Duke University School of Medicine

a woman in a face shield, mask, gloves and full protective gear looks at test tubes on a desk full of science equipment

COVID-19 variants have come to NC. What does it mean?

February 24, 2021 by Hannah Critchfield

COVID-19 variants have come to NC. What does it mean? - North Carolina Health News

Our metrics are looking better statewide, but the arrival of new variants prompts questions about vaccine effectiveness.

By Hannah Critchfield

Even as the numbers of cases, hospitalizations and deaths from the novel coronavirus are dropping in North Carolina, there is a potential dark cloud on the horizon. That’s because, as of last week, both the South African and Great Britain variants of SARS CoV2, the virus also known as COVID-19, have been identified in North Carolina.

The South African variant, known as B.1.351, appears to render current vaccines less effective, and the British mutation is significantly more contagious than earlier strains of the virus that have emerged over the past year.

Due to the limited ability to test and identify variants, the number of people infected with these strains may be higher.

“There are almost certainly more cases than have been identified,” said Dr. Whitney Robinson, professor of epidemiology at the University of North Carolina School of Public Health. ”There could really be a sudden burst of more infections, and we need to be ready for that.”

The first B.1.351 variant in North Carolina, which was identified on Feb. 18, was found in an adult “in the central part of the state who had not recently traveled,” meaning they likely caught it from another person nearby. The B.1.1.7, which originated in the United Kingdom, was first identified in North Carolina in late January.

Frequent variations

Variants are mutations of the original strain of the novel coronavirus, known as SARS-COV-2.

“When you’re typing on a keyboard, and you’re typing really fast, there’s going to be some errors that naturally happen,” said Dr. Ravina Kullar, an infectious diseases specialist and epidemiologist whose family lives in North Carolina. “Viruses are constantly replicating, so the same thing is going to happen — there’s going to be some errors, some words that are not spelled right because you’re typing so quickly. That’s how variants come about.”

Many of these variants lack any discernible difference from the original COVID-19 strain, and don’t make a difference in how sick a person gets from the virus. Sometimes, however, a mutation in the virus’s genomic coding leads it to be more infectious or makes it more difficult for a person to recover from the disease.

The UK variant, for example, appears to have several mutations on its spike protein, the area that the virus uses to attach to cells. It’s believed to be 50 percent more transmissible than the virus first identified in China last year, and 35 percent more deadly.

The U.S. Centers for Disease Control and Prevention predicts the UK strain will become the dominant strain in the U.S. by the end of March.

The more the coronavirus is able to spread, the more likely it is that variants will occur.

“Viruses can’t mutate if they don’t have hosts to copy themselves and make mistakes,” said Dr. Becky Smith, infectious disease specialist and professor at Duke University School of Medicine. “The more people that have coronavirus, the more opportunity there is for mutations to happen, which is natural — it always happens with viruses.”

‘I would be even more cautious’

While vaccines are slightly less effective on one of the variants, at this point, they appear to still be successful in preventing severe disease from the virus.

Still, future mutations could lead to variants that render existing vaccines less effective.

Reducing spread while allowing states time to get everyone vaccinated – a process that has been slowed by everything from bureaucracy to limited vaccine supply to natural disasters such as last week’s cold weather – is critical to curbing the virus’s ability to further evolve.

Shows an electron microscope image of sole COVID virus, dyed yellow with a green corona of spike protiens against a blue background — Transmission electron micrograph of a SARS-CoV-2 virus particle (UK B.1.1.7 variant), isolated from a patient sample and cultivated in cell culture. The prominent projections (green) seen on the outside of the virus particle (yellow) are spike proteins. This fringe of proteins enables the virus to attach to and infect host cells and then replicate. Image captured at the NIAID Integrated Research Facility (IRF) in fort Detrick, Maryland. Photo credit: National Institute of Allergy and Infectious Diseases

“Basically I’m just doubling down on everything I was doing before,” said Robinson. “I’ve been consistent about wearing masks, for example, if I’ve ever in an indoor setting. But I’ve started wearing better quality masks, or wearing a surgical mask with a cloth mask on top of it, to make it fit my face even tighter.”

Because the Great Britain variant is more contagious, everyone now has a greater chance of becoming infected with COVID-19.

“I would be thinking that everyone has that strain, everyone has that variant, so what can you do to protect yourself even more?” Kullar said. “I would be even more cautious about physically distancing when you’re out and about, at the grocery store, et cetera.”

Masks are one area where the public can easily ramp up their prevention efforts, experts said.

The CDC now recommends the public engage in a practice known as “double-masking” – which, if done properly, involves wearing a cloth mask over a medical-surgical mask.

Wearing two masks can both reduce your risk of getting infected and lower your chance of spreading the virus to others.

Limited activity still recommended

In North Carolina, the number of COVID-19 cases is down to pre-Thanksgiving levels, mirroring the drop in infections seen throughout the nation.

