Medical Crisis Response

West Nile Outbreak Mobilizes Physicians 

 Texas Medicine Logo 

Public Health Feature – November 2012 

 By Crystal Conde 
Associate Editor 

Tex Med. 2012;108(11):35-40.

West Nile virus was rare in Dallas County in the past two years – only two cases were reported. But this summer, mosquitos carrying the virus unleashed havoc on the area, infecting 341 people and killing 17 by early October. The outbreak mobilized physicians and local officials in a public health response to wipe out the disease-carrying mosquito population.

John Carlo, MD, chair of the Dallas County Medical Society's Community Emergency Response Committee (CERC), says his committee learned of the seriousness of the situation from a group of concerned infectious disease specialists, including experts from The University of Texas Southwestern Medical Center led by committee member James Luby, MD.

"Dr. Luby's group indicated this was as substantial outbreak," said Dr. Carlo, a member of the Texas Medical Association Council on Science and Public Health and former medical director and health authority for Dallas County Health & Human Services. "The number of people testing positive for West Nile was high through July, fairly early in the West Nile season for Dallas."

In fact, the Texas Department of State Health Services (DSHS) reported more cases of West Nile virus through July 31 than in any other year since West Nile came to Texas in 2002. By late September, Texas reported 1,355 cases of the virus – the highest in the nation – to the Centers for Disease Control and Prevention (CDC). (See "West Nile Virus Activity Through September 2012.") Also, the proportion of mosquito traps testing positive for West Nile virus in Dallas County at the time were exceedingly high – 50 percent in some parts of the county, Dr. Carlo says.

After weighing its options, CERC and ultimately the medical society recommended that local health officials begin aerial pesticide spraying. Soon after, Dallas County Judge Clay Jenkins declared a state of emergency and requested aerial pesticide from the state. DSHS approved the request, and aerial spraying began in August. Dallas County Health & Human Services Chief Epidemiologist Wendy Chung, MD, said in October that it was too early to determine the impact of aerial spraying in the county.

The response to West Nile virus in Dallas County is just one example of the valuable influence county medical societies and their committees can have in times of disease outbreaks, disasters, or emergencies, Dr. Carlo says.

"When groups of physicians come together in an organized fashion like this, they have the ability to articulate health concerns clearly and to inform the community about what's going on. These committees allow doctors to respond in ways that can benefit the health of the community," he said. "Our recommendations helped reinforce the decisions made by the local health department and the health authority."

 Dr. Chung appreciated the medical society's help during this public health crisis. Though she is a member of CERC, she had to recuse herself from voting on the aerial spraying recommendation due to her position as a health department employee.

"Effective communication between the health department and frontline physicians in the community is two-way. Health departments need to be able to rapidly communicate with local physicians to provide testing recommendations and updates during outbreak situations." She said the county medical society forwarded health advisories to 6,000 area physicians, and its committees allowed physicians "to voice their observations and concerns to public health agencies."

 State and Local Response 

In July, DSHS attributed the West Nile virus outbreak to the warm winter and summer rains, particularly in North Texas. At the time, the department said about 80 percent of the state's West Nile cases were in Dallas, Collin, Tarrant, and Denton counties.

West Nile virus can permanently damage its victims, leaving long-term health complications in its wake. Don Read, MD, knows this all too well. He survived West Nile virus after a lengthy battle with it in 2005. Dr. Read missed seven months of work, was in the intensive care unit for four-and-a-half weeks, and endured two months of inpatient rehabilitation, three months of outpatient rehab, and home care for a month. (See "West Nile Virus: It Could Happen to You.")

Because the virus can be so devastating, Dr. Chung and the health department realized the importance of physician education. She issued three health advisories. They alerted physicians to the need for testing patients with symptoms compatible with West Nile virus infection, updated them on the extent of the cases, and reiterated testing and prevention measures.

"We wanted the physicians in the community to be aware of the presence of the virus in our county, and we advised them of preventive measures for patients, such as using repellent products when going outside. Once we recognized this was going to be an unusual season, we put out the second advisory that educated physicians on virus symptoms and testing," she said.

