Emory Health Digest Spring 2021 by Emory University

SPRING 2021

THE LIFESAVING POWER OF

VACCINES

LONG COVID | 28

INSIDE A VACCINE CLINIC | 36

IMMERSIVE NURSING

| 40

travel well

ILLUSTRATION + COVER BY JOHN HERSEY

contents Not Throwing Away Our Shot 16 Vaccinations may, in fact, save the day, if we can get shots in enough arms to create herd immunity. But many questions remain. We talk with Emory immunologists and vaccinologists about what to expect . . . and when.

“Vaccination is what is going to end the pandemic, since it’s

–Marybeth Sexton, assistant professor of infectious

A sixth-grader played his

diseases, Emory Facebook Live.

trumpet outside Emory

Decatur Hospital for health care workers. Then he got invitPHOTO BY AUSTIN MCAFEE

ed to play as part of President Biden’s inauguration.

ILLUSTRATION BY BRYAN CHRISTIE DESIGN

what is going to allow us to achieve herd immunity.”

Long COVID 28 For some who get the novel coronavirus, disturbing and debilitating symptoms persist for months, ranging from heart problems to overwhelming fatigue.

contents

MUST SEE TV

The Emory Brain Health Center and Georgia Public Broadcasting (GPB) are partnering on an Emmy-nominated news magazine hosted by Emory’s Jaye Watson. Go to links.emory.edu/watchyfm

Emory Health Digest Jonathan Lewin Executive VP for Health Affairs, Executive Director of the Woodruff Health Sciences Center, and President, CEO, and Board Chair of Emory Healthcare Mary Loftus Editor

Peta Westmaas Art Director Jack Kearse Photography Director Janet Christenbury, Carol Clark, Quinn Eastman, Shannon McCaffrey, Jeff Siegelman, Kofi Stiles Contributors

Straight to the Heart 34

COVID Vaccine Clinic 36

Stacey Jones Copy Editor

A scientist, mom, and runner, Jennifer Fagan thought she had recovered from COVID-19. Then she had a heart attack.

Emory’s Northlake clinic has vaccinated more than 100,000 people. Meet the health care workers and volunteers who staff it.

Deanna Altomara Editorial Intern John Mills Online Communications, Senior Director Stuart Turner Production Manager Jarrett Epps Advertising Manager Wendy Darling Web Specialist Vincent Dollard Associate VP, Communications Jennifer Checkner Executive Director of Content

Much more about long COVID and its impact on the body remains to be determined. “How

do you know what’s related?” asks

Fagan (above).

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the well

and more

To Our Readers 4

Patient POV 44

A message from Jonathan Lewin, executive VP for health affairs, executive director of WHSC, and CEO of Emory Healthcare.

Debilitating COVID-19 symptoms have lasted months for Emory emergency physician Jeff Siegelman, increasing his empathy for others experiencing long COVID.

The Well 5

Gorillas and COVID-19, reducing youth sports injuries, research funding rises, keeping track of vaccine distribution, a promising COVID antiviral treatment.

Policy Wise 46

The pandemic may have given us a rare opportunity to boost nonpartisan support for science and public health.

Dave Holston Associate VP, Creative Cover Illustration John Hersey

Emory Health Digest is published twice a year for patients, donors, friends, faculty, and staff of the Woodruff Health Sciences Center. © 2021 Emory University Emory University is an equal opportunity/ equal access/affirmative action employer fully committed to achieving a diverse workforce, and complies with all applicable federal and Georgia state laws, regulations, and executive orders regarding nondiscrimination and affirmative action in its programs and activities. Emory University does not discriminate on the basis of race, color, religion, ethnic or national origin, gender, genetic information, age, disability, sexual orientation, gender identity, gender expression, or veteran’s status. Inquiries should be directed to the Office of Equity and Inclusion, 201 Dowman Drive, Administration Bldg, Atlanta, GA 30322. Telephone: 404-727-9867 (V) | 404-712-2049 (TDD). 21-EVPHA-EVPHA-0043

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INNER VISION

Infectious diseases epidemiologist Jodie Guest, of the Rollins School of Public Health, was the 2021 COVID-19 czar for the Iditarod, working to protect “Alaskan villages and all participants” during the world’s largest sled dog race. For more: links.emory.edu/78

SPRING SPRING2021 2021

to our readers

Jonathan Lewin, executive VP for health affairs, executive director of the Woodruff Health Sciences Center, and president, CEO, and board chair of Emory Healthcare.

We have passed the oneyear mark of the COVID-19 pandemic at Emory, and as I reflect back on a year that has been unlike any other, I am deeply proud of all that the people of the Woodruff Health Sciences Center have achieved.

Emory has now treated more than 12,000 hospitalized COVID patients, with a survival rate of 92.5%, which is among the highest in the country. Now we’re applying the same efficiencies to our vaccination efforts and have administered more than 106,000 doses of vaccine so far, with the number climbing steadily as we (and a host of volunteers) continue to vaccinate thousands of people each day (see p. 36). Exciting things are happening on the vaccine front in Emory’s research labs, from developing effective therapeutics (p. 15) to Emory’s own COVID-19 vaccine (see p. 23).

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Our health sciences faculty also are leading clinical trials, acting as public scholars (sharing important, science-based information on platforms from CNN to Facebook Live), and helping patients who, although “recovered” from acute COVID-19, are still experiencing distressing symptoms (p. 28). Since last March, Emory has received more than $137 million in COVID-specific research funding, $104 million directly from the National Institutes of Health, ranking us No. 3 in NIH awards for COVID research among US universities. While I’m proud of these and many other stellar results, I’m even more proud of the culture and attitudes that made them possible. From the earliest days of the pandemic, our teams mobilized their resources and expertise to fight this unique threat on many fronts. Please direct questions and comments to evphafeedback@emory.edu. Jon Lewin

test well

CAN GORILLAS GET COVID? THE ANSWER IS YES. by Carol Clark

Thomas Gillespie, disease ecologist and associate professor of environmental health.

