/news/20190412/healthy-people-not-at-risk-of-catching-fungal-disease-memorial-official-says
  11. K.New Superbug, Candida Auris, Spread Around The World, As We Speak, The CDC Revealed, by Karen Miller, https://canadianhomesteading.ca/science/new-superbug-candida-auris-spread-around-the-world-as-we-speak-the-cdc-revealed/9411
  12. L.A deadly infection is sweeping some NY hospitals – but health officials won’t say where, by Betsy McCaughey, https://nypost.com/2019/04/12/a-deadly-infection-is-sweeping-some-ny-hospitals-but-health-officials-wont-say-where/
  13. M.Editorial: Drug-resistant disease on the rise, https://www.thetimesnews.com/opinion/20190415/editorial-drug-resistant-disease-on-rise
  14. N.Speakeasy: Bitten by the Bug, by Pratik Kanjilal, https://indianexpress.com/article/express-sunday-eye/speakeasy-bitten-by-the-bug-5670672/
  15. O.Candida auris Spreads Through US Hospitals, by Brenda Goodman, https://www.medscape.com/viewarticle/911799

PART 2. In 30 years, I’ve never faced so tough a reporting challenge – and one so unexpected. Who wouldn’t want to talk about a fungus?…

“C. auris is a drug-resistant fungus that has emerged mysteriously around the world, and it is understood to be a clear and present danger. But Connecticut state officials wouldn’t tell us the name of the hospital where they had had a C. auris patient, let alone connect us with her family. Neither would officials in Texas, where the woman was transferred and died. A spokeswoman for the City of Chicago, where C. auris has become rampant in long-term health care facilities, promised to find a family and then stopped returning my calls without explanation.” (A)

“Candida auris, also referred to as C. auris, is a potentially deadly fungal infection that appears to be making its way through hospitals and long-term care facilities across the country. The New York City area and New Jersey have reported more than 400 cases over the last few years alone. Federal health authorities have declared this fungus a “serious global health threat.”” (B)

“The Council of State and Territorial Epidemiologists (CSTE) says Candida auris infections have been “associated with up to 40% in-hospital mortality.”

“Most strains of C. auris are resistant to at least one antifungal drug, one-third are resistant to two antifungal drug classes, and some strains are resistant to all three major classes of antifungal drugs. C. auris can spread readily between patients in healthcare facilities. It has caused numerous healthcare-associated outbreaks that have been difficult to control,” the CSTE said.

The CDC added, “Patients who have been hospitalized in a healthcare facility a long time, have a central venous catheter, or other lines or tubes entering their body, or have previously received antibiotics or antifungal medications, appear to be at highest risk of infection with this yeast.”

The CDC is alerting U.S. healthcare facilities to be on the lookout for C. auris in their patients.” (C)

“”It’s a very serious health threat,” said Dr. Irwin Redlener, Columbia University professor and an expert on public health policy. “It’s a superbug, meaning resistant to all-known antibiotics.”..

“These people would be in danger, so you don’t want somebody visiting the hospital not knowing that it’s around and somehow contracting the infection,” Dr. Redlener said. “That would be an utter disaster.”..

Dr. Redlener says the secrecy is a big mistake.

“If they’re rattled by Candida auris to the point where we have secrecy pacts among hospitals and public health agencies, then you’re just hiding something that obviously needs more attention and resources to deal with,” he said.

The state Department of Health says there is no risk to the general public and notes that the vast majority of patients have had serious underlying medical conditions.

Jill Montag, a spokesperson for the New York State Department of Health, issued a statement to Eyewitness News.

“We are working aggressively with impacted hospitals and nursing homes to implement infection control strategies for Candida auris,” it read.

Montag says they plan to include the name of the impacted facilities in their annual infection report, which will be released later this year.

Dr. Redlener says they have the information now and should release the names now…

“To keep that a secret is putting people in danger,” he said. “And I don’t think that’s reasonable or ethical.”” (D)

“We don’t know why it emerged,” said Dr. Maurizio Del Poeta, a professor of molecular genetics and microbiology at Stony Brook University’s Renaissance School of Medicine. At the very least, he is recommending hospitals develop stricter rules on foot traffic in and out of patients’ rooms because the microbe can be carried on the bottom of shoes.

The pathogen clings to surfaces in hospital rooms, flourishes on floors, and adheres to patients’ skin, phones and food trays. It is odorless, invisible – and unlikely to vanish from health care institutions anytime soon.

“It can survive on a hospital floor for up to four weeks,” Del Poeta said of C. auris. “It attaches to plastic objects and doorknobs.”..…

“If we don’t want it to become like Staphylococcus aureus, then we have to act now,” said Del Poeta, referring to the bacteria that became the poster child of drug resistance when it developed the ability to defeat the antibiotic methicillin, garnering the name methicillin-resistant Staphylococcus aureus, or MRSA…

“In order to get Candida auris out of a room, you have to take away everything – doorknobs, plastic items, everything. It is very difficult to eradicate it in a hospital,” Del Poeta said. He said his institution has never had a patient with C. auris…

Scientists such as Del Poeta contend it’s time for new methods of addressing resistant microbes of all kinds because infectious pathogens have developed the power to outwit, outpace and outmaneuver humankind’s most potent agents of chemical warfare, many of them developed in the 20th century.” (E)

“A case management program piloted by the New York City health department monitors patients colonized with Candida auris after they are discharged into the community and notifies health care facilities of their status, researchers reported at the CDC’s annual Epidemic Intelligence Service conference….

Patients can remain colonized with C. auris for months in a health care setting, but it is unclear if they remain colonized after discharge, noted Genevieve Bergeron, MD, MPH, an Epidemic Intelligence Service officer with the New York City Department of Health and Mental Hygiene (DOHMH), and colleagues.

According to Bergeron and colleagues, the state health department began referring patients colonized with C. auris to the DOHMH on Oct. 4, 2017. Approximately 12 case managers handled the referrals, conducting patient interviews and reviewing medical records to obtain relevant clinical information. They informed the patients’ providers and health care facilities about their C. auris status and infection control needs.