Philip Huang, MD, health authority for the Austin/Travis County Health and Human Services Department, says his agency acted early in the summer when samples of mosquito specimens first tested positive for West Nile virus.

"Every summer, we send out a press release notifying the public of the four Ds: Dress with long sleeves and pants, use repellent products with DEET, drain standing water, and avoid going outside at dusk and dawn," said Dr. Huang, chair of the Travis County Medical Society (TCMS) Public Health Committee.

The department relied on TCMS to spread the word to physicians.

"In addition to sharing patient education points with physicians, we informed them about testing for and reporting the disease and kept them up to speed on the situation. TCMS was a valuable partner in communicating with area doctors," Dr. Huang said.

By late September, West Nile virus had claimed three lives in Travis County, and the area had reported 103 total cases, 45 of which were neuroinvasive. According to CDC, neuroinvasive types of the virus include West Nile encephalitis, West Nile meningitis, and West Nile meningoencephalitis.

To battle the infected mosquito population, the city implemented an integrated mosquito management plan that included public education, measures to eliminate adult nesting and larvae breeding sources, and ground pesticide spraying. Dr. Huang says the City of Austin won't implement aerial spraying unless local government officials declare a public health emergency.

The effect of West Nile virus prompted DSHS to conduct a free webinar on the virus in August. DSHS Commissioner David Lakey, MD, and department staff members Robert Kaspar, MD; Paul McGaha, DO; and Tom Sidwa, DVM, discussed the virus and its epidemiology, prevention, diagnosis, and treatment. DSHS has posted West Nile virus statistics on its website.

Dr. Chung hopes surveillance data collected by local health agencies will be the basis for guidance in future outbreaks. Local health department officials interviewed those who tested positive for the virus and forwarded the information to DSHS and CDC.

"What we're able to learn about this outbreak will assist public health professionals throughout the state and nation with effective prevention messaging in the future. For instance, we need to know why some people don't wear mosquito repellent, even when they know West Nile virus has been detected in their areas. Understanding that will help us more effectively communicate the importance of preventive measures when public health threats emerge," Dr. Chung said.

Medical Societies Key to Response 

Umair Shah, MD, deputy director of Harris County Public Health & Environmental Services (HCPHES), understands the importance of collaboration among doctors, public health officials, state and local health agencies, hospitals, and others to ensure a successful response to a public health emergency.

"My parents taught me no matter how hard you try, you can't clap with one hand; you need two. Similarly, we need public health and those involved in individual clinical patient care to work together to benefit the overall health of a population on an ongoing basis. The same holds true during response to emergencies, disasters, and disease outbreaks. Physicians on the front lines are essential to the public health response," said Dr. Shah, director of the HCPHES Disease Control & Clinical Prevention Division.

That's where medical society committees come into play.

Dr. Shah serves on the Harris County Medical Society (HCMS) Emergency Care and Community Health Improvement & Communication committees.

"Both recognize the importance of population health and assist physicians in contributing to public health," he said.

For example, during the H1N1 influenza outbreak in 2009, HCPHES was in emergency response mode for more than a year.

"We all wanted to have unified messages that made physicians aware of testing and lab specimen guidelines, diagnoses information, and the nature of the epidemiology of the disease," Dr. Shah said. "HCPHES pushed out these messages through its Health Alert Network, but HCMS was instrumental in making sure a large portion of the physicians in the area received the message. Once vaccine was available for H1N1, we used the same collaboration with HCMS to apprise physicians of immunization guidelines."

David A. Marks, MD, a San Antonio pulmonologist, chairs the Bexar County Medical Society (BCMS) Emergency Preparedness Committee. In addition to serving as chief of North Central Baptist Hospital's Department of Critical Care Medicine, he is a member of the Baptist Child and Family Services disaster medical response team.

He describes the BCMS Emergency Preparedness Committee as a "resource for Bexar County physicians to educate themselves on their roles and responsibilities during disasters."