As local officials push to reopen indoor dining at restaurants across the country, experts say these venues remain some of the highest-risk settings for transmission of the virus.

“Anything where you’re inside for an extended period of time, meaning greater than 15 minutes, around others whose COVID practices you don’t know, that is of highest risk,” said Kullar. “I don’t think indoor dining is safe yet, especially with these variants circulating around.”

Even if tables are kept six feet apart, studies have shown droplets can travel long distances indoors, particularly if aided by ventilation systems. And by nature, dining requires consumers to take off their masks for extended periods of time.

“Indoor dining was something I wouldn’t do even before the spread of new variants,” said Robinson. “I would advise people if they have been doing it and it seems like it’s been okay, now’s the time to reconsider that — because everything that you do is just a little bit more dangerous now, and unpredictably so.”

Robinson noted that she’s limiting social activities of any kind, dining or otherwise, to outdoor settings.

For employees of these businesses, who are considered frontline essential workers but must wait until March 10 to become eligible for the vaccine, practicing this guidance may be impossible.

“I say do as much protection as you can in that setting, and then really minimize other sources of risk, especially to keep people safe in those settings that you can’t avoid,” said Robinson. “It might be work for some people, or school for others.”

Experts said that in the long term, ordering takeout and trying to reduce the number of indoor customers in these settings is better for both workers and restaurants, which need to shut down each time an outbreak occurs.

Still better than no vaccine

Current research shows the vaccine is less effective on the South Africa variant. This has led some to question whether to even get the vaccine.

The short answer, experts said, is to absolutely get the vaccine.

Vaccines fight against the novel coronavirus by instructing cells to make a harmless piece of the “spike protein” — not by injecting live virus into a person’s body. In response to this spike protein, our immune systems begin building up antibodies. The process teaches our bodies how to protect against future COVID-19 infection.

Existing vaccines appear to be less effective against the South Africa variant because, like the UK variant, it’s undergone changes to its spike protein.

“Enough mutations happened in the coding for that spike protein,” said Smith. “Your antibodies aren’t as specific for it, so they don’t attack it as well.”

The presence of this variant is cause for caution, experts said, but not dismay.

South Africa paused its rollout of the Oxford-AstraZeneca vaccine earlier this month, after finding it substantially reduced protection from mild to moderate COVID-19 illness in people infected with the strain. Yet preliminary data suggests other vaccines are more effective against the South African strain. The African nation has shifted to the Johnson & Johnson vaccine, for example, which is thought to be 57 percent effective in its residents, and 72 percent effective in the United States.

Even among those studied who did contract COVID-19, getting a jab appears to lessen the danger of the virus — not a single person was hospitalized or died.

Moderna and Pfizer vaccines, the only vaccines that have been approved in the United States, appear to prompt the body to release significantly fewer antibodies against the South African strain than other versions of the virus, according to studies released last week. However, while the effectiveness of both U.S.-authorized vaccines against the variant needs further study, they seem to still release enough antibodies to neutralize the virus, companies said.

“We still highly recommend vaccination,” said Smith. “It will still have a very good chance of protecting you – even for the South African variant, we’re seeing that it reduces your chance of getting severe disease.”

Getting vaccinated when it’s your turn is the best way to help curb further spread of existing COVID-19 strains and prevent even more resistant mutations from developing, epidemiologists said.

“Even if it’s not a 97 percent reduction in your probability of infection, but it’s say, a 70 percent reduction, it’s still huge – wouldn’t you want that much reduction in your risk of getting sick?” said Robinson. “And there’s some new, evolving data that vaccines likely lower your risk of transmitting it to others as well.”

This is particularly important when it comes to the South African variant, which may be more likely to reinfect people who have already had COVID-19, increasing the potential reach of its spread.

“We really want to do our best to not have that one become the endemic variety in our country,” said Smith. “Viruses can’t mutate further if they don’t have a host to do it in.

“People should get vaccinated. Having some protection is better than zero protection.”

Smith added that even with reduced efficacy, current COVID-19 vaccines are more effective at preventing infection than annual flu shots offered each year – which tend to be about 40 – 60 percent effective at preventing illness entirely and reduce the risk of an ICU visit by 82 percent.

Participants in a falls prevention workshop look at photos of common household hazards around a white table.

To prevent senior deaths from falls, NC providers turn to exercise and home-proofing

January 22, 2020 by Thomas Goldsmith

To prevent senior deaths from falls, NC providers turn to exercise and home-proofing - North Carolina Health News

Deaths following falls is on the rise among seniors. But keeping up strength and mobility can prevent falls, as can making homes safer for those at risk, say North Carolinians working to counter the trend.

By Thomas Goldsmith

The family tragedy often unfolds something like this — Cousin Lily, who’s 88, falls at home in August and enters the hospital with a broken hip. By Thanksgiving, Lily is gone; dead following complications.