“We requested that facilities flag the patient in their electronic medical records to ensure that the patient has the proper precautions, if the patient were to seek care again at those facilities,” Bergeron said in a presentation. “Case mangers sent a medical alert card to the patients for them to use when encountering health care providers unaware of their infection control needs.”” (F)

“Regions are considering the use of electronic registries to track patients that carry antibiotic-resistant bacteria including carbapenem-resistant Enterobacteriaceae (CRE). Implementing such a registry can be challenging and requires time, effort, and resources; therefore, there is a need to better understand the potential impact…

When all Illinois facilities participated (n=402), the registry reduced the number of new carriers by 11.7% and CRE prevalence by 7.6% over a 3-year period. When 75% of the largest Illinois facilities participated (n=304), registry use resulted in a 11.6% relative reduction in new carriers (16.9% and 1.2% in participating and non-participating facilities, respectively) and 5.0% relative reduction in prevalence. When 50% participated (n=201), there were 10.7% and 5.6% relative reductions in incident carriers and prevalence, respectively. When 25% participated (n=101), there was a 9.1% relative reduction in incident carriers (20.4% and 1.6% in participating and non-participating facilities, respectively) and 2.8% relative reduction in prevalence.

Implementing an XDRO registry reduced CRE spread, even when only 25% of the largest Illinois facilities participated due to patient sharing. Non-participating facilities garnered benefits, with reductions in new carriers.” (G)

“Quebec public-health authorities are bracing for the inevitable arrival of a multi drug-resistant fungus that has been spreading around the globe and causing infections, some of them fatal…

“We will definitely have cases here and there at one point,” said Dr. Karl Weiss, chief of infectious diseases at the Jewish General Hospital. “It’s almost guaranteed. The only thing is when you know what you’re fighting against, it’s always easier and we will be able to contain it a lot faster.”

C. auris poses a quadruple threat: it’s tricky to identify; it can thrive in hospitals for weeks (preying on patients with weakened immune systems); it’s resistant to two classes of anti-fungal medications; and it can cause invasive disease, with lingering bloodstream infections that are hard to treat. The mortality rate can rise as high as 60 per cent.

The pathogen has emerged at a time when hospitals in Quebec – their budgets stretched more than ever – are already struggling with antibiotic-resistant superbugs like C. difficile, MRSA and VRE that have caused outbreaks. The Institut national de santé publique du Québec published a bulletin last year on steps that hospitals and long-term centres can take to prevent C. auris outbreaks.

“The problem is if you don’t identify the fungus properly, then it can slip in between your hands, and you can have an outbreak in your institution without even knowing it,” Weiss explained.

There was a lot of mis-indentification of this with other Candida (fungi); and even the automated systems in institutions that identify bacteria and yeast were mislabelling this Candida for something else. For a while, people were not aware of this auris. But now we know how to identify it.

“The first thing we did in Quebec – and this was for all the microbiology labs – is we taught all the microbiologists how to properly identify Candida auris,” Weiss continued. “All the major labs in Quebec put in place protocols.”

Weiss, who is president of the Quebec Association of Medical Microbiologists, noted that under a quality assurance program, samples have been sent to different labs to test whether the fungus is identified correctly. The results show that that labs are detecting C. auris to a high degree.

If a patient is discovered to be infected, hospital protocol dictates that the patient be isolated. During the patient’s hospitalization, the housekeeping staff must disinfect the room daily with hydrogen peroxide and other chemicals…” (H)

“Federal officials should declare an emergency over a deadly, incurable fungus infecting people in New York, New Jersey and across the country, Sen. Chuck Schumer said Sunday.

Schumer said he’s pushing the federal government to allocate millions of dollars to fighting Candida auris, which is drug-resistant and proving very difficult to eradicate…

“When it comes to the superbug, New York could use a little more help,” said Schumer. “The CDC has the power to declare this an emergency and automatically give us the resources we need.”..

Schumer said that an emergency declaration by the CDC would lead to more cases being identified with better testing, and to better tracking of the disease. It might also reduce the number of unnecessary antibiotic prescriptions, which Schumer says have helped the disease become drug-resistant…

Schumer cited other CDC emergency declarations that helped stop the spread of deadly diseases, including a $25 million award to fight the Zika virus in 2016 and $165 million given to contain Ebola in 2014.

“Every dollar we can use to better identify, tackle and treat this deadly fungus is a dollar well spent,” Schumer said.” (I)

“Other medical experts see the overuse of human antifungal medications in agriculture and floriculture as potential reasons for resistance in Candida auris, known as C. auris, and possibly other fungi.

Dr. Matt McCarthy, a specialist in infectious diseases at Weill Cornell Medicine in Manhattan, said tulips, signature flowers of the Netherlands, are dosed with the same antifungal medications developed to treat human infections.

“Antifungals are pumped into tulips in Amsterdam to achieve flawless plants,” he said. “As a fungal expert, I know that we have very few antifungal medications, and this is a misuse of the drugs.”

Studies conducted at Trinity College in Ireland support McCarthy’s argument and have demonstrated that tulip and narcissus bulbs from the Netherlands may be vehicles that spread drug-resistant fungi.

Trinity scientists, who examined resistance in another potentially deadly fungus, Aspergillus fumigatus, uncovered why the bugs repelled the drugs known as triazoles. The fungi became resistant because of the overuse of triazoles in floriculture. As with C. auris, drug-resistant A. fumigatus can be deadly in people with poor immunity.

When patients need treatment with triazole-class medications, the drugs don’t work because the fungi have been overexposed in the environment, McCarthy said.

He added that the use of antifungal medications in floriculture is similar to the overuse of antibiotics in the poultry and beef industries, which have helped drive resistance to those drugs.

The floriculture example is just one way that drug-resistant fungi can spread around the world. Global trade networks, human travel and the movement of animals and crops are others.” (J)

“It will take further research to determine if the new strains of C. auris have their origins in agriculture, but Aspergillus has already illustrated the perils of modern farming. Antibiotics are applied on a massive scale in food production, pushing the rise of bacterial drug resistance. A British government study published in 2016 estimated that, within 30 years, drug-resistant infections will be a bigger killer than cancer, with some 10 million people dying from infections every year.