ILLUSTRATION BY EVGENY TURAEV

The news that some members of the gorilla troop at the San Diego Zoo tested positive for the virus that causes COVID-19 ramps up the urgency for protecting great apes in the wild from exposure, warns Thomas Gillespie, an Emory disease ecologist. “This first known transmission to apes confirms what we strongly suspected—that one of our closest living relatives is susceptible to the novel coronavirus,” says Gillespie, an associate professor in Emory’s Department of Environmental Sciences and Rollins School of Public Health. “More than ever, it’s a race against time. If gorillas in the wild become infected, it will be a much more dangerous scenario because we won’t have the ability to contain it.” In March 2020, Gillespie co-authored a Nature commentary warning that great apes are susceptible to human respiratory diseases and that COVID-19 could prove devastating to animals on the brink of extinction. The great apes include chimpanzees, bonobos, and gorillas, which live in equatorial Africa, and orangutans, which are native to the rainforests of Indonesia and Malaysia. The International Union for Conservation of Nature (IUCN) lists chimpanzees and bonobos as endangered species, while gorillas and orangutans are critically endangered. Even viruses that have mild effects in people, such as those causing the common cold, have been associated with the deaths of wild primates. The San Diego Zoo Safari Park reported the presence of SARS-CoV-2, the coronavirus that causes COVID-19, after two of its gorillas began coughing. Fortunately, the infected zoo gorillas appear to be making a full recovery. The zoo recently announced it is inoculating many of its great apes against CoV-2 with a vaccine that is designed for nonhuman use. Gillespie is a member of an IUCN task force focused on mitigating the impact of COVID on great apes and other primates. His lab is developing a spatially explicit model to investigate factors that affect the spread of the virus among wild primates, so governments and organizations can prioritize efforts to protect the animals. EHD

SPRING 2021

plan well

Last March, Emory Healthcare opened its COVID RN Hotline to make sure anyone seeking information

about COVID-19 could speak to a registered nurse. The hotline reached its peak volume in July, with more than 21,000 calls. Calls have now decreased, says Natalie Rogers, senior manager of clinical operations, due to a host of good reasons, including “vaccinations, mask ordinances, the honoring of social distancing guidelines, people washing their hands frequently, and more knowledge about the virus.” Nurse Kelly Hood says, “We battled fear-based disinformation. It can be tough for any organization that provides health care to get ahead of the game on that.” Callers are now focused on vaccination questions. “People were told it was best to avoid taking anything for mild symptoms after receiving the vaccine, which is false,” Hood says. “Yet a good

portion of people believed it and suffered through what could have easily been alleviated with hydration or Tylenol.” Nurse Jovonni Patrick says callers expressed emotions ranging from calm to panic. But most were grateful to speak with a nurse who could guide them on how to remain safe. “Some days were more challenging than others,” says Patrick. “You have to have outlets, mini-meditation sessions, step away for a few minutes and remind yourself that you are making a difference. That was key for me, as well as patients telling me they’re thankful for our help, and that after speaking with us, they feel better.”—Kofi Stiles

More to Explore

Emory NIH federal research dollars rise Emory received more federal research dollars from the National Institutes of Health (NIH) than ever before and continues to climb in an independent ranking of peer institutions. The fiscal year 2020 rankings from the Blue Ridge Institute for Medical Research compare schools and departments across the United States on the basis of NIH funding. Overall, Emory rose to 18th in the nation, pulling in $507 million in funding. That’s up from 19th the year before, when Emory attracted $382 million. About 20 percent of Emory’s FY2020 NIH funding supported research related to COVID-19. “The growing support from NIH demonstrated in these rankings underscores the high quality of research taking place at Emory,” says David Stephens, vice president for research at Emory’s Woodruff Health Sciences Center and chair of the Department of Medicine. “That work has only intensified in these challenging times. Emory has helped to lead the way in battling COVID, testing and developing vaccines and therapeutics as well as cutting-edge diagnostics. All the while, researchers have continued with other important work aimed at improving health and well-being.” The NIH is the largest source of funding for biomedical research in the world. In fiscal year 2020, the federal government was Emory’s largest research sponsor and the NIH accounted for 85 percent of federal funds from the sector. EHD

EMORY HEALTH DIGEST

FY2020 NIH Funding Highlights n The School of Medicine: 14th in the nation with $395.2 million n The School of Nursing: 5th in the nation with $9.3 million n Rollins School of Public Health: 4th in the nation with $58.9 million n The Department of Pediatrics received $97 million, ranking No. 1 in funding among all NIH-funded pediatric departments in the US Among the basic science departments: n Biomedical Engineering: 3rd in the nation n Microbiology and Immunology: 14th n Genetics: 15th Among the clinical science departments: and Laboratory Medicine: 6th in the nation n Surgery: 10th n Neurology: 12th n Physical Medicine and Rehabilitation: 15th n Radiology and Radiation Oncology: 15th n Internal Medicine: 16th n Urology: 17th n Neurosurgery: 18th n Pathology

ILLUSTRATION BY MIKHAIL SELEZNEV

A Reassuring Voice

Back in the Game: The Atlanta Falcons and Emory partner to help patients and players

ACL tear? Tennis elbow? Or are you a pro who needs to perfect your technique? Emory Healthcare and the Atlanta Falcons have opened the doors to a new musculoskeletal and sports medicine clinic at the IBM Performance Fields, home of the Atlanta Falcons. The Emory Orthopaedics & Spine Center at Flowery Branch is open to the public as well as being an access point for the Falcons organization and players. At 29,000 square feet, the clinic signifies a longterm relationship between the Atlanta Falcons and Emory Healthcare. In 2018, Emory Healthcare became the Official Team Healthcare Provider, adding onto its existing role as the medical provider of the Atlanta Falcons. Also open to the public is the Emory Sports Performance and Research Center, which focuses on the science of human performance, injury prevention, and recovery in young athletes and professionals. The 5,000- square-foot research facility is fully digitized for real-time 3D motion and joint force analysis combined with the most advanced imaging technologies, supporting seamless integration of neuroscience with biomechanics.