People sometimes don’t realize that Lily could still be living and that older people, in general, can increase their odds of avoiding a hip fracture with some targeted exercise and changes to their homes. That knowledge becomes even more crucial in light of a 30 percent national increase in the rate of falls among older people during a nine-year period ending in 2016, according to the Centers for Disease Control and Prevention.

Precautions are necessary because older people who break their hips face outsize risks: They are five to eight times more likely to die in the first three months after a fracture than otherwise. That increased likelihood of death continues for at least 10 years.

That’s according to researchers including geriatrician Dr. Cathleen S. Colón-Emeric, of Duke University School of Medicine, one of the authors of a widely cited 2010 paper on the relationship between falls and hastened death.

“I think many people have experienced this with older family or friends,” Colón-Emeric said in a phone interview last week. “They’ve seen somebody with this downward spiral after a fracture. A lot of families that I interact with are very aware of this, but it certainly does come as a surprise to others how quickly they see people go downhill.

“Unfortunately, we’re not as good at reversing that once it starts. It‘s much better to prevent the hip fracture from happening in the first place.“

Stronger Together

The continuing toll of fall-related deaths means that lives can literally be saved by efforts such as home visits and education efforts for older people by a group of Meredith University students. The same holds true for Tai Chi-based classes at North Carolina YMCAs in Wilmington and elsewhere.

Meredith student Paige Lawrence and classmates have worked for two years with the Cary-based Center for Volunteer Caregiving on a project called Stronger Together, designed to help older people reduce their risks of falls. She talked last week at a Wake County senior center about the student-led home modifications and evidence-based exercises promoted during visits to a group of low-income people in Wake County.

“They are cool exercises,“ Lawrence told several dozen professionals and caregivers at the workshop at a Wake County senior center. “They seem very simple, but for people who don’t get much exercise, it helps them improve their balance.“

An infographic that describes the most common ways to prevent falls among seniors. — Source: CDC.

The roomful of people kept up with Lawrence and a video as they followed along on a 10-minute, low-impact exercise routine with special attention to balance and to the neck, spine, arms and shoulders. Some used principles of Steadi, a program developed by the CDC to promote the idea that falls among older people are not inevitable.

‘A negative cascade’

People’s medical conditions before a hip fracture and the effects of the injury can both have potentially devastating results, Colón-Emeric said.

“There are a number of chronic conditions of aging that increase your risk of a hip fracture, either through decreasing your bone density, and therefore your bone strength, to make it more likely that if you fall you’re going to break a bone, or by increasing your risk of falls, or both,“ she said.

Countdown on hip fractures

A brochure from the Centers for Disease Control and Prevention lays out information about the realities of hip fractures, which can mean the end of independent living for older people.

CDC statistics and background show that:

Nationally, more than 300,000 people older than 65 are admitted to hospitals because they have had hip fractures, with almost all resulting from falls.
About three of four hip fractures happen to women, who are more prone to falls than men and who often have more brittle bones as a result of osteoporosis.
The older people get, the greater their chance of sustaining a hip fracture.

A graph that shows that fall death rates in the US increased by almost a third from 2007 to 2016 for older adults. — Source: CDC

People with dementia, for example, have a low bone density as well as an abnormal gait that goes along with their brain issues. Among other groups with low bone density are people with Parkinson’s disease, chronic lung disease, congestive heart failure and kidney disease.

“People with diabetes have actually paradoxically higher bone density, but a higher fracture risk because they have a greater risk for falling,“ Colón-Emeric said.

In addition, people caught in the “negative cascade“ that can follow falls may experience depression, broad inflammation and loss of mobility.

*Two-thirds of people will never regain the same level of mobility after hip fracture,* she said.

How to stay strong

Encouraging people to stay strong and prevent falls becomes the role of people like Bridget Carroll, a community health program coordinator at the YMCA of Southeastern North Carolina.

The facility in Wilmington keeps two 24-week balance classes going at once, with participants working on exercise day to day at home.

Women raise their hands in a classroom, which has a fall prevention workshop — Participants in a falls prevention workshop exercise along with a presenter from Meredith College at the Five Points Center for Active Adults. Photo credit: Thomas Goldsmith.

“We do an assessment in what we call the welcome class and we do the same assessment at the very last class,’’ Carroll said. “The biggest take-home has been that the class has been shown to reduce the risk of falls by 65 percent.”

Participants in classes at the Wilmington Y range in age from about 50 to 90, with an average of 65. The Moving for Better Balance program is based on proven methods and uses Tai Chi moves as well as more conventional exercises.

In Wake County, the two-year Meredith program has concluded, but participants won’t be abandoned.

“We left them with an exercise packet, encouraging them to exercise once we left,” Lawrence said, noting that participants will also have continuing reinforcement through visitors from the sponsoring Center for Volunteer Caregiving.

