PRESS RELEASE! “Maybe scientists are looking for certainty before moving forward on whether ZIKA hospital designations are necessary and appropriate, where emergency preparedness assumes uncertainty and takes the risks of decisiveness to avoid panic and a calamity.”

These headlines should be sufficient:

Vaginal Exposure to Zika Virus during Pregnancy Leads to Fetal Brain Infection (A)

Zika May Persist for Months in Newborns: Study. Brazilian infant appeared outwardly fine at birth, but neurological troubles arose later  (B)

For mom of baby born with Zika complications, waiting and uncertainty (C)

FDA Advises Zika Screening for All US Blood Centers (D)

Johns Hopkins Opens First-Known Multidisciplinary Zika Virus Center in the World (E)

Minimizing risk poses unique challenges in Zika vaccine trials, scientists say (F)

PRESS RELEASE

Former Hospital President “Designates” Zika Regional Referral Centers (ZRRCs) 

Today, Jonathan M. Metsch, Dr.P.H., former President and CEO of Jersey City Medical Center “designated” certain New York and New Jersey hospitals as Zika Regional Referral Centers.

Metsch said: “While, of course, I obviously have no official authority to “designate”, it is time for CDC or the Commissioners of Health to make sure that there is not a public Zika panic if there is a Zika surge in the height of mosquito season.”

Puerto Rico is already overwhelmed by Zika, Florida is already playing “catch-up” as more Ziska clusters are identified, and New York, with almost 600 cases, has the most of any state.  A Zika baby recently died in Texas, and a Zika baby in New York has Zika-linked microcephaly.

CDC, New York and New Jersey updates focus on community awareness, then stop at the door to the hospital ER.

“Doctors say they don’t have good answers yet to the most pressing questions they get from pregnant patients, including if their fetuses are at risk throughout the pregnancy or only certain stages, and how likely their children are to have some sort of developmental problem….Doctors also worry about what might happen to children who appear to be fine at birth. In the case of other congenital infections like cytomegalovirus, hearing and vision problems can emerge in apparently healthy children years down the road.” https://www.statnews.com/2016/08/17/hospitals-zika-virus-disease-birth-defects/

Ebola preparedness response started with ““All acute care hospitals in New Jersey are prepared to treat these types of public health threats – whether it’s MERS or H1N1, or now Ebola,”…., followed by the fiasco with the first case In Dallas. Only later were Ebola Regional Hospitals designated with a mandate that all cases be referred to them.

Metsch continued: “Maybe scientists are looking for certainty before moving forward on whether hospital designations are necessary and appropriate, where emergency preparedness assumes uncertainty and takes the risks of decisiveness to avoid panic and a calamity.”

Metsch, who is not a clinician, recommends that clinical experts immediately develop criteria for ZRRCs, perhaps including:

– ZRRCs should be academic medical centers with respected, comprehensive infectious disease diagnostic/ treatment and research capabilities, and rigorous infection control programs.

– ZRRCs should also offer robust, comprehensive perinatology, neonatology, and pediatric neurology services, with the most sophisticated imaging capabilities (and Zika-related “reading” expertise).

– ZRRCS should be national leadership in clinical trials.

– ZRRCs should have a track record of successful, large scale clinical Rapid Response, and organizational wherewithal to address intensive resource absorption.

– ZRRCs should be anchor hospitals of large hospital systems so protocols can be standardized and transfers can be quick and seamless.

In New Jersey Cooper University Medical Center, RWJ Medical Center, Hackensack University Medical Center, and University Hospital might be “vetted” first while in NY the major academic medical centers should be “vetted” first, e.g., Mount Sinai, NYP, NYU, Montefiore, Northwell, Stony Brook.

Metsch bases his recommendation on experience and Lessons Learned from: the 1975 terrorist bombing at LaGuardia Airport; the first World Trade Center bombing in 1993; September 11th; the 2004 Republic National Convention at MSG; Swine Flu preparedness in Hoboken in 2009, SARS and Ebola.

Jonathan M. Metsch, Dr.P.H.

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

August 24, 2016

(A)               http://www.cell.com/cell/fulltext/S0092-8674(16)31053-4

(B)               http://www.webmd.com/news/20160824/zika-may-persist-for-months-in-newborns-study-shows

(C)               http://www.miamiherald.com/news/health-care/article97702347.html

(D)               http://abcnews.go.com/US/wireStory/fda-advises-zika-screening-us-blood-centers-41670193

(E)                http://www.hopkinsmedicine.org/news/media/releases/johns_hopkins_opens_first_known_multidisciplinary_zika_virus_center_in_the_world

(F)                http://www.foxnews.com/health/2016/08/24/minimizing-risk-poses-unique-challenges-in-zika-vaccine-trials-scientists-say.html

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Concierge medicine is the “all the rage” but rather should we be “enraged” about it?

