Monday, November 21, 2022

How health care can break the "harm-treat-harm" climate emissions cycle

At the 27th United Nations Conference of the Parties (COP27) conference that concluded in Egypt yesterday, participants agreed that wealthy nations would provide financial aid in the form of a "loss and damage" fund to developing countries to reduce carbon dioxide emissions and mitigate climate impacts. Climate injustice, "a term used to describe the situation in which countries that contribute the least to the climate crisis nevertheless pay the highest price," is ever-present in the African continent, which has contributed only 3-4% of all emissions but suffers disproportionately from the resulting heat waves, droughts, scarcity of food and drinking water, and coastal flooding.

In an October 19 editorial that was simultaneously published in more than 200 health journals, following last year's editorial on the climate emergency, the editors-in-chief of African journals highlighted the ongoing health impacts of climate change in their countries:

Droughts in sub-Saharan Africa have tripled between 1970–1979 and 2010–2019. In 2018, devastating cyclones impacted 2.2 million people in Malawi, Mozambique, and Zimbabwe. In West and Central Africa, severe flooding resulted in mortality and forced migration from loss of shelter, cultivated land, and livestock. Changes in vector ecology brought about by floods and damage to environmental hygiene have led to increases in diseases across sub-Saharan Africa, with rises in malaria, dengue fever, Lassa fever, Rift Valley fever, Lyme disease, Ebola virus, West Nile virus, and other infections. Rising sea levels reduce water quality, leading to waterborne diseases, including diarrheal diseases, a leading cause of mortality in Africa. Extreme weather damages water and food supply, increasing food insecurity and malnutrition, which causes 1.7 million deaths annually in Africa.

The authors emphasized that the international community should not only be concerned for Africa for moral reasons, but also because "knock-on" effects of "poverty, infectious disease, forced migration, and conflict" are global in nature. "In an interconnected world," they argued, "leaving countries to the mercy of environmental shocks creates instability that has severe consequences for all nations."

As a clinically-focused journal, American Family Physician has devoted much environmental health content to what individual physicians can do in their offices to mitigate the health effects of climate change on patients and counsel them about actions that can help address the problem. In a recent position paper, the American College of Physicians went further by recommending "that the health sector must adopt environmentally sustainable and energy-efficient practices to aggressively reduce its greenhouse gas emissions." As noted in an accompanying editorial, the U.S. health care system accounts for an estimated 8.5% of national greenhouse gas emissions. Left unaddressed, these emissions cause harm that requires health care interventions, which generate more emissions that lead to more harm: the "harm-treat-harm" cycle.

What actions can clinics, hospitals, and health systems take to break this cycle? The Agency for Healthcare Research and Quality has released an evidence-informed primer for health care organizations from the Institute for Healthcare Improvement on measures and actions to reduce carbon emissions. An article in STAT News discussed energy efficiency initiatives at Boston Medical Center, the Cleveland Clinic, and Kaiser Permanente that have reduced carbon emissions associated with excess power consumption and saved millions of dollars. Notably, nonprofit hospitals are now eligible to receive renewable energy credit payments from the Inflation Reduction Act for investing in energy-saving projects.


This post first appeared on the AFP Community Blog.

Saturday, November 5, 2022

Facing the "tripledemic": RSV, influenza, and COVID-19

During the first two winters of the pandemic, social distancing and mask wearing protected many persons - particularly infants and older adults - from SARS-CoV-2 and other potentially serious viral respiratory infections. With most people having returned to pre-pandemic social interactions, the viruses are making a comeback. Children's hospitals in several states are filled to capacity with patients infected with respiratory syncytial virus (RSV)high levels of influenza-like illness are being reported across most of the South; and with waning immunity and low uptake of bivalent vaccine booster shots, many scientists predict another COVID-19 winter surge. Health officials are concerned that the combination of RSV, influenza, and SARS-CoV-2 variants may produce a "tripledemic" that could overwhelm outpatient practices and hospitals.

Prior to 2020, 2 to 3 percent of U.S. infants younger than 12 months were hospitalized for RSV bronchiolitis, and RSV was estimated to cause 177,000 hospitalizations and 14,000 deaths annually in adults aged 65 years and older. For the family physician evaluating a child with bronchiolitis, accurate risk stratification remains a key skill. Unfortunately, aside from oxygen supplementation, no other therapies offer significant benefit: bronchodilators do not improve oxygen saturation, hospitalization rate or duration; and the American Academy of Pediatrics practice guideline recommends against using systemic corticosteroids, antibiotics, nebulized hypertonic saline (unless the child is hospitalized), or chest physiotherapy. RSV prophylaxis in the first year of life with the monoclonal antibody palivizumab (Synagis) is recommended only for infants born before 29 weeks of gestation or infants with chronic lung or heart disease, neuromuscular disease, or profound immunocompromise. No vaccines have been approved by the U.S. Food and Drug Administration (FDA) to prevent RSV infections in infants or older adults.

Although not in time for this RSV season, new prevention tools are around the corner. Earlier this year, a placebo-controlled trial of 1490 late-preterm (>35 weeks gestation) and term infants reported that the monoclonal antibody nirsevimab provided reduced medically attended RSV bronchiolitis by 75 percent and hospitalization by 62 percent, with no difference in adverse events. The FDA and the European Medicines Agency are both considering approval. Several companies are also in the late stages of developing a vaccine against RSV for older adults, with two reporting positive outcomes in unpublished Phase 3 trials.

In the meantime, nonpharmacologic interventions (handwashing, avoiding sick persons, and mask wearing) remain the mainstay of preventing respiratory virus infections. Finally, to increase lagging COVID-19 and influenza vaccine uptake, the American Academy of Family Physicians has assembled an Immunizations & Vaccines web page with up-to-date clinical and patient education resources.


This post first appeared on the AFP Community Blog.