ILLUSTRATION BY ANTONIOKHR

play well

The new clinic, with 16 patient exam rooms and two exam/treatment rooms, will offer the latest innovative technology to assist in the care of patients and players. This includes two 3.0 Tesla MRI (magnetic resonance imaging) scanners, with one dedicated for research, which provide premier imaging quality in a fraction of traditional scan times, and digital X-ray machines that produce clearer images and less radiation than contemporary models, and quick and remote reviewing of images by Emory’s extensive provider network of subspecialists, as needed. Emory Orthopaedics & Spine Center at Flowery Branch will provide diagnostic services and treatment options for all spine and orthopaedic conditions, as well as physical therapy and individualized treatment plans. Concussion rehabilitation and prevention also will be a top focus area. “Emory orthopaedics experts will care for patients and players under one roof, while also looking at ways to help young teenage athletes and professionals alike prevent and fully rehabilitate from injuries so they can perform at their best,” says Jonathan Lewin, CEO of Emory Healthcare. EHD SPRING 2021

lead well

Put Me In, Coach!

Training youth coaches to reduce sports-related injuries

mory is collaborating with CoachSafely to support the Georgia CoachSafely pilot project’s goal to train 20,000 youth coaches in Georgia. CoachSafely, a nonprofit education and research organization, aims to limit youth sports-related injuries through the research, advocacy, and education of coaches, parents, physical educators, and other influential figures in young athletes’ lives. “We’re excited to develop this relationship to provide high-quality sports medicine expertise to coaches and keep youth athletes healthy and performing to their most exceptional abilities,” says Neeru Jayanthi, sports medicine

Farewell: Charles Hatcher, “Atlanta’s First Health Czar”

Charles Hatcher Jr., former vice president for health affairs at Emory and director of Emory’s Woodruff Health Sciences Center, died at Emory University Hospital on March 27, 2021, at 90.

EMORY HEALTH DIGEST

physician and co-director of the Emory Youth Sports Medicine Program. Sports medicine specialists, including orthopedic surgeons, sports medicine physicians, physical therapists, and athletic trainers, are all on hand to diagnose and treat common and complex sports injuries. “Our experts work together to design age-appropriate, individualized treatment plans that help athletes of all ages get back in the game in a safe, efficient way while rebuilding strength,” says Jeff Webb, sports medicine physician and co-director of Emory Youth Sports Medicine Program. EHD

Charles Ross Hatcher Jr. was born in Bainbridge, Georgia, graduated from the University of Georgia School of Medicine, and did his internship and residency at Johns Hopkins. After being drafted, he served as a captain in the Medical Corps at the Walter Reed Army Institute of Research. Hatcher joined Emory in 1962 as an instructor in surgery in the School of Medicine and a surgeon in the Emory Clinic. He performed Georgia’s first double- and triple-valve replacements and, in 1970, the state’s first coronary bypass, at Emory University Hospital. He was chief of cardiothoracic surgery, then director and CEO of the Emory Clinic and director of the Woodruff Health Sciences Center. Often referred to as Atlanta’s first “health czar,” Hatcher

became the founding chair and CEO of Emory University System of Healthcare. He helped create Rollins School of Public Health, expanded Yerkes National Primate Research Center, and established a 30-year contract between Emory’s School of Medicine and Grady Memorial Hospital. He served as president of the Georgia Heart Association and the Society of Thoracic Surgeons. Hatcher received the Robert W. Woodruff Medal, and was honored by the Charles Ross Hatcher Jr. Distinguished Professorship of Surgery and the Charles Hatcher Jr. Award for Excellence in Public Health. He received the Distinguished Service Award from Emory School of Medicine and the Distinguished Leadership Award from Morehouse School of Medicine. EHD

visit well

Four Qs:

How Big Is My Bubble after Vaccination?

When is someone fully vaccinated? It takes time for your immune system to build maximum protection after a vaccination. People are considered fully vaccinated two weeks after their second shot of either the Pfizer-BioNTech or the Moderna COVID-19 vaccine, or two weeks after the single-dose Johnson and Johnson/Janssen COVID-19 vaccine. Can fully vaccinated people visit with other fully vaccinated people without masking? Yes, as long as the recently issued Centers for Disease Control and Prevention (CDC) guidance is followed. If you are fully vaccinated, you can gather with small groups of other fully vaccinated people indoors without wearing masks. Can fully vaccinated people visit with people who aren’t vaccinated without masking? The CDC says fully vaccinated people can visit with unvaccinated people from a single household without wearing masks or distancing, as long as those people are at low risk for severe COVID-19 disease. The good news for grandparents is that most of their grandkids are at low risk for severe disease. That means if they are fully vaccinated, they can likely see their unvaccinated grandchildren without wearing a mask.

ILLUSTRATION BY ROBERT NEUBECKER

Infectious diseases expert Marybeth Sexton answers questions about what we can safely do after our COVID-19 vaccinations have kicked in.

Even after vaccination, however, I would still worry about being with someone who is not vaccinated and is at very high risk for COVID complications, because we still need to learn more about whether people can spread COVID after vaccination without having symptoms.

Why do fully vaccinated people need to continue to mask and distance in public? While these vaccines are working incredibly well, they are not 100% effective. They are almost completely effective at preventing severe illness, including hospitalization and death. But since even mild COVID can keep you out of work and give you long-lasting symptoms, you still want to avoid it. Also, the last thing you want to do once you are vaccinated is to infect someone who isn’t—we don’t know yet whether people who are vaccinated can spread COVID without being sick themselves. And finally, when you’re out in public, no one knows who is vaccinated and who is not. The majority of the United States is still unvaccinated, and if unvaccinated people see others Marybeth Sexton, not taking precautions, they may assistant professor of inget a false sense of security. So it’s fectious diseases, Emory a big public health service to still School of Medicine. wear a mask. EHD SPRING 2021

play well

Sweet Tunes: Student Invited to Play Virtually at Biden’s Inauguration after Honoring Health Care Staff

A sixth-grader who sought to bring “happiness and hope” to health care workers by playing his trumpet outside Emory Decatur Hospital was featured as part of President Joe Biden’s inauguration.