Is Concierge Medicine simply an under-the-radar way of letting CM members “jump to the front of the line” silently creating a dual system of care based on ability to pay a “private” surcharge? (A)

A stated goal of the Affordable Care Act is to “Make coverage more secure for those who have insurance, and extend affordable coverage to the uninsured.” (B)

Obamacare was enacted to give millions of people access to health care. That is, to change the system where those who had insurance walked in the front doors of the health care system, while those without insurance were relegated to the Emergency Room (and then chastised for ER “abuse”) or just didn’t get care.

Some background.

“The Association of American Medical Colleges estimates that there will be a shortage of 91,500 doctors by 2020 as the Obamacare insurance coverage provisions are implemented and 30 million Americans become eligible for health insurance coverage.” (C)

So let’s talk about Concierge Medicine.

“In this type of medical practice (also called boutique medicine, retainer-based medicine or direct care), doctors — mainly in primary care — see fewer patients so they can spend more time with ones they do see.

For their part, patients pay an out-of-pocket fee that typically ranges from several hundred dollars to $15,000 annually. In addition to longer visits, patients receive a comprehensive annual physical examination, a commitment to shorter waits and, in many cases, the doctor’s cellphone number and email address so they can get in touch quickly.

Concierge medicine is not a substitute for health insurance. The retainer, no matter how steep, does not cover out-of-office visits to specialists, emergency room care, hospitalization, major surgery or high-tech diagnostic tests, such as CT scans and MRIs. The fee is not reimbursed by either private health insurance or Medicare, although patients’ health savings accounts may cover some of the cost. (D)

Some concerns about CM.

Although Concierge Medicine is a “business model” it markets itself as a clinical model. “The American Academy of Private Physicians (AAPP) is a nonprofit organization founded in 2003 for the purpose of supporting and fueling the growth of medical practices that provide “concierge” and other forms of personalized, value-based medical care. AAPP members are united by their common efforts and dedication to making medical care more accessible and convenient to patients by redefining and re-pricing medical services in ways that are not possible for medical practices that rely solely on insurance payers for their revenue.” (E)

“Concern for quality of care the patient receives should be the physician’s first consideration. However, it is important that a retainer contract not be promoted as a promise for more or better diagnostic and therapeutic services. Physicians must always ensure that medical care is provided only on the basis of scientific evidence, sound medical judgment, relevant professional guidelines, and concern for economic prudence.” (F)

“Typically, the concierge medical practice is on safer legal ground when it includes only medical services that are typically non-covered by insurance. The insurance legal problem is most thorny where Medicare is involved. If the concierge practice charges patients an access fee for services that are covered under Medicare, federal enforcement authorities could see this as violating Medicare rules. In such case, the safest legal strategy may be to simply opt out of Medicare.” (G)

And food for thought:

“Simply running away from the problems and inefficiencies of our current health care system and into the comforts of “retainer medicine” does little to advance health and well-being for the vast number of patients or address some of medicine’s biggest challenges (e.g., cost and access). These are difficult times for physicians and patients alike. We must be careful not to compromise on our commitments and renew our efforts to find sustainable solutions that support physicians in the advancement of the health and well-being of all patients.” (H)

(A) http://www.thehealthjournals.com/concierge-medicine/

(B) http://www.hhs.gov/about/strategic-plan/strategic-goal-1/index.html

(C) https://www.thehappymd.com/blog/bid/285923/Concierge-Medicine-will-get-Massive-Boost-from-Obamacare

(D) http://www.aarp.org/health/healthy-living/info-01-2013/boutique-doctors.html(E) http://aapp.org/about-us-2/

(F) https://sites.sju.edu/icb/question-is-concierge-medicine-ethical/

(G) https://conciergemedicinetoday.org/2013/10/21/legal-concierge-medicine-raises-legal-issues/

(H) http://journalofethics.ama-assn.org/2013/07/ecas3-1307.html

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“With little known about Zika virus, hospitals scramble to stay ahead.”

As many of you know I have been advocating (unsuccessfully) for the designation of Zika Regional Referral Centers (ZRRFs).

Perhaps this article from STAT will convince policy makers that it is time to stage Zika hospital preparedness.

With little known about Zika virus, hospitals scramble to stay ahead

By Andrew Joseph  https://www.statnews.com/2016/08/17/hospitals-zika-virus-disease-birth-defects/

“The threat of Zika virus is reshaping operations at hospitals across the country, as medical teams rush to figure out how best to provide care for pregnant women with the disease and monitor and treat babies with related brain damage.

With scientists still trying to better understand the virus — and without any treatments available — hospitals have been forced to adapt to a changing Zika outbreak, particularly in states such as Florida, Texas, and New York that are at risk for local transmission or have seen large numbers of travel-related cases.