We don’t have to end up there. Pesticide use on most farms can be greatly reduced, or even eliminated, without reducing crop yields or profitability. Methods of organic farming, even as simple as crop rotation, tend to promote the growth of mutualistic fungi that crowd out pathogenic strains such as C. auris. Unfortunately, because conventional agriculture is heavily subsidized and market prices don’t reflect the costs to the environment or human health, organic food is more expensive and faces an uphill battle for greater consumption.

Of course, improved technology could help, with drugs of new kinds or in breeding and engineering resistant strains of plants. There’s also plenty of opportunity for lightweight agricultural robots, which can weed mechanically or spray pesticides more accurately, reducing the quantity of chemicals used. But tech shouldn’t be the sole focus just because it happens to be the most profitable route for big industries.” (K)

“The recent outbreak of the so-called superbug – and other drug-resistant germs – has thrown a spotlight on locally based Xenex Disinfection Systems. The company makes a robot that uses pulsing, ultraviolet rays to disinfect surgical suites and other environments that are supposed to be germ-free.

With the spread of C. auris, Xenex officials say they’ve seen an uptick in queries about their LightStrike Germ-Zapping Robots, which are in use at more than 400 health-care facilities around the world since manufacturing started in 2011.

These devices – often called R2Clean2, Mr. Clean and The Germinator – disinfect rooms in a matter of minutes. A dome on the top of the robot rises up, exposing a xenon bulb that emits UV light waves that kill germs on contaminated surfaces.

Bexar County-owned University Hospital has a fleet of six Xenex robots. One of the robots is assigned to the Cystic Fibrosis Center to help protect patients from infection by other patients.

“We are taking every measure possible to reduce the risk of infections, and this is an additional layer of security that bathes the room in UV-C light,” said Elizabeth Allen, public relations manager at University Health System…

Another study, recently published by a doctor at the Minnesota-based Mayo Clinic, showed that when the hospital used the robots in rooms that had already been cleaned, infection rates of another superbug – called Clostridium difficile, or C. diff – fell by 47 percent.” (L)

“It wasn’t publicized locally, but within the past few years teams of health officials at two Oklahoma health facilities took rapid actions to contain the spread of a fungal “superbug” that federal officials have declared a serious global health threat.

Only one patient at each facility was infected, and both patients recovered. But the incidents reflect the growing alarm among health officials over the deadly, multidrug-resistant Candida auris, or C. auris, which can kill 30 percent to 60 percent of those infected…

In April 2017, a team of experts from the federal Centers for Disease Control and Prevention converged on the University of Oklahoma Medical Center in Oklahoma City after a patient tested positive for the drug-resistant fungus.

About a year later, a patient at a southeast Oklahoma health facility tested positive for the germ during a routine test. In both cases, health officials isolated the patients, locked down their rooms and ordered dozens of lab tests to see if the multidrug-resistant fungus had spread…

Unlike with outbreaks in Illinois, New York and New Jersey, the potentially deadly infection was quickly contained.”..

Public knowledge about the OU Medical Center case makes it an exception. Typically, health care facilities across the nation don’t release to the public information when C. auris and other drug-resistant pathogens are found. No law or policy requires them to do so.

Patient-rights advocates maintain that the public has the right to know when and where outbreaks or even single cases occur. But health officials have routinely fought back, suggesting that it could violate patient rights and discourage patients from seeking hospital care.

But the CDC allows states to make that decision.

Burnsed said the Department of Health tries to walk a tight line between notifying the public and protecting the patient’s privacy.

He said he would be more likely to identify a facility if it’s anything more than an isolated case or if officials believed the exposure wasn’t contained.

“What we consider is if there was a risk to a broader group of individuals and if there was any evidence that there were a breach in lab controls,” Burnsed said. “We didn’t put out anything at the time (on Oklahoma’s two cases) because we didn’t think there was a greater risk to the public, but it’s a good question to consider.”” (M)

“How many people will needlessly die from a deadly bug sweeping through New York hospitals and nursing homes before local health officials acknowledge the danger publicly – and act accordingly?..

Yet public-health officials here have been slow to let patients know in which hospitals the bug is lurking. Folks are left to take their chances. That’s outrageous.

Why are officials mum? Partly because they fear that if they disclose the information, some people who need treatment won’t go for it.

That’s a weak excuse: As McCaughey notes, there are plenty of local hospitals that aren’t plagued by Candida auris, so patients could get care and avoid the risk, if they know where it’s safe to go.

More likely, no one wants to damage the reputations (or incomes) of the affected hospitals. Yet the best way to protect those reputations is to make sure the facilities are Candida auris-free…

Meanwhile, officials say they will reveal which hospitals have the germ – in their next yearly report. But that could be months away; patients need to know now.

If neither the hospitals nor their government regulators are willing to move sooner, perhaps state lawmaker should step in and require them to do so… (N)

Infectious disease experts tell Axios they agree with a dire scenario painted in the UN report posted earlier this week saying that, if nothing changes, antimicrobial resistance (AMR) could be “catastrophic” in its economic and death toll.

Threat level, per the report: By 2030, up to 24 million people could be forced into extreme poverty and annual economic damage could resemble that from the 2008–2009 global financial crisis, if pathogens continue becoming resistant to medications. By 2050, AMR could kill 10 million people per year, in its worst-case scenario.

“There is no time to wait. Unless the world acts urgently, antimicrobial resistance will have disastrous impact within a generation.”..

By the numbers: Currently, at least 700,000 people die each year due to drug-resistant diseases, including 230,000 people from multidrug-resistant tuberculosis, per the UN. Common diseases – like respiratory infections, STDs and urinary tract infections – are increasingly untreatable as the pathogens develop resistance to current medications.

The Centers for Disease Control and Prevention says AMR causes more than 23,000 deaths and 2 million illnesses in the U.S. annually…

What needs to be done: Jasarevic says the economic and health systems of all nations must be considered, and targets made to increase investment in new medicines, diagnostic tools, vaccines and other interventions.”