Jason Zgonc, from Deca-

tur, Georgia, was selected to perform virtually during the inauguration on January 20. During the video segment, Jason performed “God Bless America” at Emory Decatur Hospital, with health care workers watching in the background. Over the summer, the 12-yearold played outside the hospital for 100 days, except during severe weather. “I wanted to bring happiness and

hope to health care workers who are working so hard because of the coronavirus,” he says. Jason chose “Over the Rainbow” as well as other movie theme songs and classical selections. His mother, Karen Zgonc, says the experience helped Jason improve as a young aspiring musician. “Jason has fed our souls for over 100 days,” says Edna Brisco, assistant chief nursing officer for Emory Decatur Hospital. “He inspired us, he brought smiles to our faces, and he supported us throughout our shifts. We cannot thank him enough.” EHD

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2/4/21 11:55 AM

work well

The National Academy of Medicine (NAM)

elected Denise Jamieson MD MPH (top left) and Susan Margulies PhD (bottom left) to its 2020 class of 100 new members. Election to NAM is considered one of the highest honors in the fields of health and medicine.

Jamieson is the James Robert McCord Professor and Chair in the Department of Gynecology and Obstetrics, Emory School of Medicine, and chief of gynecology and obstetrics for Emory Healthcare. Jamieson’s research interests focus on emerging infectious diseases in pregnancy. Margulies is the

Wallace H. Coulter Professor and Chair in the Department of Biomedical Engineering (BME) at Emory and Georgia Tech. She is also a Georgia Research Alliance Eminent Scholar in Injury Biomechanics. Her research centers around traumatic brain injury in children and ventilator-induced lung injury.

Emory Healthcare nurses were honored for nursing excellence at the 2020 March of Dimes Georgia Nurse of the Year Awards.

The 11th annual event, held virtually this year, paid tribute to the nursing profession by recognizing extraordinary nurses who are making a difference throughout the greater Georgia community. More than 350 nurses were nominated for the awards, which acknowledged nurses for compassion, leadership, and excellence in the health care settings and communities in which they work. Emory Healthcare nurse honorees, and the categories in which they were recognized, are: DISTINGUISHED NURSE OF THE YEAR: Mary Gullatte, PhD, RN, Corporate Director for Research and Evidence-Based Practice, Emory Healthcare NURSING ADMINISTRATION: Bob Dent, DNP, RN, Chief Nursing Officer, Emory Decatur Hospital SURGICAL SERVICES: Callie Cross, BSN, RN, Clinical Nurse, Operating Room, Emory University Hospital

Carrie McDermott, PhD, RN, Corporate Director, Nursing Professional Practice, Emory Healthcare

Health Sciences Schools Ranked among Best by US News Emory’s health sciences schools and programs are among the best in the nation, according to US News & World Report’s 2022 edition of the “America’s Best Graduate Schools” guide. In national rankings: n

NURSING EDUCATION:

EMERGENCY/CRITICAL CARE: Joseph

Smith, MSN, RN, Unit Director, Cardiovascular ICU, Emory University Hospital RISING STAR/EMERGING LEADER: Victoria Curry, BSN, RN, Clinical Nurse, Advanced Respiratory ICU, Emory University Hospital

n n

CARE MANAGEMENT: Misty Landor, MSN, RN, Care Coordination, Emory Clinic, and Adjunct Professor, Nell Hodgson Woodruff School of Nursing COMMUNITY HEALTH: Shekita

James, BSN, RN, Nurse Manager in Endocrinology, Emory Clinic Virginia Njoroge, MSN, RN, Specialty Director, General Medical, Emory Decatur Hospital (tie)

GENERAL MEDICAL:

Melissa White, BSN, RN, 6G Unit Nurse Educator, Emory University Hospital (tie)

GENERAL MEDICAL:

he Nell Hodgson Woodruff School of Nursing master’s T program ranks 2nd and its doctor of nursing practice program is 8th. The Rollins School of Public Health ranks 4th. he School of Medicine ranks 22nd among research-orientT ed schools and 36th among primary care schools. mory and Georgia Tech’s Coulter Department of BiomediE cal Engineering PhD program ranked 2nd. I n specialty rankings, Emory’s anesthesiology program ranks 21st, internal medicine 19th, obstetrics and gynecology 23rd, pediatrics 15th, radiology 16th, and surgery 17th. The physician assistant program (not newly ranked) remains 5th and the physical therapy program 8th. mong nursing master’s programs, Emory’s nursing adminA istration program ranks 3rd; family nurse practitioner 3rd; nurse practitioner, adult gerontology/acute care 4th; nurse practitioner, adult/gerontology, primary care 6th; nurse practitioner, psychiatric mental health 8th. Among Emory nursing doctoral programs, adult gerontology/acute care ranks 5th, pediatric acute care 4th, family practice 6th, and community health/public health 8th.

seeing well

EMORY HEALTH DIGEST

seeing well

The Robots Are Here (to Help) A new robotic imaging system at Emory Saint Joseph’s Hospital will enable doctors to work more efficiently and effectively in treating heart and vascular conditions. The Artis Pheno imaging system, the first in the state, uses a robotic arm that rotates 360 degrees around the patient to generate high-resolution 3D images, providing a clear view to help guide interventional treatments. The new C-arm robotic angiography system is part of the hospital’s hybrid operating room, a surgical suite that combines the capabilities of a cardiac surgery room and a catheterization room. “The 3D imaging provided by this new system, combined with the capabilities of a hybrid operating room, allows us to treat complex cases with minimally invasive procedures that reduce risk to the patient and improve recovery times,” says Michael Halkos, chief of cardiothoracic surgery at Emory Healthcare, which operates one of the largest cardiothoracic (CT) surgery programs in the country and the largest in Georgia. EHD

SPRING 2021

live well

Are Vaccines Reaching Hard-Hit Areas? KEEPING TRACK:

Shivani Patel, assistant professor of global health, Emory’s Rollins School of Public Health.