Hospitals say they have built up their diagnostic tools, started performing more regular ultrasounds for patients, and are keeping closer-than-usual watch on amniotic fluid levels and fetal heart rates. Social workers and physical, speech, and occupational therapists are preparing to work with babies born with Zika-associated defects, should they require their care.”

…..

“To bridge the gap, hospital officials say they have assigned doctors to keep up with the growing body of literature and confer with public health agencies. They are also bringing together obstetricians trained in high-risk pregnancies, pediatrician specialists, and virologists and other biomedical researchers.

Doctors say they don’t have good answers yet to the most pressing questions they get from pregnant patients, including if their fetuses are at risk throughout the pregnancy or only certain stages, and how likely their children are to have some sort of developmental problem.

Doctors also worry about what might happen to children who appear to be fine at birth. In the case of other congenital infections like cytomegalovirus, hearing and vision problems can emerge in apparently healthy children years down the road.”

…..

To read the full STAT article click on    https://www.statnews.com/2016/08/17/hospitals-zika-virus-disease-birth-defects/

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Did you ever talk to a radiologist (or a pathologist) – I did, maybe you should too

Several months ago my GI physician ordered a “rule out” MRI. On my next visit my doctor clicked on the images and went over them with me; it was clear he had gone down to the radiology suite and gone over the “films” with the radiologist. In fact since the senior MRI radiologist was on vacation, he reviewed the images with him too when he returned.

While I did get a copies of the MRI reports, I never spoke directly to the radiologist. No one ever does with the exception of women talking to their breast radiologist.

Fast forward to another MRI and x-rays for chronic back pain. In each case I asked to meet the radiologist and in both cases the radiologist went over the images with me, before I went back to the referring physiatrist. WOW!!

Now the back MRI and x-rays were outpatient in a free-standing imaging center, and the radiologist was right there. Not so easy if you are in an ER, or a hospital bed, or if the images are read “off-site.”

Like dermatologists who are now really surgeons, some radiologist are now interventionalists like cardiologists and vascular surgeons.

What is Interventional Radiology?

“In the realm of interventional oncology, we specialize in image-guided tumor treatments including radioembolization, chemoembolization, radiofrequency ablation, cryoablation, microwave ablation, and high intensity focused ultrasound. For venous diseases, we offer state-of-the-art therapy for DVT, varicose veins, and chronic venous occlusion. In women’s health, we offer a variety of services to alleviate pelvic pain including uterine artery embolization for the treatment of symptomatic fibroids and gonadal vein embolization for pelvic congestion syndrome. We are experts in the endovascular treatment of arterial disease, from angioplasty and stenting of occluded blood vessels to endograft repair of aneurysms.” (A)

You wouldn’t, I hope, let a cardiologist stent you without knowing who is doing the procedure, and his or her training, experience and performance results. Same goes with an interventional radiologist. You should meet the IR radiologist before and after the procedure.

What is “teleradiology”? “Night Hawks”

“Teleradiology is the ability to obtain….medical images in one location and their transmission over a distance so that they can be viewed and interpreted for diagnostic or consultative purposes by a radiologist.

This recent practice is becoming widely implemented by hospitals, urgent care clinics and specialist imaging companies. The reason for its increased implementation is because it addresses the lack of adequate staff to provide radiological coverage and the lack of expertise in this specialty.”

Many hospitals do not have 24/ 7 in-house radiology coverage. In some such cases images are read by off-site radiologists, often referred to as “Night Hawks”, employed by for-profit corporations, covering many hospitals at once. While the hospital radiologist may do the final read and report, Night Hawk readings may be used for emergency clinical decision-making, e.g., in the ER. and help determine whether you are admitted or discharged.

You have a right to know who is providing your care including who is viewing your imaging and providing radiologic diagnoses. ASK!!!

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“I got Zika. The US health care system had no idea what to do with me…”

CDC’s revised Zika Interim Response Plan (July) states:  ”Neither vaccines nor proven clinical treatments are expected to be available to treat or prevent virus infections before local transmission begins within CONUS or Hawaii.”; “Scientific understanding of Zika virus continues to evolve, and new characteristics of the virus and how it is spread may arise.” (A)

“CDC director Tom Frieden has said that the mosquitoes carrying Zika in Miami could be developing resistance. Researchers can project what Zika infection rates will look like in multiple scenarios, but not what will happen if Zika is evolving at the DNA level or if its vectors multiply beyond sex and mosquitoes, both of which are real possibilities.” (B)

The New Jersey and New York Departments of Health Zika pages focus on community awareness, default to CDC, then stop at the door to the hospital ER. (C)

So we are not dealing with Zika “evidenced based medicine” but “best practices” aggregated and amended from Swine Flu, Ebola,  Dengue, and other mosquito transmitted viruses.