Fall-proofing the home

Another key means of preventing falls involves taking a close look at an older person’s living quarters for hazards such as scatter rugs and slippery bathtub accessories. John Abernethy, 76, attended the Raleigh workshop looking for tips on safekeeping for his wife, Judy, 77, who had a stroke years ago. Recently, she had a fall, only from the height of a sofa, that produced a compressed vertebra, he said.

Abernethy and other caregivers each mentioned particular scenarios, not necessarily foreseeable, that could cause problems.

“The shower mat that I bought was OK, but a better one had a lot more suction cups on the bottom,“ he said. “It doesn’t move.“

Workshop attendee Carolyn Casey, 50, of Raleigh, keeps up with her dad, Bill, who lives by himself. Their problem: Bill takes his hearing aids out at night and can’t hear or find the phone, even if he falls out of bed, Casey said. What could she do?

“Alexa!“ came a chorus of voices. “He can say, ’Alexa, call my daughter!’“

Finally, caregivers and physicians both should take an older person‘s medications in account when trying to ensure her safety.

“Older adults are on a number of medications and some of those can increase your

chances of falling,“ Colón-Emeric said. “And some of those can affect your bone density. So it’s a good idea to have your physician review your medication list with an eye toward minimizing medications that might make you more prone to fall.’’

A person in a sports cap holding a needle box to be packed away and delivered to needle exchange participants. Dunlap says they meth use never went away in Haywood County.

Even as opioids ravage WNC, mountain folks say meth never went away

December 3, 2019 by Liora Engel-Smith

Even as opioids ravage WNC, mountain folks say meth never went away - North Carolina Health News

While the current conversation surrounding drug use is dominated by opioids, residents in North Carolina’s Appalachians say meth has always been there.

By Liora Engel-Smith

Jesse-Lee Dunlap goes where not even the mail carrier does. The Haywood County resident, who works with the N.C. Harm Reduction Coalition, routinely navigates into dirt pathways so narrow they hardly count as roads.

On a recent afternoon, Dunlap maneuvered a white rental van up one such trail, squeezing up a steep hill past a row of faded mailboxes. The 38-year-old parked the vehicle near a mobile home surrounded by shaggy bushes — the first supply drop of the afternoon.

Dunlap hopped out of the van, greeting the people who clustered on the driveway, then popped the trunk to pull out care kits that volunteers put together earlier that day. The brown bags and boxes had band aids and other wound care items, vitamin C packets and tiny cotton balls through which to filter drugs. There were also dozens of 30-gauge syringes, the type a diabetic person might use.

Related: A new meth surge gathers momentum

But the people in the quiet neighborhood in Clyde, a town of almost 1,300 roughly 25 miles west of Asheville, aren’t getting needles because they’re diabetic.

There’s been much talk about drugs in Appalachia, particularly as opioids — first prescription pills, then heroin and its much deadlier cousin, fentanyl — tore through already distressed mountain communities. But even as state and federal agencies set their sights and budgets on ways to combat the opioid epidemic, another drug is wreaking havoc in Western North Carolina: methamphetamine. A stimulant that rose to national infamy in the 1990s and early 2000s, meth has been part of life here for years.

Residents say that even as opioid misuse blossomed, meth never went away.

‘THE drug’

Out of the shaded porch came Carrie Brayson, who grew up in the nearby community of Waynesville. Her eyes light up as she spots Dunlap. Having been part of the needle exchange since 2017, Brayson has come to trust the program. Dunlap comes around roughly once a week to collect used syringes and replace them with fresh ones.

The two chat amicably as Dunlap gathers the packages.

A map of counties in the Appalachian region showing fatal overdoses from all drugs, including meth — Drug overdose deaths in Appalachian Counties from 2013-17. Source: Appalachian Regional Commission

To explore the map further, visit the Appalachian Regional Commission.

Brayson shifts her gaze from Dunlap to the mountains that tower over her neighborhood. It’s a view that draws countless tourists to Haywood County and the mountain region. In 2013, domestic tourists generated $155.38 million for the county’s economy, up almost 5 percent over the previous year.

But not everyone in Haywood benefits from those tourist dollars. Many employment options in the county are low-wage service or retail jobs. And while the county’s older population is generally wealthier, families with children experience significant poverty, the county’s 2018 community health assessment shows. The 2017 Census figures quoted in the report show that Haywood’s overall poverty rate is roughly 17 percent, but close to half of children under five live in poverty here.

The mountains may be pretty, Brayson said, but life here has significant disadvantages. Social services can be hard to come by. With limited transportation options, those who don’t have cars either have to walk or hitch rides from friends and family members.