The bottom line: Action must be taken to avoid a catastrophic future.” (O)

“A recent study of patients at 10 academic hospitals in the United States found that just over half care about what their doctors wear, most of them preferring the traditional white coat.

Some doctors prefer the white coat, too, viewing it as a defining symbol of the profession.

What many might not realize, though, is that health care workers’ attire – including that seemingly “clean” white coat that many prefer – can harbor dangerous bacteria and pathogens.

A systematic review of studies found that white coats are frequently contaminated with strains of harmful and sometimes drug-resistant bacteria associated with hospital-acquired infections. As many as 16 percent of white coats tested positive for MRSA, and up to 42 percent for the bacterial class Gram-negative rods.”

It isn’t just white coats that can be problematic. The review also found that stethoscopes, phones and tablets can be contaminated with harmful bacteria. One study of orthopedic surgeons showed a 45 percent match between the species of bacteria found on their ties and in the wounds of patients they had treated. Nurses’ uniforms have also been found to be contaminated.

Among possible remedies, antimicrobial textiles can help reduce the presence of certain kinds of bacteria, according to a randomized study. Daily laundering of health care workers’ attire can help somewhat, though studies show that bacteria can contaminate them within hours…

It’s a powerful symbol. But maybe tradition doesn’t have to be abandoned, just modified. Combining bare-below-the-elbows white attire, more frequently washed, and with more conveniently placed hand sanitizers – including wearable sanitizer dispensers – could help reduce the spread of harmful bacteria.

Until these ideas or others are fully rolled out, one thing we can all do right now is ask our doctors about hand sanitizing before they make physical contact with us (including handshakes). A little reminder could go a long way.” (P)

  1. A.Candida auris: A mysterious fungus that nobody wants to talk about, by Matt Richtel, https://www.business-standard.com/article/health/candida-auris-a-mysterious-fungus-that-nobody-wants-to-talk-about-119051100970_1.html#
  2. B.Fungal Infection Identified at More than 400 Health-Care Facilities in NYC and NJ, by Michael Ksiazek and Jeffrey Krawitz, https://www.law.com/njlawjournal/2019/05/10/fungal-infection-identified-at-more-than-400-health-care-facilities-in-nyc-and-nj/
  3. C.CDC: Deadly, drug-resistant fungus spreading through hospitals, http://www.fox13news.com/health/cdc-deadly-drug-resistant-fungus-spreading-through-hospitals
  4. D.7 On Your Side Investigates: New York health officials won’t disclose facilities hit by deadly superbug, by Jim Hoffer, https://abc7ny.com/health/ny-officials-wont-disclose-facilities-hit-by-deadly-superbug/5287285/
  5. E.Multi-drug-resistant fungus known as C. auris affecting hundreds in New York, by Delthia Ricks, https://www.newsday.com/news/health/multi-drug-resistant-fungus-1.30597796
  6. F.NYC monitors patients colonized with C. auris upon their release, https://www.healio.com/infectious-disease/emerging-diseases/news/online/%7Bdacd8123-8ff6-4914-a56a-0e664355ab72%7D/nyc-monitors-patients-colonized-with-c-auris-upon-their-release
  7. G.How Introducing a Registry with Automated Alerts for Carbapenem-Resistant Enterobacteriaceae (CRE) May Help Control CRE Spread in a Region, by Bruce Y Lee, MD, MBA Sarah M Bartsch, MPH Mary K Hayden, MD Joel Welling, PhD Jay V DePasse Sarah K Kemble, MD Jim Leonard Robert A Weinstein, MD Leslie E Mueller, MPH Kruti Doshi, MBA, https://academic.oup.com/cid/advance-article-abstract/doi/10.1093/cid/ciz300/5486092?redirectedFrom=fulltext&utm_source=STAT+Newsletters&utm_campaign=a1d03797e3-MR_COPY_01&utm_medium=email&utm_term=0_8cab1d7961-a1d03797e3-149527969
  8. H.Quebec hospitals brace for C. auris, a drug-resistant fungus, by AARON DERFEL, https://montrealgazette.com/news/local-news/quebec-hospitals-brace-for-c-auris-a-drug-resistant-fungus
  9. I.Schumer urges feds to declare emergency over incurable superbug fungus, by Clayton Guse, https://www.nydailynews.com/new-york/ny-schumer-cdc-candida-auris-emergency-20190505-cnpnmj3yuje75elk6nzrh3mshy-story.html
  10. J.C. auris, isolated in Japan a decade ago, now on global list of superbugs, by Delthia Ricks, https://www.newsday.com/news/health/superfungus-candida-auris-1.30592736
  11. K.C. auris, isolated in Japan a decade ago, now on global list of superbugs,by Delthia Ricks, https://www.newsday.com/news/health/superfungus-candida-auris-1.30592736
  12. L.San Antonio company creates robots that can combat ‘superbugs’, by Laura Garcia, https://www.expressnews.com/business/article/San-Antonio-company-creates-robots-that-can-13780935.php
  13. M.Two Oklahoma Hospitals Fought Off Deadly Fungal ‘Superbug’, by Trevor Brown, https://oklahomawatch.org/2019/04/17/two-oklahoma-hospitals-fought-off-deadly-fungal-superbug/
  14. N.It’s time for NY health officials to come clean about this killer bug, https://nypost.com/2019/04/20/its-time-for-ny-health-officials-to-come-clean-about-this-killer-bug/
  15. O.Drug resistance could kill 10M people per year by 2050, experts say, by Eileen Drage O’Reilly, https://www.axios.com/drug-resistance-kill-10million-people-year-2050-4f048f02-8664-4000-8315-e4ca51c29ff7.html
  16. P.Why Your Doctor’s White Coat Can Be a Threat to Your Health, by Austin Frakt, https://www.nytimes.com/2019/04/29/upshot/doctors-white-coat-bacteria.html

PART 3. May 28, 2019. CADIDA AURIS. “Antibiotic-resistant superbugs are everywhere. If your hospital claims it doesn’t have them, it isn’t looking hard enough.”

“So far, 12 states from coast to coast have had confirmed cases of Candida auris, which has spread with particularly speed in New York, which has had more than half of the nation’s infections.