Examples of some recent news reports make it clear that Zika parameters are changing so quickly, that only medical school affiliated teaching hospitals should be caring for Zika patients.

  1. “Zika virus infection during pregnancy may be related to a severe birth defect called arthrogryposis, whereby the joints – particularly those in the arms or legs – are deformed. This is the finding of a new study published in The BMJ.” “Researchers focused on seven babies whose mothers were infected with Zika while pregnant. Six of the seven developed microcephaly—  the most widely publicized birth defect from Zika— but six also had trouble swallowing, six had clubfoot, five had eye abnormalities, and two needed breathing and feeding tubes.” (D)
  2. “NEW ORLEANS — Officials at the front lines of fighting the Zika virus are warning residents that mosquitos that carry the disease are already here.” (E)
  3. “Texas reported its first Zika-related death Tuesday after a baby girl whose mother traveled to El Salvador while pregnant died shortly after birth in a suburban Houston hospital. The girl, who died a few weeks ago, had microcephaly linked to the Zika virus….” (F)
  4. “In an effort to detect any local transmission of the Zika virus, the New York City Department of Health and Mental Hygiene said on Tuesday that it had expanded the guidelines on who should be tested for the disease to include anyone with its most-common symptoms.” (G)
  5. “Amid news of a Zika outbreak in the Miami area, the U.S. Food and Drug Administration’s Center for Veterinary Medicine (FDA-CVM) has cleared the experimental release of genetically modified (GMO) mosquitoes in the Florida Keys to help combat the virus. “ (H)
  6. “Suncoast Blood Bank announces they are testing all donated blood for the Zika virus. Effective immediately the blood bank will test all donors for the virus.” They say this is a proactive measure to protect the community blood supply.” (I)
  7. “I got Zika. The US health care system had no idea what to do with me. How do you spell Zika?”I stood at the front desk of a major Washington, DC, hospital last month. I had a head-to-toe rash that developed after I’d returned from the Dominican Republic, where Zika is much more common than it is stateside. The friend I’d traveled with was showing symptoms of the virus. I’d come to the emergency room to find out if I had it too.This was not a question I wanted to hear from the man who was checking me in.But ignorance of what Zika is, and uncertainty about how to deal with it, was common in my quest to get diagnosed — even from parts of the medical community that I expected would know what to do.” (J)
  8. “On Thursday, scientists described two cases in which the semen of men who contracted Zika in Haiti early this year continued to test positive for the virus, even though it has been six months since they were infected.The semen of one tested positive 188 days after he first experienced symptoms of the illness. Testing on day 181 came back positive for the other man. Both men are still being followed. Previously, the longest period in which evidence of virus was seen in the semen of a Zika-infected man was 93 days.” (K)
  9. “Until this week, there had been no reported cases of birth defects related to Zika in Canada.Public health officials are releasing no other information about the fetus, including whether or not he or she is alive. It represents the second confirmed case of maternal-to-fetal transmission of the Zika virus in Canada.” (L)
  10. “U.S. Sen. Bob Menendez can add a personal motivation to his efforts to get Congress to approve federal funding to combat the spread of the Zika virus. Menendez said this week his daughter is five months’ pregnant in Miami with his first grandchild.”(M)
  11. “Beyond Zika: How Congress Is Flirting With Medical Disaster. The dysfunctional response to the Zika virus lays bare a system that is increasingly ill-equipped to respond to outbreaks.” (N)
  12. “While the Zika virus has its moment, few people are discussing the problems underlying the worldwide increase in emerging infectious diseases.” (O)
  13. “Zika fits into the category of unforeseen emerging threats that migrate into new environments where they suddenly pose major hazards to unprepared populations — think severe acute respiratory syndrome (SARS) or Ebola, for instance. These required “urgent mobilization to protect and manage the introduction of these alien, and dangerous, pathogens,”….(P)

Soooooo……if you are concerned that you may have been exposed to Zika, until there are national protocols in place, bypass your community hospital ER, and go to the nearest medical school affiliated teaching hospital.

