Archive for category: Other

For years an urban legend has circulated that the poor and uninsured use emergency departments as a substitute for a doctor visit because hospitals are non-profits and won’t turn these sick and injured patients away.

You don’t have to be in healthcare or public health to “know” that hospitals won’t or can’t turn anyone away. The overcrowded, underfunded “county” hospital is a common trope in television and movies; County General Hospital of “ER” fame is probably the most prominent example. The fictional doctors there routinely treated the indigent and homeless, and their outrage at greedy private hospitals dumping uninsured patients on their doorstep was a recurring plot point.

This practice of transferring patients who don’t have insurance and can’t pay for treatment has occurred, and has been covered by news outlets. It was one of the reasons for the creation of the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA), which instituted penalties for hospitals that denied emergency care to patients that required it. That law, and the fact that most institutions already practiced a policy of treating all emergency patients, likely contributed to the urban legend.

Even Snopes, the Internet clearinghouse for all urban legends, has weighed in on the topic, albeit indirectly. It addresses the specific question of a high profile hospital delivering more babies to illegal immigrants than legal residents. The recent political focus on immigration has brought that particular consequence of EMTALA and related legislation into the national consciousness.

But does this popular understanding of how emergency departments and EMTALA work reflect reality? Do the un(der)insured use emergency departments as a substitute for primary care providers, and do they do it because they can’t be turned away?

To begin with, let’s consider the implications of the EMTALA more closely. While it does protect patients who require emergency treatment and does include provisions for women in labor (making it relevant to the immigration conversation), the law does not mandate that all patients be treated for every complaint. If a qualified medical professional determines that there is no emergency, the patient can be turned away. This limits the ability to use emergency departments for preventive care, treating minor injuries and illness, and other primary care functions.

A recent report in JAMA by Raven et al would seem to bear this out. In an examination of nearly 35,000 emergency department visits, only 6% were found to be “primary care treatable.” Furthermore, of those 6%, nearly 90% had chief complaints identical to visits that did qualify as emergencies. Therefore, it may very well be that most nonurgent emergency department visits are not actually preventable by providing insurance to all individuals so they can get primary care. Instead, those visits may result from legitimate ambiguity on the patient’s part about the nature of their condition.

This was also corroborated in Massachusetts, where recent reforms improved access to insurance. A study by Smulowitz et al in the Annals of Emergency Medicine found that while low-severity visits to emergency departments were reduced after the reform, and the reduction was highest among the uninsured and those with newly subsidized insurance plans, only a small percentage of all low-severity visits were eliminated. Presumably other factors besides insurance were leading to the choice of the emergency department for healthcare.

There is a 10-15% fatality rate in reported cases of Powassan encephalitis, with many survivors suffering long-term neurological damage. Symptoms usually begin suddenly 7-14 days following infection, and include headache, fever, nausea and vomiting, stiff neck, and sleepiness. Later, breathing distress, tremors, confusion, seizures, coma, paralysis, and death can occur.

The illness was discovered in 1958 after a five year old boy from Powassan, Ontario died of severe encephalitis. Between 1958 and 2010 fewer than 60 cases of Powassan encephalitis were reported in North America. In 2011, there were 16 confirmed cases in the United States. Recently, the number of cases reported in upstate New York has increased dramatically.

Rick Ostfeld, a disease ecologist at the Cary Institute of Ecosystem Studies said, “We’ve seen a rise in this rare but serious illness in parts of New York State that are hotspots for Lyme disease. And we suspected it was tied to an increase in black-legged ticks carrying deer tick virus, particularly on the east side of the Hudson River.”

Over the course of a five-year study, researchers assessed more than 13,500 ticks of seven species of ticks in seven counties and proved Mr. Ostfeld’s theory – there was an increase in the number of black-legged ticks carrying deer tick virus in counties east of the Hudson river.

Laura Kramer, a research scientist at the Wadsworth Center, said, “Our findings are consistent with deer tick virus infection rates in people revealed in clinical tests by the New York State Department of Health. Of fourteen individuals testing seropositive for deer tick virus, ten were residents of Westchester, Putnam, or Dutchess counties. Another two were from Albany and Suffolk counties, areas with burgeoning black-legged tick populations.”

Unlike Lyme disease, anaplasmosis, and babesiosis, which take feeding black-legged ticks hours to transmit, deer tick virus transmission can occur in just 15 minutes. This leaves very little “grace period” for removing ticks, and underscores the importance of vigilance in tick hotspots.

Ostfeld concludes, “When patients present with encephalitis symptoms in areas with high levels of Lyme disease, especially during the summer, physicians need to consider Powassan encephalitis. While rare, it’s associated with significant complications. There is no vaccine or specific antiviral therapy, the best strategy remains prevention.”

Knowledge of Powassan encephalitis has grown largely as a result of West Nile virus surveillance. Both are part of the flavivirus group of arboviruses. More extensive arbovirus testing may reveal that deer tick virus is more widespread than previously thought.

The study indicated each patient would, on average, infect 0.69 others–so three infected patients would pass the virus on to just two people–as compared with an infection rate of 9.8 per patient for the SARS virus.

From September 2012 to date, the World Health Organization has been informed of a total of 79 laboratory-confirmed cases of infection with MERS-CoV, including 42 deaths. It was reported yesterday that a man in the UK has died from a case of MERS-CoV.

“Given the overall pattern where we’re seeing steady cases, and where we don’t know what the future brings, what we just want to make sure is that we can move as quickly as possible if we need to,” said Keiji Fukuda, the WHO’s assistant director-general for health security and environment, at a briefing in Geneva today. “We’re not in the midst of any acute event right now.”

The WHO plans to convene a committee of experts on July 9th (and again on July 11th if necessary) to decide whether MERS-CoV poses a public health emergency of international concern. The experts gathered for the committee will assess information on the outbreak and advise the WHO on whether it needs to make any further recommendations about the risk posed by the virus.

“That filtering mechanism, just like the filters in your house, can be overwhelmed to where they don’t work anymore,” said Dr. Jason Sigmon, “And then you’re going to be directly challenged by those things in the environment. Those are the things that we see with patients who typically don’t have lung problems.”

Wearing a mask in areas of heavy debris can be very effective at preventing tornado cough. For public health officials in Oklahoma, their capability to track the number of patients reporting tornado cough symptoms will determine their ability to mitigate such issues in the future.

In related news, a recent article in Popular Science revealed that scientists have discovered billions of bacteria thriving in Earth’s upper atmosphere. The scientists collected samples from the air 33,000 feet above the earth’s surface and discovered that  20 percent of what they had assumed to be just dust or other particles was actually alive.

The researchers found E. coli in the samples, which they believe hurricanes lifted from cities. They plan to investigate whether the bacteria could be making its way into rain water. This news is especially revelatory in light of the SARS-like spread of MERS coronavirus.

The WHO has also reported laboratory-confirmed cases of MERS-CoV originating in Jordan, Qatar, Saudi Arabia, and the United Arab Emirates.

The virus has appeared in France, Germany, Italy, Tunisia, and the United Kingdom as well, but the patients were either transferred there for care, or returned from the Middle East and subsequently became ill. In France, Italy, Tunisia and the United Kingdom, there has been limited local transmission among patients who have not been to the Middle East but have been in close contact with laboratory-confirmed or probable cases.

A clinical study published in The Lancet last week suggests that MERS-CoV might have a longer incubation period than previously thought, which would mean that longer quarantine periods may be required to rule out infection among patient contacts.

Based on the current situation and available information, the WHO encourages all Member States to continue their surveillance for severe acute respiratory infections and to carefully review any unusual patterns.