Some are even calling for the federal government to declare a national state of emergency and fund better containment of the fungus. 

Health officials there are scrambling to contain what the Centers for Disease Control and Prevention (CDC) have deemed an emerging health threat, but without stricter guidelines and screening, the fungus will only get more deadly…

Doctors sometimes struggle to diagnose fungal infections, in part because their symptoms are little different from those of bacterial infections…

‘Candida auris has the ability to develop resistance and has developed mechanisms to survive,’..

‘It’s at least starting to figure that out, and that’s obviously concerning.’

There are really only three antifungal medications in the US, so it doesn’t take long for a fungus to become wholly drug resistant.

Dr Chiller says that approximately 90 percent of strains the CDC has logged are resistant to the first-line drug, another third are resistant to a second, and between 20 and 30 percent of Candida auris infections have acquired multi-drug resistance.

‘Some are pan-resistant and those need to be isolated and stopped and we need to try to prevent them from developing,’ he says. 

Neither the CDC, other nation’s health officials or any of the 12 affected states have been able to work out where the fungus came from, or how exactly it has spread from state-to-state… 

If states don’t require their hospitals to report cases the fungal infection, the CDC may be severely underestimating the number of cases across the country.

‘It’s a bit of an uphill battle and it needs to be a really concerted effort on multiple tiers of the health care system,’ Dr Chiller says…

‘We need to stay on top of it and not let our guard down.’   (A)

“New York State health officials are considering rigorous new requirements for hospitals and nursing homes to prevent the spread of a deadly drug-resistant fungus called Candida auris.

The requirements could include mandatory pre-admission screening of patients believed to be at-risk and placing in isolation those patients who are infected, or even those just carrying the fungus on their skin.

Dr. Howard Zucker, the state health commissioner, and a fungal expert from the federal Centers for Disease Control and Prevention met last Friday in Manhattan with nearly 60 hospital officials from across the state to discuss the proposed guidelines. State health officials said they were seeking hospital input before issuing the guidelines, which they acknowledged would likely be a hardship for some institutions.

“One of our guiding objectives is to stop the geographic spread,” said Brad Hutton, the state’s deputy commissioner of public health. He said the state’s efforts to contain the spread have required significant resources — including sending individual infection specialists to investigate more than 150 cases — and that New York now needs help from individual institutions.

“We’re at a point where our response strategy needs to change,” he said. He added that he hoped the guidelines would be finalized by the end of the year, but said the state is still determining whether to apply them statewide or just to New York City and surrounding areas. It has yet to be decided whether the guidelines would be recommendations or regulatory requirements, he said…

For the moment…. hospitals are pre-screening many patients who appear to be at risk. But it can take a week to get skin-swab results back from the state laboratory, posing challenges for housing patients in isolation during the interim. Further, she said, regular testing is likely to turn up patients who are carriers but not infected, increasing the number of patients who require isolation, appropriately or not.”..

For now, much of the burden for surveillance has fallen to the state. The effort has involved the development of a fast-screening test that can analyze a skin swab in a matter of hours. But all hospitals, for the moment, have to send those tests to a state laboratory in Albany and wait several days before receiving the results, though hospitals say the backlog means tests can take a week.” (B)

“Unlike cholesterol drugs taken by millions of people for their entire lives, or $100,000 cancer drugs designed to prolong life, antibiotics are short-term drugs with limited shelf lives.

“Antibiotics are not valued by society as a high-value product, so they’re not priced very high,” said Gregory Frank, director of infectious disease policy at the Biotechnology Innovation Organization, in a phone interview.

A 2014 paper.. cited a London School of Economics study showing that while a new arthritis drug’s net present value – a measure of a drug’s net value over the ensuing decades – would be $1 billion, that of a new antibiotic would be negative $50 million…

People will buy innovative products in almost any other part of the economy, but doctors will still keep even the most innovative antibiotic behind the glass and use it only in the most dire circumstances.

“Antibiotic stewardship is a good thing, but devastating for the company developing it,” Outterson said…

Jersey City, New Jersey-based Scynexis is one company developing a treatment for drug-resistant fungal infections, ibrexafungerp, currently in several clinical trials, including one for C. auris. The company plans to file its first approval application with the FDA for ibrexafungerp next year. The drug is expected cost $450-600 per day, in line with the pricing of other antifungals, said company CEO Marco Taglietti, in a phone interview…

The race against drug-resistant infectious is ultimately a scientific one.  It’s not about finding better treatments, but newer ones in an endless war that requires always staying one step ahead of ever-evolving germs, Taglietti said. On the one hand, it’s important to practice good stewardship in order to delay resistance.

“But that creates a big challenge from an economic point of view – from the moment you launch your product after spending several hundreds of millions to develop it, it doesn’t sell,” he said.

The problem appears to be a vicious cycle of science and economics: Even existing push incentives, however generous, don’t make up for antibiotics’ lack of the large and chronic patient populations of cardiovascular disease drugs or the high prices of cancer drugs.” (C)

“Demanding that hospitals release lists of every superbug they find within their walls, however, as many transparency advocates want, is not the answer. The irony is that the hospitals that see the most superbugs are often the best ones we have, for the simple reason that they have the most sophisticated diagnostic platforms, the most powerful antibiotics and the experts to administer them.

Compelling a world-class hospital like Massachusetts General Hospital, where I saw my first superbug as a medical student, to reveal a microbe list would only freak patients out. It wouldn’t explain where the microbes came from, whether any patients were infected, and how they were cured.

In a worst-case scenario, more transparency could lead to patients avoiding medical care out of a misplaced fear of encountering drug-resistant bacteria. Hospitals might start refusing patients with certain infections, especially those coming from nursing facilities where these microbes are common, out of a concern that the patient’s bacteria could be added to the list. This would do everyone a disservice: Patients wouldn’t receive optimal care and superbugs would multiply.

But hospital administrators and government officials do need to be honest about the microbes in our medical centers and explain what is really going on. No comment will no longer suffice. People have questions and this story is not going away. To ensure that patients are well-informed, hospitals should train spokesmen to address these issues and states should revisit their reluctance to disclose information. Above all, health care workers and administrators should speak openly about the measures their hospitals are already employing to keep people safe.