EMORY HEALTH DIGEST

Emory researchers are enhancing a dynamic COVID-19 Health Equity dashboard to shine a light on how US states are progressing on vaccinations. Reports indicate that Black communities, which have been disproportionately impacted by the virus, are also falling behind in getting the vaccine. Visitors to the vaccination tracker can see national and state data about the vaccine rollout and find the racial breakdown of COVID-19 deaths along with social determinants information such as poverty, access to health care, health insurance coverage, underlying health conditions, and housing issues. Shivani Patel, a social epidemiologist at Emory’s Rollins School of Public Health who led the team that developed the dashboard, points out that the burden of COVID has been unequal. Some communities—particularly those

with a large minority population—are suffering higher infection rates, hospitalizations, and deaths. “The original goal of the health equity dashboard was to show the virus’s differential impact. We added the vaccination tracker so that we can see how well we are reaching communities that have been hardest hit,” she says. On the equity dashboard homepage, users can see a snapshot of COVID deaths across the country. Selecting a state brings up a map displaying mortality by county. Drilling down, users can select a county to see how it compares to the rest of the state and country. “There’s no one-size-fitsall approach to combat this pandemic,” Patel says. “To prepare for the future, it’s critical to understand the underlying risk factors leading to higher incidence and mortality.” EHD

live well

Antiviral Drug Shows Promise in Treating COVID An antiviral drug initially discovered by Emory’s nonprofit drug development company, DRIVE, appears safe and reduces SARS-CoV-2 to undetectable levels in COVID-19 patients after five days of administration, according to data from a Phase II clinical trial. Molnupiravir, previously known as EIDD-2801, can be provided as a pill in an outpatient setting, which would improve ease of distribution and convenience. Although remdesivir and antiviral monoclonal antibodies have received Emergency Use Authorization from the FDA, they must be given intravenously or by injection. In addition, drugs like molnupiravir could flexibly tackle SARS-CoV-2 variants, which have emerged as a concern in recent months.

“There’s still an urgent need for an antiviral drug against SARS-CoV-2 that can be easily produced, transported, stored, and administered,” says George Painter, CEO of DRIVE (Drug Innovation Ventures at Emory) and director of the Emory Institute for Drug Development. EHD

After noticing unusual blood clotting in many patients diagnosed with COVID-19, doctors believe there may be a connection to the thickness of their blood, known as hyperviscosity, with inflammation and clotting. “It has been a mystery why so many patients with COVID-19 have had atypical blood clots. We realized we needed to think beyond our typical testing strategies to understand why this might be happening,” says lead author Cheryl Maier, assistant professor of coagulation and transfusion medicine in the Pathology and Laboratory Medicine department at Emory School of Medicine and medical director

of the Special Coagulation Laboratory. “Blood needs to flow smoothly for proper circulation throughout the body. Imagine the difference between something flowing like molasses or honey, instead of like water.” The correspondence, which links hyperviscosity and severity of illness, appears in The Lancet. The researchers tested plasma viscosity (thickness of blood plasma) in 15 critically ill COVID-19 patients with pneumonia who were admitted to Emory Healthcare intensive care units (ICUs). All of them had plasma viscosity levels above the normal

ILLUSTRATION BY JIM FRAZIER

Thick Blood May Lead to COVID-19 Complications

range. The sickest patients had the highest plasma viscosity, more than double normal levels, and were also more likely to have a blood clot. EHD SPRING 2021

VACCINES: WHAT WE NEED TO KNOW . . .

by Mary Loftus • Illustration by John Hersey

NOT THROWING AWAY OUR SHOT E M O R Y R E S E A R C H E R S TA L K VA CC I N E S

Vaccinations may, in fact, save the day if we can get enough shots in arms to get close to herd immunity, which would deprive the novel coronavirus of new hosts. But many questions remain. How long will the vaccines’ effectiveness last? What exactly is an mRNA vaccine anyway? Will we ever return to normal?

We spoke with six Emory immunologists and vaccinologists about COVID-19, the pandemic, vaccines past and present, and what we can expect in the future in this special vaccine section of Emory Health Digest.

SO MANY QUESTIONS . . .

What do you do? p.19

When did COVID first come onto your radar? n RAFI AHMED, Charles

Howard Candler Professor, microbiology and immunology, School of Medicine, director, Emory Vaccine Center, Georgia Research Alliance Eminent Scholar in Vaccine Research

n SRI EDUPUGANTI,

associate professor, infectious diseases, School of Medicine, Emory Vaccine Center, Medical Director of Hope Clinic

n NADINE ROUPHAEL,

professor, infectious diseases, School of Medicine, executive director of Hope Clinic

p.19

How difficult was the pivot to COVID research? p.20

If we could have changed one thing . . . ? p.20

Has anything good come from the pandemic? p.21

Are we close to resuming normal life? p.21

n RAMA RAO AMARA ,

Charles Howard Candler Professor, microbiology and immunology, School of Medicine, Emory Vaccine Center, Yerkes National Primate Research Center

n COLLEEN KELLEY,

associate professor, infectious diseases, School of Medicine, assistant professor, epidemiology, Rollins School of Public Health

n MEHUL SUTHAR,

assistant professor, pediatrics, infectious diseases, School of Medicine, Emory Vaccine Center

Why study infectious diseases and vaccines? p.22

What vaccine, in the history of vaccines, is your favorite? p.22

SPRING 2021

M Before it even “became a glob-

al pandemic, I was aware of [COVID-19]. But I did not realize it would be at our doorstep so quickly.”

RAFI AHMED, Charles Howard Candler Professor, microbiology and immunology, School of Medicine, director, Emory Vaccine Center, Georgia Research Alliance Eminent Scholar in Vaccine Research

I knew about “pandemics but I’m

not sure even I expected the day-today human impact of it. Kids out of school for a year? Who could have predicted that?”

COLLEEN KELLEY,

associate professor, infectious diseases, School of Medicine, assistant professor, epidemiology, Rollins School of Public Health