And…..remember:

EMERGENCY ROOMS are not all created equal! (Q)

Stop the name games! University hospitals and regional medical centers should live up to their billing. (R)

 

 

 

(A)   http://www.cdc.gov/zika/pdfs/zika-draft-interim-conus-plan.pdf

(B)   http://www.vogue.com/13464580/why-zika-is-scarier-than-donald-trump/

(C)   http://www.nj.gov/health/cd/zika/  https://www.health.ny.gov/diseases/zika_virus/

(D)   http://www.medicalnewstoday.com/articles/312229.php

(E)    http://www.wwltv.com/news/health/mosquitos-that-carry-zika-already-in-new-orleans/292487541

(F)    http://blackamericaweb.com/2016/08/10/infants-death-is-first-zika-related-fatality-in-texas/

(G)  http://www.nytimes.com/2016/08/10/nyregion/zika-testing-new-york-health-dept.html?_r=0

(H)   http://www.nationofchange.org/2016/08/08/fda-approves-genetically-modified-mosquitoes-combat-zika-florida/

(I)     http://www.snntv.com/2016/08/09/suncoast-blood-bank-begins-testing-zika/ 

(J)     http://www.vox.com/2016/8/11/12422314/zika-virus-united-states

(K)   https://www.statnews.com/2016/08/11/zika-virus-semen-sexual-activity/

(L)    http://ottawacitizen.com/news/national/only-a-matter-of-time-first-zika-related-birth-defects-reported-in-canada

(M) http://www.wftv.com/news/local/us-sen-bob-menendez-has-personal-stake-in-push-for-zika-funding/421039501

(N)  https://newrepublic.com/article/136022/beyond-zika-congress-flirting-medical-disaster

(O)  http://www.americanscientist.org/issues/pub/2016/5/zika-goes-viral

(P)   https://www.thecipherbrief.com/article/exclusive/north-america/zika-national-security-threat-1095

(Q)  http://doctordidyouwashyourhands.com/2016/04/emergency-rooms-are-not-all-created-equal/

(R)   http://doctordidyouwashyourhands.com/2016/07/stop-the-name-games-university-hospitals-and-regional-medical-centers-should-live-up-to-their-billing/

 

APPENDIX

Many of you might be familiar with my advocacy for designating Zika Regional Referral Centers. If not see links below.

We don’t know what we don’t know” – The challenge to emergency preparedness….. http://doctordidyouwashyourhands.com/2016/04/we-dont-know-what-we-dont-know-about-zika-1-the-challenge-to-emergency-preparedness/

Former hospital prez says: Designate local Zika centers now. “Medical experts do not know if, or where, or how much, or on what trajectory the Zika virus may spread across the United States.” http://doctordidyouwashyourhands.com/2016/06/former-hospital-prez-says-designate-local-zika-centers-now-medical-experts-do-not-know-if-or-where-or-how-much-or-on-what-trajectory-the-zika-virus-may-spread-across-the-united-states/

Suspending a chicken over your bed could protect against Zika virus and malaria (A)  http://doctordidyouwashyourhands.com/2016/07/suspending-a-chicken-over-your-bed-could-protect-against-zika-virus-and-malaria-a/

Zika “panic” – IS YOUR HOME TOWN READY FOR ZIKA?

http://doctordidyouwashyourhands.com/2016/08/zika-panic-is-your-home-town-ready-for-zika/

 

 

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

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Zika “panic” – IS YOUR HOME TOWN READY FOR ZIKA?

Three episodes taught me about the unpredictability of emergency preparedness and the need to think quickly and decide carefully.

On September 11th Jersey City Medical Center, where I was the President, was in the epicenter of the response to WTC attacks. After Bellevue, St. Vincent’s and NYDT, JCMC played the biggest roll screening thousands on the Jersey City waterfront transported by ferries and receiving 175+ casualties. JCMC was not in the NYC disaster plan, neither were the ferries. We immediately received five seriously injured NYC fireman but before we could get them to the ORs they were whisked away by NYC EMS. As others arrived ,many needed surgery for non-life-threating injuries. Fortunately the physician managing triage on the ER tarmac, a retired Army trauma surgeon, deferred them all so as not to block the ORs for patients who might arrive needing life-saving surgery. Then the buildings collapsed, no more casualties arrived, and the ORs were opened for use.

In 2009 all the maps showed H1N1 “Swine Flu” aiming right towards NYC/ Hoboken. So the Mayor of Hoboken formed a Hoboken H1N1 “Swine Flu” Task Force. Assignments included:

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. HPD& HFD: 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 treatments plans.

Surprise! No Swine Flu surge in the NYC metropolitan area. Probably due to “herd immunity” (A) from the previous year’s sub clinical Swine Flu “epidemic” from the year before.

Finally the Ebola preparedness response started with ““All acute care hospitals in New Jersey are prepared to treat these types of public health threats – whether it’s MERS or H1N1, or now Ebola,”…., followed by the fiasco with the first case In Dallas. Only later were Ebola Regional Hospitals designated with a mandate that all cases be referred to them.

We are likely to see local Zika “panic” as cases are identified in areas other than south Florida. It seems that most new local cases will initially affect people who have returned from Zika pandemic/ epidemic areas like Puerto Rico. Then in some areas Zika might be further transmitted by sexual contact, indigenous mosquitos, and perhaps the blood supply.