I’m not particularly interested in the microbes that dwell inside of a given hospital; what matters is whether its employees follow the strict protocols that prevent these organisms from going where they shouldn’t…

Silence and evasion gives the perception that this is a problem spiraling out of control when, in fact, it’s not. An intricate tracking system exists so that epidemiologists across the country can monitor any outbreaks to ensure that proper protocols and containment strategies are implemented. We need to hear more from these superbug hunters.” (D)

“A new study published in the Journal of Occupational and Environmental Health has established protocols for containing the drug resistant Candida auris (C. auris ) in an animal facility, and by doing so, has identified four simple rules that can potentially be adopted by healthcare facilities to limit exposure to staff and patients. The study found that their double personal protective equipment (PPE), work ‘buddy’ system, disinfection and biomonitoring protocols were effective at containing high levels of C. auris infection within their animal facility, even six months after their experiments…

Before entering the animal holding and procedure rooms, staff donned a second layer of booties, gloves and gowns, which were later removed and placed in biohazard bins before exiting the rooms. Handling of infected cages and equipment was restricted to biosafety cabinets where a buddy system was implemented so that one person handed clean cages and supplies to a second person working inside the contaminated biosafety cabinet. This system-controlled workflow from clearly defined ‘clean’ to ‘dirty’ areas and allowed workers to monitor each other to ensure proper procedures were followed. Surfaces and equipment that came in contact with infected mice or tissues were treated with a strict disinfection protocol of 10% bleach followed (after five minutes) by 70% ethanol. The effectiveness of the workflow and protocols were continually monitored using swab testing on surfaces suspected to be contaminated, and as a second measure, Sabbaroud dextrose plates were placed inside the biosafety cabinet and on the floor underneath to determine whether C. auris was aerosolised within the cabinet or whether any debris contaminated the floor.

The researchers found that possible contamination came from direct contact with the infected mice or tissues but not from aerosolisation.” (E)

“A pernicious disease is eating away at Roy Petteway’s orange trees. The bacterial infection, transmitted by a tiny winged insect from China, has evaded all efforts to contain it, decimating Florida’s citrus industry and forcing scores of growers out of business.

In a last-ditch attempt to slow the infection, Mr. Petteway revved up his industrial sprayer one recent afternoon and doused the trees with a novel pesticide: antibiotics used to treat syphilis, tuberculosis, urinary tract infections and a number of other illnesses in humans…

The use of antibiotics on citrus adds a wrinkle to an intensifying debate about whether the heavy use of antimicrobials in agriculture endangers human health by neutering the drugs’ germ-slaying abilities. Much of that debate has focused on livestock farmers, who use 80 percent of antibiotics sold in the United States.

Although the research on antibiotic use in crops is not as extensive, scientists say the same dynamic is already playing out with the fungicides that are liberally sprayed on vegetables and flowers across the world. Researchers believe the surge in a drug-resistant lung infection called aspergillosis is associated with agricultural fungicides, and many suspect the drugs are behind the rise of Candida auris, a deadly fungal infection.” (F)

 “A large Candida auris outbreak at a hospital in England appears to be linked to reusable patient-monitoring equipment, a team of researchers reports today in the New England Journal of Medicine.

The outbreak in the neurosciences intensive care unit (ICU) at Oxford University Hospitals involved 70 patients who were infected or colonized with C auris, a fungus that has become increasingly resistant to azoles, echinocandins, and polyenes—the three classes of antifungals used to treat infections caused by Candida and other fungal species.

An epidemiologic investigation and case-control study by investigators from the University of Oxford, Public Health England, and elsewhere found that the most compelling explanation for the prolonged outbreak was the persistence of the organism on reusable skin-surface axillary probes, a device placed in a patient’s armpit for continuous temperature monitoring.

“Our results indicate that reusable patient equipment may serve as a source of healthcare-associated outbreaks of infection with C. auris,” the authors of the study write.” (G)

  1. A.Desperate attempts to curb a drug-resistant germ that thrives in hospitals: Dozens of doctors meet with the CDC to work out how to keep beds clean and save lives, by NATALIE RAHHAL, https://www.dailymail.co.uk/health/article-7067063/US-health-officials-desperate-curb-drug-resistant-fungus.html
  2. B.To Fight Deadly Candida Auris, New York State Proposes New Tactics, by Matt Richtel, https://www.nytimes.com/2019/05/23/health/candida-auris-hospitals-ny.html?smid=nytcore-ios-share
  3. C.New antibiotics are urgently needed, but economics stand in the way, by ALARIC DEARMENT, https://medcitynews.com/2019/05/new-antibiotics-are-urgently-needed-but-economics-stand-in-the-way/
  4. D.What Superbug Hunters Know That We Don’t, by Matt McCarthy, https://www.nytimes.com/2019/05/20/opinion/hospitals-antibiotic-resistant-bacteria-superbugs.html
  5. E.Potential solutions for limiting exposure to Candida auris in healthcare facilities, by TAYLOR & FRANCIS GROUP, https://www.eurekalert.org/pub_releases/2019-05/tfg-psf051619.php
  6. F.Citrus Farmers Facing Deadly Bacteria Turn to Antibiotics, Alarming Health Officials, by Andrew Jacobs, https://www.nytimes.com/2019/05/17/health/antibiotics-oranges-florida.html?smid=nytcore-ios-share
  7. G.Study links hospital Candida auris outbreak to reusable thermometers, by Chris Dall, http://www.cidrap.umn.edu/news-perspective/2018/10/study-links-hospital-candida-auris-outbreak-reusable-thermometers

PART 4. CANDIDA AURIS. “.. nursing facilities, and long-term hospitals, are…continuously cycling infected patients, or those who carry the germ, into hospitals and back again.”

“Maria Davila lay mute in a nursing home bed, an anguished expression fixed to her face, as her husband stroked her withered hand. Ms. Davila, 65, suffers from a long list of ailments — respiratory failure, kidney disease, high blood pressure, an irregular heartbeat — and is kept alive by a gently beeping ventilator and a feeding tube.