The view from a Clyde neighborhood, a part of an area with people who are using meth. — Carrie Brayson’s home in Clyde is atop of a hill that overlooks the mountains. Photo credit: Liora Engel-Smith

Brayson, who says she used to be a nurse, came to drugs by a way of opioid pills at age 18. Later, she sought recovery and managed to stay clean for seven years. After her dad died, Brayson started using meth. The 37 year old said it was the lesser of two evils. Coming off of opioids was a horrible experience, she said, and she vowed to never take an opioid pill again.

“A lot of people think it is definitely heroin that is a problem, but meth, you can’t OD on it,” Brayson said. “It’s cheaper and lasts longer and gives you energy to where you can still maintain. You can still go to work.”

Dunlap, who knows many other people who use drugs in the county, said that a significant proportion prefer meth. Out of roughly a hundred clients who participate in the exchange, roughly three-quarters use meth, according to Dunlap.

And though some meth is now tainted with fentanyl, a synthetic painkiller 50 times more potent than morphine, the stimulant remains popular. So does the belief that it is safer.

“Meth is THE drug here,” Dunlap said.

‘You get some stuff done’

Overdosing on meth is not impossible, said Cynthia Kuhn, professor of pharmacology at Duke University School of Medicine. Methamphetamine gives its users energy, she said, keeping them awake for prolonged periods and sometimes causing hallucinations and paranoia.

“You can absolutely overdose and die with a methamphetamine,” she said.“I think what helps people titrate, to dose a little bit better, is the behavioral excitement that you feel can allow you to sort of track the dose that you’re getting.”

There's a building with an orangish-red roof. Behind it are mountains, and in front of it is a busy parking lot with many vehicles. It's the Haywood County Health Department where the needle exchange for the county stores supplies. Haywood County has seen consistent meth use despite opioids' surge — The Haywood County Health Department serves as a needle distribution site, but volunteers also travel to participants across the county. Photo credit: Liora Engel-Smith

Over time, methamphetamine can damage the cardiovascular system and in large quantities, it can cause a heart attack or a stroke. Unlike the high that opioids create for a user — a sleepy, dreamlike state that can also depress breathing — meth supplies a frantic, hyper-focused high.

It’s those stimulating qualities that can allow meth use fly under the radar, Dunlap said.

“[People who use meth are] more productive,” Dunlap said. “You’re not seeing this person that’s injecting something and nodding out and going to sleep, you see someone that’s working two jobs because that’s what you do when you’re on meth — you get some stuff done.”

A numbers problem

It’s hard to quantify exactly how common meth use is in Haywood County. National studies have noted a rise in meth use, either alone or in combination with opioids, but state data on indicators of meth use such as overdoses and hospitalizations aren’t reported as frequently as opioid data. North Carolina updates its opioid dashboard monthly, but methamphetamine-related deaths are clustered with other psychostimulant drugs — methamphetamines, Ritalin, Adderall and ecstasy — and these are updated once a year. The most recent year for which data is available is 2018.

Haywood County had seven fatal overdoses from psychostimulants in 2018, and a total of seven such deaths from 2009-2017, the data show. In that same timeframe, psychostimulant use caused at least 69 hospitalizations in the county, 12 of which occurred in 2018.

A representative from the state Department of Health and Human Services said in an email that the data focuses on the harm of opioids because these drugs make up the bulk of the deaths in North Carolina. But the data show there has been a rise statewide in deaths from psychostimulants, from nine in 2009 to 267 in 2018. Because of that surge, the spokeswoman wrote, the department plans to release a monthly medication and drug emergency department visit report for psychostimulants and cocaine — another drug with increasing impact in the state — beginning next year.

Whether the data capture it or not, there are telltale signs that meth is available on demand in Western North Carolina. Though law enforcement agencies in Clyde and Haywood County did not respond to interview requests for this story, there are news reports of recent meth busts and arrests across the region. Last year, the Haywood County Sheriff’s Office also told local media that methamphetamine use is a persistent problem.

“You don’t have many people overdose on meth,” one law enforcement officer told the Mountaineer. “You don’t have that dramatic incident in their life like you do with an overdose of opioids.”

Those who use it have largely moved away from producing small quantities of meth in local labs, according to the article. Instead, most of the county’s meth supply comes from Atlanta.

Up until a few weeks ago, Brayson was among the group that’s driving local demand for meth. She had said she wasn’t ready to give up meth.

“If you’re not ready, you’re wasting their time, you’re wasting your time,” she said. “I will know when I’m ready.”

But that’s changed, according to Dunlap who said Brayson has been sober for weeks. Further, she’s been helping Dunlap distribute needle exchange supplies.

Nestled in every needle exchange kit are pamphlets with local recovery resources. Those who receive the kits may not be ready for recovery yet, but they may change their minds. And when they do, Dunlap wants to be sure the information they need is at their fingertips.

A man leans down with a stethoscope to listen to a child's lungs or heart.