Newborns with microcephaly will turn panic into an “all hands on deck” scenario. Then the demand for screening, diagnosis and treatment (there isn’t any) will challenge the “surge capacity” of local hospitals.

The critical Lesson Learned is to protect important resources  in the front end “panic” so they are available immediately in the back end “surge.”

 

 

APPENDIX 1

IS YOUR HOME TOWN READY FOR ZIKA?

“…surge capacity may be described in the following manner:

The ability to obtain adequate staff, supplies and equipment, structures and systems to provide sufficient care to meet immediate needs of an influx of patients following a large-scale incident or disaster.” (B)

“The American College of Emergency Physicians (ACEP) believes that:

  • ◦Emergency departments, as principal portals of entry into crowded health care systems, are increasingly faced with the challenge of ensuring patients have access to care during periods when demand exceeds available resources. This challenge is magnified when mass casualty incidents or epidemics occur.

◦Surge capacity is a measurable representation of ability to manage a sudden influx of patients. It is dependent on a well-functioning incident management system and the variables of space, supplies, staff and any special considerations (contaminated or contagious patients, for example).

◦Health care systems must develop and maintain outpatient and inpatient surge capacity for the triage, treatment, and tracking of patients at the facility or in alternative sites of care or alternative hospitals during infectious disease outbreaks, hazardous materials exposures, and mass casualty incidents.

◦Health care facility and system plans should maximize conventional capacity as well as plan for contingency capacity (adapting patient care spaces to provide functionally equivalent care) and crisis capacity (adapting the level of care provided to the resources available when usual care is impossible).

◦Development of surge capacity requires augmenting existing capacity as well as creating capacity by limiting elective appointments and procedures and practicing ”surge discharge” of patients that can be effectively managed in non-hospital environments.

◦Effective surge capacity planning integrates facility plans with a regional disaster response program involving other area health care institutions and considers hazard vulnerability assessments (HVAs) and historical natural disaster threats. “ (C)

 

(A)                  http://www.pbs.org/wgbh/nova/body/herd-immunity.html

(B)                  http://www.medscape.com/viewarticle/704505_7

(C)                  https://www.acep.org/Clinical—Practice-Management/Health-Care-System-Surge-Capacity-Recognition,-Preparedness,-and-Response/

 

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APPENDIX 2

Some related posts:

We don’t know what we don’t know” (1) The challenge to emergency preparedness…..http://doctordidyouwashyourhands.com/2016/04/we-dont-know-what-we-dont-know-about-zika-1-the-challenge-to-emergency-preparedness/

Former hospital prez says: Designate local Zika centers now. “Medical experts do not know if, or where, or how much, or on what trajectory the Zika virus may spread across the United States.” http://doctordidyouwashyourhands.com/2016/06/former-hospital-prez-says-designate-local-zika-centers-now-medical-experts-do-not-know-if-or-where-or-how-much-or-on-what-trajectory-the-zika-virus-may-spread-across-the-united-states/

Suspending a chicken over your bed could protect against Zika virus and malaria (A)  http://doctordidyouwashyourhands.com/2016/07/suspending-a-chicken-over-your-bed-could-protect-against-zika-virus-and-malaria-a/

 

 

 

APPENDIX 3

Following are some article abstracts which might help you assess your HOME TOWN’s emergency preparedness for Zika.

 

Trump: Florida governor probably has Zika ‘under control’

http://thehill.com/blogs/ballot-box/presidential-races/290346-trump-florida-gov-probably-already-has-zika-under-control

Republican presidential nominee Donald Trump commended Florida Gov. Rick Scott for how he is dealing with cases of the Zika virus in Florida.

“You have a great governor who’s doing a fantastic job, Rick Scott, on the Zika, and it’s a problem, it’s a big problem,” Trump said in an interview with CBS12 in West Palm Beach.

“But I watch and I see and I see what they’re doing … and I think he’s doing a fantastic job and he’s letting everyone know exactly what the problem is and how to get rid of it,” the real estate tycoon continued.

He’s going to have it under control. He probably already does.”

 

Zika in the United States, explained in 9 maps

http://www.vox.com/2016/8/4/12363312/zika-florida-united-states

Where the virus is in the US, and where it could potentially spread.

“Generally, cities with the highest levels of travel, the highest numbers of mosquitoes in peak summer months, and those that are in the climate range in which the mosquitoes thrive are the most at risk.

The National Center for Atmospheric Research produced the map above after analyzing the relative Zika risk of 50 US cities.

Its research, which was published in PLOS Current Outbreaks in March, combines meteorological records, simulation of Aedes aegypti mosquito population growth, estimates of human-mosquito exposure, and transportation data.