Doctors recently added another diagnosis to her medical chart: Candida auris, a highly contagious, drug-resistant fungus that has infected nearly 800 people since it arrived in the United States four years ago, with half of patients dying within 90 days.

At least 38 other patients at Ms. Davila’s nursing home, Palm Gardens Center for Nursing and Rehabilitation in Brooklyn, have been infected with or carry C. auris, a germ so virulent and hard to eradicate that some facilities will not accept patients with it…

Much of the blame for the rise of drug-resistant infections like C. auris, as well as efforts to combat them, has focused on the overuse of antibiotics in humans and livestock, and on hospital-acquired infections. But public health experts say that nursing facilities, and long-term hospitals, are a dangerously weak link in the health care system, often understaffed and ill-equipped to enforce rigorous infection control, yet continuously cycling infected patients, or those who carry the germ, into hospitals and back again.” (A)

“A team of doctors at Lenox Hill Hospital has reported that a patient at their facility lost an eye due to panophthalmitis, which was caused by a Candida auris infection. In their report published in the Annals of Internal Medicine, the group describes the patient, his symptoms and treatment…

In this new finding, a 30-year-old male patient came to the trauma center at Lenox Hill Hospital complaining of eye pain and loss of vision in one eye. He was diagnosed with panophthalmitis—a condition, not a disease—in which the entire eye becomes inflamed. The doctors treating him reported that the eye was damaged beyond repair. They removed it and cleaned up the socket. Lab tests showed that the inflammation was due to Candida auris—the first such infection of its kind seen in the eye. The doctors also noted that the patient did not have a compromised immune system despite having syphilis and HIV. After dispensing treatment aimed at eradicating the fungus, the patient was discharged with instructions to return for a follow-up. But he did not do so, thus it is not known if the infection was fully cleared, or if the patient infected anyone else.” (B)

“A relatively new fungus has scientists scratching their heads in 30 countries, including India. Called Candida auris (C. auris), it has become a red flag for the medical community. Why? C. auris is drug-resistant, it can survive almost anywhere – even on sterilized medical equipment – and it is increasingly causing infections in patients in the Intensive Care Unit (ICU).

Normally Candida, a species of fungus, causes the most superficial skin infections and can be treated with over-the-counter drugs. C. auris, by contrast, does not respond well to antifungal drugs – not only is C. auris resistant to most medicines, it is actually more likely to affect patients who are given antifungal drugs to prevent common Candida infections.

First isolated in japan in 2009, C. auris was originally thought to cause ear infections. Since then, scientists have discovered that it is more invasive – and deadly. In India, the first cases of C. auris infection came to light in 2011.

According to the US-based Centres of Disease Control and Prevention (CDC), there’s a higher chance of C. auris infection in patients in a hospital set-up, and among those fitted with a central venous catheter and other devices which go inside the body. CDC data also show that patients who have received antibacterial or antifungal drugs are at the highest risk of C. auris infection than those who have not. The CDC says that 30-60% of patients infected with C. auris infection die, however, most had a prior serious illness with a compromised immune system…

 “What makes C. auris even more dangerous is that it can grow in all kinds of places – dry areas, moist places, plastic surfaces, and sterilized areas and equipment,” said Dr Archana Nirula, medical officer, myUpchar.com…

It’s an understatement to say that C. auris is quirky. Even as scientists are throwing all their weight behind research to find a cure, doctors are banking on good old hygiene and echinocandins – an antifungal drug that seems to work in select cases of C. auris infection. ICMR has even recommended that doctors schedule any interventional procedures for C. auris-infected patients at the end of the day – C. auris can survive sterilization and the infection can spread to other patients through medical equipment.” (C)

“When this deadly fungus first emerged in America, it was not disclosed to the public for a lengthy period of time. Then, when details of deaths in hospitals due to the superbug went public, the national news media reacted but then went silent. Why?…

“Those pushing for increased transparency say they are up against powerful medical institutions eager to protect their reputations, as well as state health officials who also shield hospitals from public scrutiny.”

“Who’s speaking up for the baby that got the flu from the hospital worker or for the patient who got MRSA from a bedrail? The idea isn’t to embarrass or humiliate anyone, but if we don’t draw more attention to infectious disease outbreaks, nothing is going to change,” Arthur Caplan, PhD…

 “The average person calls Candida infections yeast infections,” William Schaffner, MD, Professor and Chair, Department of Preventative Medicine at Vanderbilt University Medical Center, told Prevention. “However, Candida auris infections are much more serious than your standard yeast infection. They’re a variety of so-called superbugs [that] can complicate the therapy of very sick people.”

The CDC reports that, as of May 31, 2019, there have been a total of 685 cases of C. auris reported in the US. The majority of those cases occurred in Illinois (180), New Jersey (124), and New York (336). Twenty more cases were reported in Florida, and eight other states—California, Connecticut, Indiana, Maryland, Massachusetts, Oklahoma, Texas, and Virginia—each had less than 10 confirmed cases of C. auris.

The CDC states the infection seems to be most prominent among populations that have had extended stays in hospitals or nursing facilities. Patients who have had lines or tubes such as breathing tubes, feeding tubes, or central venous catheters entering their body, and those who have recently been given antibiotics or antifungal medications, seem to be the most vulnerable to contracting C. auris…

The fungus typically attacks people who are already sick or have weakened immune systems, which can make it challenging to diagnose, the CDC notes. C. auris infections are typically diagnosed with special clinical laboratory testing of blood specimens or other body fluids. Infections have been found in patients of all ages, from infants to the elderly…

The CDC states that it and its public health partners are working hard to discover more about this fungus, and to devise ways to protect people from contracting it. Average healthy people probably don’t need to worry about becoming infected with Candida auris. However, individuals who are at high risk, and healthcare professionals, microbiologists, and pathologists, should be on the alert for this new superbug strain of fungus.” (D)

“A new report from the US Centers for Disease Control and Prevention (CDC) warns health care organizations and providers that overseas hospitalization and carbapenemase-producing organism (CPO) colonization or infection should be seen as warning signs for the presence of Candida auris.