EMORY HEALTH DIGEST

ONDAY, DECEMBER 14, WILL GO DOWN IN HISTORY AS THE DAY SOME HOPE RETURNED TO AN EMBATTLED NATION. That morn-

ing, the first federally authorized doses of Pfizer-BioNTech’s highly effective COVID-19 vaccine were given in the US. A week later, the Moderna vaccine was greenlighted. Soon after the first vaccine shipment entered Georgia, Emory Healthcare began inoculating employees. Emergency room nurse manager Nicole Baker was the first person at Emory Healthcare to receive a COVID-19 vaccine. “I actually cried when I was told I would receive the vaccine,” says Baker, who has now had both Pfizer shots. “But I also continue to social distance and double mask. As a nurse, I do feel confident in the science as long as we the people listen to the guidance that science provides.” Emory’s vaccine mobilization was part of a vaccine distribution effort that spanned the globe, but it was highly personal for health care workers. “We are excited to begin the process of vaccinating our frontline staff members today, who have courageously battled this pandemic caring for patients with COVID-19 for so many months,” announced Jonathan Lewin, CEO of Emory Healthcare. Some of the vaccines being given that day had been tested for safety and effectiveness at Emory, including clinical trials for the Moderna vaccine as well as Novavax, Johnson & Johnson’s Janssen Pharmaceutical, and Sanofi vaccines. The university has been conducting clinical trials of vaccines for more than 30 years, as well as developing research facilities and recruiting experts in the field with help from the Georgia Research Alliance. The schools of medicine and public health, the Vaccine Research Center and its clinical arm, the Hope Clinic in Decatur, and the Yerkes National Primate Research Center have allowed Emory to play a pivotal role in fighting COVID-19 through research, clinical trials, and vaccine testing and development. “We not only had vaccine expertise but also an in-depth knowledge of human immunology,” says Rafi Ahmed, Charles Howard Candler Professor of Microbiology and Immunology and director of the Emory Vaccine Center. “Our largest vaccine program has been for HIV, and we also have a significant influenza vaccine program. That experience and infrastructure is paying off now.” Vaccines are one of the most effective public health interventions in history, saving the lives of 2.5 million each year (pre-COVID-19) and protecting millions more from illness and disability. Smallpox was eliminated from the world in 1980, the first infectious disease to be eradicated by vaccine. Due to vaccines, polio and rubella have been eliminated in the US, and tetanus, measles, and diphtheria are rare. Vaccines now exist for mumps, seasonal influenza, HPV, hepatitis, pertussis (whooping cough), yellow fever, typhoid fever, shingles, rotavirus, rabies, chickenpox, pneumonia, and many more dreadful diseases. We sat down with (well, actually, spoke over Zoom with) several Emory vaccinologists, immunologists, and infectious disease experts to talk about vaccines past and present, why they were drawn to the work of infectious disease and the immune system, and what we can expect now that COVID-19 vaccines—and variants—are here.

Describe your primary vaccine work at Emory:

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COLLEEN KELLEY: I’ve been engaged in HIV prevention research for many years. My research was based at the Hope Clinic, so I was well versed in clinical trials for not only HIV vaccines but other infectious disease vaccines. We’ve always had a strong vaccinology presence, so that set us up to be leaders when COVID-19 hit.

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RAFI AHMED: In addition to Hope Clinic, another entity very involved in all of this has been the Infectious Diseases Clinical Research Consortium (IDCRC), co-led by Emory VP of Research David Stephens, who has coordinated many of these vaccine trial evaluations. A lot of the immunology and assays are being done through the IDCRC and the Vaccine Trial Evaluation Unit, which was given to us due to the infrastructure we had already built for human immunology, vaccines, and infectious disease under division director Monica Farley, Jonas Shulman Professor of Medicine.

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MEHUL SUTHAR: My lab primarily focuses on emerging viral infections and we’ve been working in several areas, mainly flaviviruses and, more recently, coronaviruses. We study the immunology and virology of pathogens like West Nile, Zika, and Dengue viruses to understand the antibody responses, the innate immune responses, and what their primary target cells are in vitro (lab) and in vivo (animal models). My lab was one of the first to work with SARS-CoV-2 at Emory because we have a high containment facility.

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NADINE ROUPHAEL: I work at the Hope Clinic, where we conduct clinical trials for vaccines and also investigate successful vaccines so we can facilitate the development of other safe and effective vaccines. We’ve tackled different kinds of pathogens, from emerging infections, to community- and hospital-acquired infections, to bioterrorism. We’ve also investigated the best delivery system for vaccines and worked with Georgia Tech on using dissolvable, thermostable microneedles to deliver influenza vaccines. SRI EDUPUGANTI:

“My main focus at the

Hope Clinic has been on HIV vaccine development, although I’ve been involved with work on vaccines for other diseases, such as yellow fever. Emory was well prepared for the COVID vaccine clinical trials, as we have an excellent infrastructure and experienced faculty and staff from previous vaccine trials such as Ebola, Zika, avian influenza, HIV, and other infectious pathogens.

When did COVID first come onto your radar?

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KELLEY: Infectious disease specialists were aware from December, watching closely nearly from day one. I got concerned in January and texted family and friends when cases in California started showing up in people with no travel history, which meant community spread was already happening. I thought, oh no, this is bad. But even then, I thought the worst of it was that a trip I had planned to California might get canceled. I knew about pandemics, but I’m not sure even I expected the day-to-day human impact of COVID-19. Kids out of school for a year? Who could have predicted that, or all the other ways the virus would change our way of life?”

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SUTHAR: I was on vacation in Los Angeles, funny to say now, at a big family reunion. I saw on the news a novel coronavirus emerging in China, and I knew right then there were three ways it could go: The virus could die out. It could not be that problematic—like MERS, where it causes infection but is not very transmissible. Or it could spread like wildfire. In January, some reports came out about asymptomatic individuals spreading the virus, and I knew at that point it was going to be a big deal, that the ability to control this virus’s spread, with the amount of travel we do, was going to be very difficult.

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ROUPHAEL: A colleague forwarded an article about an unknown pneumonia in Wuhan, China, in December. We had been granted our renewal for the Vaccine and Treatment Evaluation Unit (VTEU), and on January 21 I went to D.C. for the inaugural meeting of the Infectious Diseases Clinical Research Consortium. Dr. Tony Fauci was addressing the group about how big a threat coronavirus was and the first confirmed US case SPRING 2021

had just been identified in Seattle. I quickly came to realize SARS-COV-2 would become the focus of our research efforts and would change our lives forever.

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EDUPUGANTI: It was late February and I was actually traveling back to the US from Capetown, where I had attended an HIV meeting. They were checking everyone’s temperature when I arrived at the airport, and I ended up sitting next to a passenger who was coughing the whole time. I just got lucky; they easily could have had COVID-19. I did not have a mask on during the flight. That’s when I started worrying.

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AHMED: Very early, in late 2019, I heard what was happening in Wuhan. I was contacted by several colleagues in China, which I visit quite often. Before it even became a global pandemic, I was aware of it. But I did not realize it would be at our doorstep so quickly. I thought it was going to be a serious problem, but I had no idea it would spread like it did. I don’t think anyone did. It was shocking how quickly it got to Europe.

