Monday, September 28, 2020

Guest Post: A New Approach to Preventing Firearm Injuries

- Gregory Engel, MD, MPH, FAAFP 

As family physicians, we see the effects of firearm injuries every day in our clinics and hospitals. We treat not only the bullet wounds but also their myriad consequences for patients and their families. At this year’s annual meeting, the AAFP House of Delegates will consider a resolution in support of creating a National Bureau for Firearm Injury Prevention. The resolution, passed by the King County Academy of Family Physicians and the Washington Academy of Family Physicians and supported by the King County Medical Society, addresses the fact that, in spite of rising firearm fatalities over the past two decades, our country lacks a comprehensive, coherent, long-term public health-based strategy to prevent the 40,000 fatal and 80,000 nonfatal firearm injuries that occur in the United States every year.

The United States has successfully faced a long-term challenge of this magnitude before. In the 1960s, the National Highway Safety Bureau - an agency dedicated to reducing motor vehicle injuries and deaths – reduced the motor vehicle death rate by two-thirds. Analogously, a National Bureau for Firearm Injury Prevention would lead a comprehensive, long-term, public health-based effort to reduce firearm deaths and injuries. Like the National Highway Safety Bureau, the National Bureau for Firearm Injury Prevention (NBFIP) would take the lead in setting the nation’s research agenda and developing, testing, and implementing firearm safety technologies. It would oversee campaigns to encourage behaviors likely to reduce firearm injuries, set out legislative priorities for saving lives, and direct priorities for enforcing firearm laws. Importantly, as a single agency dedicated to reducing firearm injuries, the NBFIP could coordinate the synergistic action of research, technology, public awareness, and legislation.

Momentum toward this approach has been building. Washington’s governor recently signed a law creating the country’s first state Office for Firearm Violence Prevention. Grassroots organizations throughout the country, like States United to Prevent Gun Violence, have endorsed as well.

As family physicians, we are the center of this health issue; it is our duty to do our part to safeguard the health of our patients and our communities. Creating a National Bureau for Firearm Injury Prevention is the most effective way to reduce firearm deaths and injuries in the decades to come.

Dr. Engel is a Copello Health Advocacy Fellow and serves on the National Steering Committee for Gun Violence Prevention. He is an attending physician at Samuel Simmonds Memorial Hospital in Utqiagvik, Alaska.

Monday, September 21, 2020

Coronavirus vaccine is unlikely to be a "magic bullet" that ends the pandemic

 - Kenny Lin, MD, MPH

Last week, federal health officials announced an ambitious plan to begin free distribution of a vaccine against SARS-CoV-2 within 24 hours of its approval or emergency authorization from the U.S. Food and Drug Administration (FDA). That an efficacious vaccine could, remarkably, become available less than one year after the isolation of the virus that causes COVID-19 is due in part to a public-private program to accelerate vaccine, diagnostic test, and therapy development led by the U.S. Departments of Defense and Health and Human Services known as "Operation Warp Speed." In a New England Journal of Medicine commentary, Drs. Moncef Slaui, Shannon Greene, and Janet Woodcock reviewed the progress of Operation Warp Speed on multiple fronts, including the most promising candidate vaccines in phase 2 and 3 clinical trials. Ultimately, though, the impact of any vaccine on the course of the pandemic in the U.S. and abroad will depend not only on how protective it is against infection and disease transmission, but how the allocation of initially limited supplies is prioritized (e.g., health care and essential workers, vulnerable groups) and what proportion of the population agrees to receive it in the absence of a requirement to do so.

A simulation study in the American Journal of Preventive Medicine estimated the efficacy and percent population coverage that a coronavirus vaccine would need to extinguish the epidemic in the absence of other public health measures such as social distancing and wearing face coverings - in other words, what it would take for a vaccine to allow life to "go back to normal." The effects of a vaccine on productivity losses, hospitalizations, medical costs, and deaths vary depending on what percentage of the population has already been exposed to SARS-CoV-2; one seroprevalence survey from late March to mid-May found a range from 1% to 7% at 10 sites in the U.S., but these figures are likely to be higher four or more months later. To extinguish the epidemic after 5% of the population has been exposed, for example, the AJPM researchers calculated that a vaccine would need to have at least 80% efficacy if administered to 75% of the population.

Unfortunately, expecting any of the coronavirus vaccines in development to have 80% efficacy is unrealistic.  By comparison, the Centers for Disease Control and Prevention (CDC) estimated that the 2019-20 influenza vaccine was only 45% effective, consistent with the 40-60% range in previous years when the available vaccines were antigenically matched to circulating influenza viruses. The highest influenza vaccine coverage was during the 2018-19 season, when 63% of children (state range, 46%-81%) and 45% of adults (state range, 34%-56%) received the vaccine. Although some may be more willing to be vaccinated against SARS-CoV-2 than influenza due to the former's greater morbidity and mortality, influenza vaccine also has a long safety track record that a coronavirus vaccine would not.

It is possible that public health measures in place to slow the spread of COVID-19 will substantially reduce the impact of influenza during the 2020-21 season. A CDC surveillance report showed that U.S. cases of laboratory-confirmed influenza fell sharply after the national COVID-19 emergency declaration on March 1, reflecting not only the natural waning of the flu season but also mitigation interventions implemented by states around this time. In the Southern Hemisphere nations of Australia, Chile, and South Africa, where influenza activity normally peaks in June or July, COVID-19 mitigation was associated with a near-complete suppression of influenza circulation.