The warning, published in the CDC’s Morbidity and Mortality Weekly Report, comes after a case in Maryland last September in which a patient was admitted to the hospital with multiple CPO colonizations/infections. The patient had previously spent a month in a Kenyan hospital after suffering a cerebral hemorrhage while visiting the African country…

The CDC recommends that anyone who has been hospitalized overnight overseas in the past 12 months be screened for C auris. The agency also recommends contact precautions and CPO screening for any patient with an overnight overseas hospital stay in the previous 6 months.

Richard B. Brooks, MD, of the Division of Healthcare Quality Promotion at the CDC’s National Center for Emerging and Zoonotic Infectious Diseases, told Contagion®  that overseas travel is an important risk factor for C auris, but he said awareness of the link between C auris and receiving care overseas varies from hospital to hospital and provider to provider.

In the case of the Maryland patient, public health officials were already on alert since the health department had previously found CPOs and C auris in a patient who had been hospitalized in India.

Unfortunately, Brooks said, many hospitals miss opportunities for screening because they are unaware that a patient has traveled overseas…

If a patient is indicated for C auris screening, Brooks cautioned that most routine hospital testing platforms can easily misidentify C auris, and he noted that commercial testing is not currently available to hospitals. However, Brooks said the CDC’s Antibiotic Resistance Laboratory Network will perform the test free of charge. Health care facilities can request testing through their state health departments. The test itself is simple, he said.

“Screening for C auris colonization requires gently rubbing a cotton swab over a patient’s skin in their axillae (armpits) and groin areas, and is not particularly difficult, invasive, or time-consuming,” he said.” (E)

“Prevention of invasive Candida infections requires antibiotic stewardship, improved maintenance practices for central venous catheters, and targeted antifungal prophylaxis.

Multidrug-resistant Candida auris is an urgent antimicrobial resistance threat and the key method of C auris prevention is strict adherence to infection control measures, according to a short opinion paper published in the Annals of Internal Medicine.

Unlike other Candida spp, C auris is commonly transmitted between patients in healthcare settings and primarily colonizes the skin and nares. Currently, there are no known strategies for C auris decolonization…

Although early identification is key to controlling C auris transmission, “many laboratories lack mycology capacity, and those that have it may not routinely determine yeast species, even in sterile site isolates” according to the researchers.

Antibiotic stewardship, improved maintenance practices for central venous catheters, and targeted antifungal prophylaxis are all required for preventing invasive Candida infections; however, the key difference for C auris prevention is strict adherence to infection control measures.

While much more needs to be learned about C auris, “preventing the spread of this organism is a priority that requires bolstering laboratory detection capacity, strengthening public health surveillance, and improving infection control practices, especially in postacute care settings,” concluded the researchers.” (F)

“In any other year, it seems, this would be big news: A drug-resistant yeast is spreading around the world, behaving like a cross between a fungus and a bacterium. It lodges itself so tenaciously in hospital environments that cleanups can resemble demolitions. It can’t be easily identified with standard laboratory methods, and it kills 30% to 60% of the people it infects.

The yeast, Candida auris, “is a creature from the black lagoon,” according to Dr. Tom Chiller, who heads the Mycotic Diseases Branch of the U.S. Centers for Disease Control and Prevention. At the 20th Congress of the International Society for Human and Animal Mycology in Amsterdam in 2018, he also noted that C. auris is ” more infectious than Ebola.” Indeed, by the end of May C. auris had been reported in more than 30 countries, according to the CDC.

This sounds like the stuff of nightmares, or material for an update to the 2011 medical action thriller, “Contagion.”

Surprisingly, Chiller seems unperturbed about the secrecy, stating that C. auris “is not something I want the general public to go home and be concerned about.”..

This is why transparency is critical. When Chiller and others argue that the general public doesn’t need to be concerned about C. auris, they are drawing a distinction between concerns of public health and matters of personal health. Obviously these are different, but they are also linked.

Secrecy in medicine has a long and sordid history, including the familiar scandals around experimentation, mistakes and malpractice, and price gouging. Healthcare, pharmaceutical, and agricultural organizations, ever sensitive to their reputations and the bottom line, respond to public pressure.” (G)

“Facing the spread of the deadly and highly resistant Candida auris fungus, New York might require nursing homes and hospitals to conduct pre-admission screenings and isolate carriers and the infected.

The considerations by New York State health officials were reported by the New York Times last week. The newspaper reported that Howard Zucker, M.D., the state health commissioner, and a fungal expert from the federal Centers for Disease Control and Prevention met this month with nearly 60 hospitals to discuss possible guidelines.

New York has handled 331 cases of C. auris since it was first identified in 2009. It spreads easily, is extremely resistant to drug treatments, is hard to kill on surfaces and may spread in the air. While scientists are working on ways to short-circuit the fungus itself, New York wants to stop the costly geographic spread.

“We’re at a point where our response strategy needs to change,” Brad Hutton, the state’s deputy commissioner of public health, told the Times. He said it remains undecided whether final guidelines, expected by year’s end, would apply statewide or only in New York City.

Hospitals and other providers have raised concerns about the cost and capacity for rapid testing, while isolation for carriers who aren’t actively infected could take away beds needed by others.” (H)

“”To keep that a secret is putting people in danger,” said Dr. Irwin Redlener, a Columbia University professor with an expertise in Public Health policy. “And I don’t think that’s reasonable or ethical.”

Palm Centers declined comment on repeated questions by Eyewitness News regarding the presence of Candida auris at the facility.

The New York State Department of Health provided a statement about its efforts to contain the bug.

“The Department of Health has made controlling the spread of C. auris a top priority and has conducted extensive training and education on infection control policies and procedures for Palm Gardens and other nursing home providers throughout this region. We take complaints regarding quality of care extremely seriously and ensure all appropriate steps to protect the health and well-being of nursing home residents,” said Jeffrey Hammond, NY Department of Health spokesperson.

Hammond added that a list of facilities with C. auris cases will be released later this year in the 2018 Hospital Acquired Infection Report.” (I)

Share on LinkedInShare on Google+Share on FacebookTweet about this on Twitter