How difficult was the pivot to COVID research?

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SUTHAR: If you work with SARS-CoV-2 (the virus that causes COVID-19) or animals that are infected with the virus, this requires a Biosafety Level 3 lab—high containment facilities that require rigorous training and extra protection. Since my lab leads a BSL3 facility, this has allowed us to be really dynamic with these pathogens. For COVID, we’ve put a tremendous amount of effort into understanding antibody responses during natural infection and after vaccination. My lab has developed a critical viral neutralization assay using the actual virus, which allows us to test hundreds of samples a week and essentially tells us how well the antibodies generated from infection or vaccination block the virus from infecting target cells. More recently, we’ve expanded these efforts to test COVID-19 viral variants as well.

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ROUPHAEL: When SARS-CoV-2 started circulating in Atlanta, we began doing research right away. I was so impressed by how everyone stepped in, from the clinic staff to the commu-

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nity, to make that possible. In record time we were able to collect samples, even from subjects who had come back from the Princess Diamond Cruise, who were among the first Americans to have COVID-19. Then the National Institutes of Health selected Emory as a site for the Moderna trial, and we immediately said yes. Within two weeks, we were giving the vaccine to the first volunteers in Atlanta.

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AHMED: One of the experiences that helped to strengthen our knowledge—clinically and in terms of the science—was our Ebola effort. The Emory Vaccine Center published a paper describing antibody responses in the four Ebola patients we had at Emory University Hospital’s Serious Communicable Diseases Unit. It was the most comprehensive analysis of Ebola-infected patients that has ever been done—a two-year, detailed analysis of how the B-cell response evolved. Similar approaches and techniques are being used to look at the B-cell responses to COVID-19.

If you could change one thing about our response in the beginning, what would it have been?

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KELLEY: A major misstep was the failure to embrace masks because we did not have good solid scientific data that masks are effective in preventing transmission of respiratory viruses. We all have seen Asian countries embrace masks all along, even before COVID-19, to control respiratory viruses, and I didn’t understand why we weren’t following in their footsteps. Masks are part of the culture for control of respiratory viruses in Asia, and they were doing really darn well, so why were we trying to say that we knew better?

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SUTHAR: In November 2019, I gave a lecture to fifth graders at my daughter’s school and, as part of that talk, I taught them about viruses. I gave two examples of pandemics during our lifetime: one was Ebola virus, which I like to connect back to Emory’s response. The other was SARS coronavirus. I gave an example about how quickly those viruses could spread from, say, India to

China, to Australia, to the US without any hesitation. We knew about the threat of emerging viruses and the importance of preparation. And yet, we were not prepared.

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ROUPHAEL: Looking back a year later, I think we’ve learned to never underestimate an outbreak that can appear to be local but then becomes an international pandemic. We should invest in preventing and addressing future threats. Emory integrates clinical, translational, and basic research, and we do it extremely well, but there is still room to do better.

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AHMED: People like to criticize, but I think the scientific community did pretty well. I’m tired of Monday morning quarterbacking. I can’t comment on the public health issues, but the vaccine community stepped up and outperformed itself. It’s amazing to have, in less than a year, multiple licensed vaccines. I would not have predicted 95% efficacious vaccines.

Has anything good come from the pandemic?

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KELLEY: While we are dealing with vaccine hesitancy, we have also ignited a global interest and love of vaccines and vaccinology that had tapered off before the COVID-19 pandemic. Certainly there are no silver linings to COVID-19, with so many millions dead, but for young scientists to be inspired to commit their careers to vaccinology, that’s a great thing. And I think countries and governments are going to reexamine their public health systems, reexamine vaccines from development to deployment and all steps in between, to improve health for everyone.

virus seeks “outThisindividuals

who are not infected; it’s the virus’s best chance at replication and transmissibility. And the more the virus does this, the more variants will emerge.”

MEHUL SUTHAR, assistant

professor, pediatrics, infectious disease, School of Medicine, Emory Vaccine Center

Do you believe we are close to resuming normal life?

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SUTHAR: It’s going to take a while before we return to some degree of normalcy. I think we’re getting closer day by day. Increasing the number of people getting vaccinated has been a very positive development, but people will have to continue to wear masks to reduce viral transmission. This virus seeks out individuals who are not infected; it’s the virus’s best chance at replication and transmissibility. And the more the virus does this, the more variants will emerge. Biden’s “Mask for 100 Days” was a fantastic idea. Hopefully it tamps down the number of infections at the same time that we’re increasing the number of vaccinations. If we can do that, we will start to see aspects of normalcy emerge again.

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EDUPUGANTI: This is a completely rough estimate, but I think we will return to somewhat normal once a significant portion of the population is vaccinated, my guess is 70% to 80%. So it’s mostly dependent on vaccine rollout, but people will still need to continue masking and social distancing.

we will re“turnI think to somewhat normal once a significant portion of the population is vaccinated, my guess is 70% to 80%.”

SRI EDUPUGANTI,

associate professor, infectious diseases, School of Medicine, Emory Vaccine Center, Medical Director of Hope Clinic SPRING 2021

What drew you to study infectious diseases and vaccines?

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AMARA:

As I was growing up, my dad always wanted me to go into medicine. It wasn’t related to the money, it was more that ‘doctors save lives.’ He inculcated that idea into my mind: Whatever you do, it should be helpful for the people around you; you are basically working for the community. When I began studying immunology, molecular biology, I was so fascinated. Understanding the immune system and learning how to tweak it, I hooked onto that and never looked back. SUTHAR:

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Since my undergraduate years, I have been fascinated with RNA viruses. Most RNA viruses encode a very small number of viral proteins (with the exception of coronavirus), so they are small yet can completely overtake the host and shut down the immune system. Their proteins can do many different things at once and, ultimately, the more pathogenic ones cause disease in humans.

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KELLEY: My initial draw was to HIV medicine. I loved science, virology, immunology, and the science around HIV—while, at the same time, I hated the immense impact of the HIV epidemic on humanity. To study infectious disease seemed this amazing way to tie together science and social justice. There aren’t many fields in medicine that do it so seamlessly.

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ROUPHAEL: Growing up, I was fascinated that there was an unknown virus able to suppress the immune system of people, which turned out to be HIV. I wanted to know what could be done. I was drawn to the complexity of infectious disease and immunology, the challenges, and the power of prevention through immunization.