After Florence, Medical Relief Team Serves Migrant Farmworkers

October 2, 2018 by Taylor Knopf

After Florence, Medical Relief Team Serves Migrant Farmworkers - North Carolina Health News

Migrant farmworkers often live in poor housing conditions, have little access to health care, and high rates of workplace injuries and illnesses. Natural disasters exacerbate these problems.

By Taylor Knopf

Hurricanes typically hit poorer, more vulnerable populations the hardest.

So a week after Florence, a medical mission team based out of Toledo, Ohio traveled to eastern North Carolina specifically to serve migrant farmworker communities.

Hurricanes or natural disasters tend to worsen existing health care and housing issues for farmworkers, said Justin Flores, vice president of Farm Labor Organizing Committee (FLOC), a multi-state agricultural worker organization.

A make shift tent with tables underneath is held down by a car to the left of the picture as people walk around underneath. — Dr. Richard Paat, who heads the medical missions out of the University of Toledo, walks through the makeshift relief clinic set up outside a latino business in eastern North Carolina to serve migrant farm workers after Hurricane Florence. Photo credit: courtesy of Farm Labor Organizing Committee (FLOC)

FLOC is also based in Toledo, Ohio, but has a strong presence in North Carolina. Flores spends his time in Charlotte and in Dudley, where the group’s North Carolina headquarters are located.

Farmworkers often dwell in housing units supplied by growers, Flores noted, and he said many depend on their employers for rides anywhere.

“Your employer has a lot of say over when and where you get health care,” he said. “So those issues already exist and a hurricane just adds to that.”

Access to care also varies county to county in North Carolina, and he said some farmworkers are able to physically get to low-cost health clinics. But after transportation difficulties, low wages also makes it difficult to pay for, and receive, care.

A medical student wearing blue scrubs listens to a patient's heart. — Ferdinand Jose Melendez Padilla, a fourth year medical student from Puerto Rico, joined the medical mission team that served migrant farm workers in eastern North Carolina after Hurricane Florence. Photo credit: Farm Labor Organizing Committee (FLOC)

There are a lot of workplace injuries and illnesses, Flores noted, such as green tobacco sickness, exposure to pesticides, stress, falls and snake bites.

Major hurricanes such as Florence wipe out a lot of the crop fields, and for farmworkers, it can result in a loss of work, wages and sometimes housing. Flores said some workers will be without work for a week or two after the storm.

The 83rd mission

Richard Paat, clinical professor of medicine at the University of Toledo College of Medicine, runs the school’s global medical mission team.

When Paat heard from Toledo-based FLOC staff about the migrant farmworkers in Florence’s path, he gathered a medical mission team – the 83rd group to go out to deliver care. Some missions are scheduled annually to places such as Honduras and Guatemala, others occur in the aftermath of natural disasters such as Puerto Rico after Maria and Texas after Harvey.

Stark reality

Over the course of three days, the team saw about 300 patients. The first day they set up at the FLOC building, the second day outside La Tropicana Mexican market in Clinton, and the third they split into mini teams and visited farmworker camps.

A young women in blue scrubs listens to a child's back using a stethoscope under a makeshift outdoor medical clinic. — Mariah Truscinski, a fourth year medical student from the University of Toledo, treats children of migrant farm workers in eastern North Carolina during a medical mission following Hurricane Florence. Photo credit: courtesy of Farm Labor Organizing Committee (FLOC).

Paat said he often sees upper respiratory infections and skin issues following a hurricane, as well as anxiety and depression. And with the migrant workers, Paat said he saw green tobacco sickness for the first time.

They informed people about the clinics through FLOC and put up flyers in local Latino businesses. All clinic visits and medications are free to patients. Paat said he tries to remove all barriers to care during these relief missions.

When visiting the migrant worker housing on the last day, Paat said he was hit by a “stark reality.”

They drove past the growers’ residences first, which Paat said are always very nice. Then they passed the stables, which he said are well-kept. Up next are the farmworker housing units.

“Then you realize the horses have better homes than the migrant workers,” Paat said.

The migrant farmworkers also have complex mental health needs. Paat said his team encountered high rates of depression and anxiety stemming from fear of being deported, legal issues with their employers, poor living conditions, and family separation.

A young man wearing scrubs and facing the camera talks to two women at a hurricane relief clinic in eastern North Carolina — Martin Roldan Auffant, a third year medical student from Puerto Rico, helps the migrant farm worker community after Hurricane Florence. Photo credit: Courtesy of Farm Labor Organizing Committee (FLOC).

Others talked about the loss of crops, jobs and wages resulting from Florence.

“I heard the tobacco was mainly gone. They were hoping the sweet potato crop would come in,” Paat said. “And a lot were looking to work in the Christmas tree industry coming up.”

He said many use alcohol as a way to treat their depression.