While the Aedes aegypti, the mosquito most likely to transmit the virus in the US, can’t tolerate the cold of winter in many US cities, its numbers start to increase as temperatures rise. The exceptions are Florida and Texas, where the mosquitoes can live year-round. The risk decreases for the more Northern cities as summer turns to fall.”

 

Cities, counties scramble to take on Zika

http://www.cnn.com/2016/08/04/health/zika-virus-cities-counties-preparation/

“ (CNN) — Zika was worrying local health officials long before Florida announced the nation’s first local transmission from an infected mosquito in late July.

Previously, the virus had already hit US territories, Puerto Rico in particular, and there were almost 1,700 cases in the US, most of them stemming from travelers who had visited a Caribbean or South American country.

But the news out of Florida ramped up concerns. It meant the mosquitoes infected with the virus had arrived in the US, and mosquitoes being far harder to corral and track than humans, concerns about Zika’s spread shot to the forefront of many local health departments’ agendas.

“If we do nothing, a lot of people will get Zika,” wrote Dr. Jane Orient, executive director of the Association of American Physicians and Surgeons in an op-ed this week. “Most will have no symptoms, and most of the rest will have a short, mild illness and become immune to future infections. The epidemic will die down when most prospective hosts are immune. But this is not the strategy we want to follow.”

Many cities and counties along the coast and border know this and are preparing in sometimes creative ways. While the list of locales below is by no means exhaustive, it does represent a broad spectrum of efforts to combat Zika or its potential arrival.

For city specific detailed information click on http://www.cnn.com/2016/08/04/health/zika-virus-cities-counties-preparation/

Laredo, Texas

Savannah, Georgia

New Orleans

Houston

Los Angeles

New York

Charleston, South Carolina

Corpus Christi, Texas

San Diego

 

CDC awards $16 million to states and territories to fight Zika

http://www.cdc.gov/media/releases/2016/p0802-zika-cdc-awards-funding.html

“Funding provided for states and territories to respond to the emerging threat, quickly identify cases of microcephaly and other adverse birth outcomes linked to Zika, and refer infants and families to services

The Centers for Disease Control and Prevention (CDC) has awarded more than $16 million to 40 states and territories to establish, enhance, and maintain information-gathering systems to rapidly detect microcephaly–a serious birth defect of the brain–and other adverse outcomes caused by Zika virus infection. These awards are a stopgap diverted from other public health resources until Zika funds are provided by Congress.

The funding will also help states and territories ensure that infants and their families are referred to appropriate health and social services. Finally, the awards will enable states and territories to monitor the health and developmental outcomes of children affected by Zika.

“It is critical to identify infants with birth defects related to Zika virus so we can support them and their families,” said CDC Director Tom Frieden, M.D., M.P.H. “This CDC funding provides real-time data about the Zika epidemic as it unfolds in the United States and territories and will help those most devastated by this virus.”

The funds will allow states and territories to:

  • Enhance information-gathering to carry out strategies for real-time, population-based monitoring for microcephaly and other birth defects caused by Zika virus;
  • Enhance capacity development through partner collaboration and infrastructure improvements;
  • Provide referral of infants and families to health and social resources;
  • Participate in CDC data reporting; and
  • Expand access to examination of health and monitoring of developmental outcomes of children born to women with positive or inconclusive Zika virus test results.”

 

Zika-Spreading Mosquitoes Are Becoming More Resistant to Common Pesticides

https://gma.yahoo.com/zika-spreading-mosquitoes-becoming-more-resistant-common-pesticides-171405120–abc-news-topstories.html#

“Health officials working to contain Zika outbreak in northern Miami are now investigating whether the Zika-spreading mosquitoes have become resistant to common pesticides used to combat the insect — as studies suggest has been the case in other parts of the world.

Currently, 14 people have been found to be infected with the Zika virus from mosquito bites in a 1-square-mile area in northern Miami, according to the U.S. Centers for Disease Control and Prevention. Mosquito control measures were implemented after four people were found infected with Zika in July, but health officials said on Monday those initial mosquito control measures were not enough.

The Aedes aegyti mosquito has been called a “cockroach” mosquito for its ability to live indoors and reproduce even in tiny pools of water. The insect is the primary way the Zika virus is spread, although the disease can also be transmitted through sexual contact.

“Aggressive mosquito control measures don’t seem to be working as well as we would have liked,” CDC Director Tom Frieden told reporters on Monday after 10 additional Zika cases were announced. He pointed out that it was unclear if the insects themselves are biologically resistant to the chemicals used in common insecticides used or if there were other environmental factors like standing water that was not visible that lead to the mosquito population bouncing back.

Frieden said an expert was investigating the mosquitoes to test if they are genetically resistant to pesticides but that it could take weeks to get the findings.”