He says the committee works to ensure the physician community can respond to any catastrophe in San Antonio, Bexar County, and South Central Texas. The group also helps city and county officials plan and coordinate the efforts of physicians, hospitals, emergency medical services, military, and other agencies.

"Following Hurricanes Katrina and Ike, San Antonio experienced a flood of people seeking shelter from the storms. BCMS contacted member physicians to notify them of opportunities to provide medical care to those who needed it. County medical societies and their committees make it easy for physicians to get involved and assist the public during times of emergency," Dr. Marks said.

Contact your county medical society to find out how to get involved.

Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email. 

 SIDEBAR 

 West Nile Virus Activity Through September 2012 

                                     Total No. of Cases      No. of Deaths

United States                          3,545                     147
Texas                                     1,355                       52
Dallas County                            341                       17

Source: U.S. Centers for Disease Control and Prevention 

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SIDEBAR
 

West Nile Virus: It Could Happen to You  

By Don R. Read, MD 

I will never be normal like I was before I got sick. I couldn't run if it were an emergency. I cannot ride a bicycle, although I can sort of halfway dance with my wife. I can't carry my grandchildren up the stairs.

I am never sick. I was a perfectly healthy surgeon, working 88.7 hours a week on average. I had missed only four days of work from illness in my 27 years of practice until a mosquito bit me seven years ago. A few days later, on a Tuesday, I was unusually exhausted after performing a colon operation, so I went home and went to bed.

The next morning, I had only a low-grade fever, but I had terrible muscle aches all over. I felt like I was going to die. I thought that if I didn't feel better soon, I would have to go to the emergency department. Fortunately, I starting feeling a little better, so I went to work and did several colonoscopies, after which I had to go home and go back to bed. I canceled all my office patients for the next two days. I felt as though I was carrying a backpack with 1,000 pounds of bricks in it.

Despite feeling like I was going to die, I did not have any localizing symptoms — no sore throat, runny nose, cough, or diarrhea. Thursday morning, while making rounds in the hospital, I ran into one of my infectious disease colleagues in the hall. I told him how I felt and asked him if it could be West Nile virus. He said that it could but that I hadn't had the symptoms long enough to be able to test for it. I told him I was supposed to fly to Indiana in two days to attend my daughter's doctoral organ recital. He said, "Oh, go ahead. If you still feel bad when you get back, we'll run some tests and see if that's what you had."

On Saturday, I flew to Indiana. By that time, I was sleeping 20 hours a day. On the day of my daughter's recital, a week from the onset of my disease, I slept all day, got dressed, videotaped the recital, and then went back to bed. The following morning, I tried to get out of bed, only to discover that my legs were paralyzed. My family took me to the emergency department. By that evening, I was in the intensive care unit (ICU). My legs were completely paralyzed; my arms were mostly paralyzed; I was sleeping 23-and-a-half hours a day. I could not talk. I could not hear. I could not write. I could not even turn over in bed. My legs cramped so badly that I required IV Dilaudid for pain control.

I spent four-and-a-half weeks in ICU, then two months in an inpatient rehabilitation hospital, followed by one month of home care and three months of all-day outpatient rehab. I had to relearn how to walk, how to talk, and how to write. I was out of work for seven months. When I first went back to work, I could see patients for only one hour before I had to go home, exhausted, and go back to bed. It took a year to be able to work 35 hours a week. Because of the residual leg weakness from the polio-like paralysis, I have to wear braces on both legs and therefore had to give up performing abdominal surgery. Although it continues to improve very slowly, my stamina is far from normal. I am happy to be alive, but my body will never be normal again.

Dallas County is using aerial – at the urging of my colleagues at the Dallas County Medical Society (DCMS) and me – to prevent more people from contacting this life-threatening virus. I want to prevent as many people as I can from going through what I did.

Dr. Read is a member of the TMA Board of Trustees. He is past president of the Texas Society of Colon and Rectal Surgeons. 

Reprinted with the permission of KevinMD.com.  

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