Treating mental health issues for this population is difficult, Paat said. In some cases, his team could prescribe a three-month supply of antidepressants or anxiety medication. Permanent North Carolina residents have the option to see a local provider.

But for a number who are seasonal employees, often moving from place to place, it can be more difficult to obtain and maintain treatment.

Before and after

As for pre-storm warnings, FLOC worked to get the word out about shelters and resources through emails, text chains and Facebook posts to the 10,000 farmworkers the organization represents.

Flores said he got the sense that Spanish language messaging and advisories ahead of Hurricane Florence were better than for Matthew in 2016, which he attributes to the projected magnitude of the storm.

Employers are responsible for evacuating farmworkers if necessary. And Flores said FLOC put the word out to members to report those bosses who didn’t help with evacuation.

Overall, with the exception of maybe one or two, Flores said employers did a good job of doing what they were supposed to do.

FLOC had volunteers at the clinics to help people who wanted to apply for FEMA assistance.

But people who may qualify for assistance through a U.S. citizen child sometimes are hesitant to do so. The applications require lots of information and for migrant workers who are undocumented, it can be intimidating, he said.

a woman and man stand side by side wearing matching FLOC T-shirts at an outside of tents containing a medical clinic — Jackkie Castillo, a farmworker and FLOC organizer with Justin Flores, vice president of FLOC help out at a medical mission clinic for migrant farm workers in eastern North Carolina after Florence. photo credit: courtesy of Farm Labor Organizing Committee (FLOC)

shows a pink piggy bank wearing stethoscope and the listening end of the stethoscope is on a dollar bill, spending, money

Study: Fewer Cancer Patients Uninsured after Obamacare Implemented

October 24, 2017 by Taylor Knopf

Study: Fewer Cancer Patients Uninsured after Obamacare Implemented - North Carolina Health News

The study from Duke University found that patients in states that expanded Medicaid were about half as likely to be uninsured and unable to pay for cancer care.

By Taylor Knopf

A recent Duke Cancer Institute study found that the number of uninsured cancer patients dropped by half in states that chose to expand Medicaid under the Affordable Care Act.

The expansion particularly benefited minority and low-income patients living in expansion states. North Carolina is one of 19 states that have not expanded Medicaid, which was allowed for under the ACA.

Photo of a woman in red-framed glasses looking at the camera. She's wearing a white physician's jacket. — Fumiko Chino. Image courtesy: Duke University

Lead author of the study Fumiko Chino, a fourth year radiation oncology resident at Duke University school of medicine, summed up the study saying, “Do you want more or less uninsured cancer patients? If less, then the ACA works.”

Chino’s study is in the process of being peer-reviewed, and results are not yet published. She presented her findings last month at the annual American Society for Radiation Oncology (ASTRO) meeting in San Diego.

She and her co-authors examined information from more than 197,000 records in the National Cancer Institute database of cancer patients ages 18 to 64 who received radiation treatment between 2011 and 2014.

The study includes all forms of cancer and radiation treatment. Chino said they looked at smaller groups such as breast and lung cancer patients, but did not find compelling differences in the data.

Rates of cancer patients receiving radiation who were uninsured dropped from 4.4 percent to 2.1 percent between 2011 to 2013 and the first year of the Medicaid expansion in 2014. A lot of those patients ended up on Medicaid, enrollment went up from 15.2 to 18 percent in those states.

“Rates of uninsured cancer patients in states without Medicaid expansion also declined,” the study preview reads. “But in these states, improvements appeared to primarily benefit white patients and residents of low-poverty areas, with a portion transitioning to non-Medicaid health insurance.”

Chino said she suspects that these patients were able to find individual plans in the ACA exchanges.

She and her colleagues also found Medicaid enrollment for cancer patients receiving radiation dropped in states that did not expand, going from 15.9 percent to 14.9 percent.

shows 19 states, mostly in the South, with some midwestern states, Wisconsin and Maine have not expanded Medicaid. — Current status of state Medicaid expansion decisions. Image courtesy: Kaiser Family Foundation

In ACA-compliant plans, there are essential benefits guaranteed. Chino said many cancer patients also deal with mental health issues such as depression and anxiety. She said her patients are terrified of losing coverage.

“With the increasing level of ACA sabotage that’s going on, we are chipping away at some of the gains we were making,” Chino said. “We are setting up people to buy sham insurance.”

She said the recent increase in insurance coverage will likely lead to better in mortality rates for cancer patients.

“President Trump has been honest about it. He wants the ACA to fail,” Chino said. “If it can’t happen legislatively, it’s clear they are trying to do it through executive order.”

“That’s sad for me as a cancer doctor because the ACA has helped out my patient population,” she added.

Data-Driven Environmental Detective

December 9, 2016 by Catherine Clabby

Data-Driven Environmental Detective - North Carolina Health News

Duke scientist and collaborators hunt for health risks in records collected for other purposes in North Carolina

By Catherine Clabby

Assessing how your zip code affects your health or your life expectancy is a tough puzzle.