For family physicians, preparing for flu season during the COVID-19 pandemic, with a coronavirus vaccine potentially around the corner, means adapting to many uncertainties. What hasn't changed from previous years is that the CDC's Advisory Committee on Immunization Practices continues to recommend influenza vaccination for all people six months and older who do not have contraindications, ideally by the end of October. Whenever it arrives, the coronavirus vaccine is unlikely to be a "magic bullet" that ends the pandemic on its own. So it's critical that clinicians all continue to echo the message about cloth face coverings that CDC Director Robert Redfield, MD delivered at a recent Senate hearing: "These face masks are the most important, powerful public health tool we have" for controlling the pandemic.

Monday, September 14, 2020

Preparticipation physical exam and return to sports during the COVID-19 pandemic

 - Kenny Lin, MD, MPH

For primary care practices that care for children, the preparticipation physical exam (PPE) is an annual rite. My residency program usually sets aside two full days in late summer where the residents and attending physicians do nothing but "sports physicals" in order to meet the demand for these exams from prospective high school athletes. Although the utility and effectiveness of this traditional evaluation has long been debated - a 2019 AFP article on Right Care for Children included the PPE in its list of overused interventions - many clinicians also use the time to address non-sport related issues, making the visit "a potential preventive care entry point and an opportunity to provide routine immunizations, screen for other conditions, and provide anticipatory guidance." Last year, the American Academy of Family Physicians, the American Academy of Pediatrics, and several sports medical societies published the 5th edition of the Preparticipation Physical Evaluation monograph, which was summarized in the June 1 issue of AFP.

The COVID-19 pandemic closed schools and cancelled youth sports nationwide beginning in early March. As schools are now reopening in virtual, in-person, and hybrid models, some students are also returning to competitive sports. To address the medical needs of these athletes, the American Medical Society for Sports Medicine (AMSSM) recently released Interim Guidance on the Preparticipation Physical Exam for Athletes "to provide clinicians with a clinical framework to return athletes of all levels to training and competition during the pandemic."

In addition to the physical risks inherent in playing a sport, student athletes now must also be concerned about minimizing their risk of contracting SARS-CoV-2 where maintaining physical distancing is not possible. The AMSSM notes that unlike professional teams, high school and most college teams will not have the resources to perform testing, contact training, and quarantine. It advises discussing COVID-19 risks in detail with the patient and family at the time of the PPE, and considering factors "such as the disease burden in the community, the overall health of the athlete, the living environment, [and] each athlete's network of friends and family members who have have comorbid conditions" in the decision to play.

Athletes who have apparently recovered from COVID-19 "may have silent clinical pathology in any organ, including the heart," and consequently "should be evaluated in their medical home prior to resuming physical activity and organized sports." Table 2 in the guidance document (p. 27) outlines the recommended cardiopulmonary evaluation in athletes with prior COVID-19 infection, depending on the specific clinical scenario.

The AMSSM also provides guidance on specific conditions that may pose an increased risk for severe COVID-19, including pregnancy, diabetes, hypertension, asthma, and severe obesity. Although athletes with sickle cell trait are not at higher risk for adverse outcomes in general, they may have an increased risk of hypercoagulability complications for several months after recovery.

Monday, September 7, 2020

Introducing the 2020-2021 AFP Jay Siwek Medical Editing Fellows: Dr. Natasha Pyzocha

Jennifer Middleton, MD, MPH

It's my pleasure to introduce our second 2020-2021 Jay Siwek Medical Editing FellowDr. Natasha Pyzocha, whose fellowship year also began on June 1. Here are some highlights from a recent interview:

1. Tell us a little about yourself and your background.

I was born and raised in a small town in New Hampshire and my childhood was filled with memories of adventuring outdoors. I enjoyed the sciences and thought I’d become a palentologist, veterinarian, or doctor. After tearing my anterior cruciate ligament playing soccer, I enjoyed seeing the impact that doctors could have on an individual. I shadowed our local Family Physician, volunteered in domestic and international hospitals, and during college fell in love with the profession. I always had an interest in the military as well, so I joined the Army through the Health Professions Scholarship and attended medical school at the University of New England College of Osteopathic Medicine.

After medical school I was fortunate enough see many parts of the world. Most notably, I enjoyed my time during residency in Washington and as a Flight Surgeon in Colorado. Treating soldiers and their families was the best, but running aid stations with my medics and flying in helicopters was awesome as well. During my time in the Army, I also worked with the World Class Athlete Program and now continue to volunteer with the United States Olympic Committee. I’ve enjoyed teaching medics, medical students, peers, or anyone will listen throughout my various jobs and am currently working as adjunct faculty at Rocky Vista University College of Osteopathic Medicine. My most recent employer is a primary care telemedicine company and I’ve enjoyed the technical component of modernizing medicine.


2. What got you interested in medical editing and writing?

In residency, part of the graduation requirement was scholarly activity, so as an intern in an attempt to knock out my preconceived notion of a ‘check the box’ event, I fell in love with being able to learn from others and make an impact on education. Many of my Army residency faculty were so inspirational that I owe my initial interest efforts to them. I still continue to collaborate with some of these physicians on a regular basis! Even though the writing requirement is no longer there, I’ve continued to enjoy it so much I sought out the fellowship.


3. What are you hoping to get out of the fellowship?

Personally, I aim to refine the skills I have in both writing and editing by learning from a highly experienced editorial team. Writing for the different departments for AFP will increase my ability to think outside the box and become intimately involved in different styles of writing. Ultimately though, I hope to make an impact and inspire other Family Physicians to become leaders in writing. 


4. Is there anything else you'd like AFP readers to know about you?

In my free time I enjoy skiing, snowboarding, hiking, biking, and paddleboarding with my husband, two year-old daughter, and two dogs. I’m looking forward to safe travel again in the future! I am a Fellow of the Academy of Wilderness Medicine and also am a physician volunteer with the United States Ski and Snowboard Association.