 

I’m concerned about Zika impacts we may not be detecting: Doctor

http://www.cnbc.com/2016/08/04/

“Recent studies suggest the effects of the Zika virus infection on fetuses may be worse than previously thought, but local outbreaks are “eminently controllable,” Dr. Scott Gottlieb said Thursday.

Gottlieb, an American Enterprise Institute senior fellow, spoke after Florida confirmed 15 cases of locally transmitted Zika in the Miami area and the Centers for Disease Control and Prevention warned pregnant women not to travel to the South Florida neighborhood where most of the infections originated.

Isolated local outbreaks can be easily quelled with mosquito abatement, Gottlieb said. What is more concerning is recent research that suggests Zika can produce a higher rate of fetal anomalies than previously thought, he said.

The CDC has concluded that a Zika infection in pregnant mothers can lead to microcephaly and other birth defects. Researchers initially thought women in the first trimester of pregnancy infected with Zika had a roughly 1 percent chance of their unborn child developing microcephaly, Gottlieb said. But CDC research released in May suggested it could be as high as 13 percent.

“You start to worry that any virus that’s powerful enough to have that kind of an effect on a developing fetus probably is having other impacts as well that we’re just not detecting, so the infection itself seems to be more concerning than what we initially thought,” Gottlieb told CNBC’s “Squawk Box.””

 

As Zika spreads in Miami, pregnant women race to get tested

http://www.miamiherald.com/news/health-care/article93631267.html

“Since health officials warned pregnant women to avoid the Wynwood area because of ongoing Zika transmission — and the Centers for Disease Control and Prevention urged those who had visited the district on or after June 15 to get tested for the virus — expectant mothers and women planning to conceive in South Florida are making a run on lab tests while others are freezing their eggs, delaying their pregnancies or, in the most extreme cases, planning to leave town to finish out their terms.

Florida Gov. Rick Scott has pledged that Zika tests will be provided free for all pregnant women statewide. But since testing supplies are limited, and not all the available tests are equally effective at detecting the virus, the explosion of demand has overwhelmed the public health agencies that Floridians are relying on for answers, said Ellen Schwartzbard, an OB/GYN at South Miami Hospital.”

“I don’t feel the Department of Health is prepared for this right now,” she said.”

 

Should Every Pregnant Woman Be Assessed for Zika?

http://www.fitpregnancy.com/pregnancy/pregnancy-news/should-every-pregnant-woman-be-assessed-for-zika

“According to the CDC, all pregnant women should be assessed for the Zika virus. This is a recent recommendation, as new Zika-related findings have prompted the group to push for new screening practices. The CDC believes every prenatal medical visit should include a Zika assessment, where a doctor asks an expectant mother if she or her partner has traveled to an area where Zika is being transmitted. …..

Back in January, the CDC issued a recommendation for pregnant women to avoid areas where the virus is actively spreading. That’s still the case, but the virus is closer to home now: Miami’s Wynnwood neighborhood is now home to an outbreak, with 14 people infected locally, according to USA Today. Pregnant women are advised to avoid travel to Florida’s Miami-Dade County as a result, and expecting mothers who live in the area are urged to avoid contact with mosquitoes by wearing insect repellant and covering their arms and legs when outdoors.

Women who experience fevers or rashes, which are two of Zika’s main symptoms, should certainly be tested for the virus, as should any pregnant women who could have been exposed via travel or sexual contact. But according to the CDC, this isn’t enough: Regular assessment of pregnant women who don’t have any real reason to believe they’ve been infected is important as well, as this will allow medical practitioners to make informed decisions about whether or not they should be thoroughly tested.

This is not to be taken lightly: Zika’s symptoms are on the mild side for most people, but the virus has been linked to microcephaly, a birth defect that causes babies to be born with abnormally small heads and incomplete brain development, when it infects pregnant women.”

 

Two babies in California born with microcephaly from Zika, officials say

http://www.latimes.com/local/lanow/

Two babies in California were born with microcephaly after their mothers were infected with Zika virus, state health officials said Thursday.

The mothers had traveled to countries with outbreaks of the illness before becoming infected. Officials would not release any more information about the women or the babies.

 

 

537 Zika Cases Reported in New York, But All Appear to Be Related to Travel

http://www.nbcnewyork.com/news/local/Zika-New-York-Cases-Mosquito-Miami-Pregnant-Women-388974172.html

New York state has confirmed 537 cases of Zika so far – though officials say all appear to be connected to travel to affected areas and there’s no evidence the virus is spreading through local mosquitoes.

Of those cases, 414 were in New York City and 123 were upstate. Nearly all of them involved people who had visited regions affected by the mosquito-borne virus; five cases were sexually transmitted.

While the specific mosquito species known to spread Zika is not native to New York, a related species is present in downstate areas.

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