But analyze the right population-scale data, and lots of it, and important clues will emerge.

That’s what Julia Kravchenko is finding. Kravchenko is a Duke University research scientist and physician investigating health differences among people living in unusual environments in North Carolina.

For instance, Kravchenko and collaborators are finding that people residing in North Carolina zip codes hosting densely packed hog farms are more likely to die from one of a host of diseases than are people who do not.

Those diseases include hypertension, aplastic anemia, diabetes and asthma, with the higher mortality persisting even when researchers account for population-level rates of smoking, income, education, whether people have health insurance and other factors.

Julia Kravchenko. Photo courtesy: Duke University

Residents of counties hosting coal ash waste dumps are more likely to die from Alzheimer’s disease than people living in counties without them, the researchers are also finding. The more waste, the greater the difference.

Let’s be clear: Kravchenko’s preliminary findings do not prove cause and effect. But the results are signals that Kravchenko hopes can be used to improve the aim of studies trying to link environmental exposure to health.

“We’re at the beginning. We’re just describing the problem,” Kravchenko said.

Big data

The Belarus-trained researcher has already successfully demonstrated strong links between environment and health in this state on a decidedly more positive note.

A study she and colleagues published in 2014 found improved air quality in North Carolina accompanied declining death rates from respiratory illnesses such as emphysema, asthma and pneumonia. They did the analysis by comparing mortality trends from state public health data, along with monthly measurements from air-monitoring stations across the state from 1993-2010, capturing changes following passage of the state’s 2002 Clean Smokestacks Act.

“Julia has been a tremendous asset in the field of environmental health research in North Carolina,” said June Blotnick, executive director of CleanAir Carolina. “We have evidence-based research that shows North Carolina’s landmark bipartisan legislation was successful.”

Kravchenko first explored exposure risks in her native Belarus, where she worked at the Institute of Radiation Medicine. There, she helped assess harm from radioactive exposures among clean-up workers and citizens after the 1986 Chernobyl nuclear power plant disaster.

In her work at Duke, Kravchenko collaborates with experts in medicine, epidemiology, data analysis, environmental sciences and public policy to explore risks in the U.S. and abroad. A primary strategy is to mine trends visible in large masses of data that governments collect for other purposes, such as statistics on diseases that prompt hospital admissions, causes of death, air and water pollution monitoring results, cigarette smoking rates, locations and size of hog-raising operations, and data on the tons within coal-ash impoundments.

“The use of ‘big data’ type analysis is important because it leverages and uses in a timely and cost effective manner data that currently exists and is being collected in an ongoing fashion,” said Kim Lyerly, a Duke School of Medicine professor who runs the university’s Environmental Health Scholars program and conducts research with Kravchenko.

“This allows us access to massive amounts of data, which would be cost- and time- prohibitive if we were going to prospectively collect and pay for the collection and storage.”

Environmental differences

When Kravchenko presented preliminary data at the health scholar program’s 2016 Fall Forum, she described ways that counties hosting concentrated animal feeding operations (CAFOS) and coal ash waste might also house distinctive risks.

North Carolina is home to roughly 8.6 million farmed pigs. Many of the pigs are kept in confined shelters, producing malodorous waste that can harm nearby residents. Photo courtesy of U.S. Environmental Protection Agency

Densely packed hog farms produce large amounts of manure that can carry pathogens such as E. coli, growth hormones, antibiotics and traces of chemicals used on farms, she explained. And coal ash can contain heavy metals such as arsenic, lead and mercury. In both settings, unwelcome emissions can reach air and water.

But sorting out how either affect people’s health is not simple, Kravchenko stressed. When it comes to the Alzheimer’s disease death indications, it’s important to consider that natural geologic condition produce arsenic in parts of North Carolina, an exposure that can do neurological harm. Studies comparing Alzheimer’s disease among people living near coal ash without natural arsenic could help clarify that risk, she said.

In addition to environmental differences, people who live in counties with large hog farms tend to be poorer than residents in counties that do not. They may have less access to health care, something that needs to be explored and, if confirmed, remedied, Kravchenko said.

To get a better sense of environmental risks from concentrated animal feeding operations (CAFOS), Kravchenko and collaborators intend to use public databases of emissions monitoring results to tackle more detailed studies about what known pollutants are present in the water and air nearby.

She believes the scale of hog farming in this state requires that sort of closer look.

“Almost 200,000 people are living in areas with more than 50 pigs for each human,” Kravchenko said.

Ultimately, she wants her projects to produce sound data that are useful to policymakers and people trying to decide where they will live and raise families. Ideally they could help specify what locations are safer than others.

“Our main objective is to provide people with knowledge,” Kravchenko said.

Additional Thanks

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