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EDUPUGANTI: I like that a lot of infectious diseases are curable. And, also, that you have to take into account the person’s whole life—where they live, how they live, hobbies, pets, travel, job. All those details, and the epidemiology of the disease, go into making a diagnosis.

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What vaccine, in history, is your favorite?

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KELLEY: I think the HPV vaccine is pretty amazing, in that it helps to prevent cancer. The link between infectious diseases and cancer and vaccinology is pretty awesome.

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SUTHAR: The smallpox vaccine, since it eradicated smallpox throughout the world. My runner-up would be the yellow fever vaccine due to how quickly it was developed in a lab where they didn’t have a lot of the modern tools and techniques we have today.

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AMARA: Smallpox, because it has saved so many lives. But really, it’s whatever I am working on currently. Nearly every day something new comes out of the lab. It’s so exciting—what is it I’m going to hear today?

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ROUPHAEL: We celebrate all vaccines and believe in the power of vaccines to prevent disease. When I was small, I always enjoyed getting vaccines from my pediatrician, a few drops on a sugar cube, it tasted great. So, early on, I had developed a very positive image of vaccines. I guess my dream vaccine would be a pan-coronavirus vaccine, something that will cover any kind of coronavirus that will emerge. It’s amazing how this disease occurred every decade, and we still hadn’t taken it seriously until the pandemic hit.

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EDUPUGANTI: Rubella (part of MMR vaccine, for German measles), because it protects both mother and child—a two-for-one deal!

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AHMED: Honestly, I don’t have a favorite. But the huge importance of the smallpox vaccine is there for us to recognize. It’s a very logical choice since it changed the world in many ways, and it’s the only vaccine so far that resulted in the eradication of the pathogen. Our very own Bill Foege (Presidential Distinguished Professor of International Health Emeritus) and Walt Orenstein (professor of medicine, pediatrics, and global health) were involved in the effort. They were CDC superstars before they were Emory superstars.

Like the Moderna and Pfizer vaccines, the Emory MVA vaccine induces strong neutralizing antibodies, says researcher Rama Rao Amara (left). But it takes protection even further by inducing killer CD8 T cells. The Emory vaccine is easily adaptable to variants and can be effective with a single dose.

Developing Emory’s COVID-19 Vaccine A Multipronged Approach Yerkes researchers, led by Rama Rao Amara, have developed a COVID-19 vaccine that has proven safe and effective in mice and monkeys. The Emory vaccine uses modified vaccinia Ankara (MVA), a harmless version of a poxvirus that is well-known for its use in HIV/AIDS vaccines. Amara spoke with Emory Health Digest about building Emory’s MVA vaccine. HOW IT BEGAN: I knew there were so many

great minds in the country already working on a vaccine that, at first, I didn’t really think about pivoting from my HIV-vaccine research. As the infections were growing, and my family in India started asking me questions, I began to feel terrified and wondered what would happen if the virus infected the rest of the world.

DECIDING TO GO FOR IT: I vividly remember the

night Rafi Ahmed and Guido Silvestri joined me in my research lab, and I started to think it would be great to use our decades of

experience in vaccine research to develop a COVID-19 vaccine. Everybody was saying “Let’s do it,” which gave me and my research team so much energy. ANIMAL MODEL SUCCESS: My team worked very

hard to make the vaccine. Sailaja Gangadhara built the MVA vaccine, and Nanda Kishore Routhu, Narayanaiah Cheedarla, and Venkata Satish Bollimpelli tested it in animals. When we gave the vaccine to mice, we saw a very strong neutralizing antibody response. At that point, we knew we had something and decided to move into the monkey model SPRING 2021

for further evaluation. We got the same great antibody responses as well as great protection in the lungs.

If the virus mu“tates and escapes

the antibody, the other arm of the immune system can fight and control the virus. We built our vaccine with long-term immunity in mind.” RAMA RAO AMARA is a researcher at Yerkes National Primate Research center, a member of the Emory Vaccine Center, and a professor in the department of microbiology and immunology, Emory School of Medicine

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NEXT STEP? We really wanted to know what was happening in the lungs, so we collected and sequenced cells, and looked for a key symptom of the virus— increasing inflammation. The vaccinated animals didn’t experience this, which gave us confidence that the vaccine was working. VACCINE IMPROVEMENTS?

The vaccine is even better now because we improved the neutralizing antibodies at least fivefold. This combined with strong T-cell responses can help combat variants. Also, we think the current vaccine could work as a single-dose vaccine as well as work synergistically with other vaccines, so that’s what we’ll be testing next. Both of these are important for ensuring vaccine availability worldwide, especially in lower-income countries.

WHY TWO DIFFERENT RESPONSES? Because

that’s a comprehensive way to attack the current virus and potentially any more to come. T-cells are important for immune response. CD8 T cells (killer cells) can kill the virus-infected cells and clear them. CD4 T cells (helper cells) help both killer T cells and B cells that make antibodies in response to infection. T-cell responses can be targeted against multiple regions of the virus. And, if the virus mutates and escapes the antibody, the other arm of the immune system can fight and control the virus. We built our vaccine with long-term immunity in mind, so you don’t have to keep vaccinating people as new viruses come up. A BETTER VACCINE? We’re making this vaccine so that it can be added to the regimen for people who are already vaccinated, working synergistically rather than interfering. Any vaccine you take, this vaccine should be able to work with. That’s where we are trying to go.

WHAT VIRUS WILL YOU TARGET NEXT? Tuberculo-

sis (TB), which was the focus of my doctoral studies. My research team was working on a TB vaccine when the pandemic began. We look forward to moving forward with that work.

RISKY BUT WORTH IT?

Absolutely! For me, as a vaccinologist, it matters a lot to step up and say, “OK, we can do this.” I wanted Emory to have a vaccine that could help stop the current pandemic and work against variants. Everyone was terrified about the unknowns, but Yerkes came together to develop the vaccine and care for the animals. If people can adhere to the precautionary practices for just a few more months, we can minimize new variants and use the coming months to build a vaccine that will potentially work against multiple viruses. EHD

EXPERTS WEIGH IN

“What I like to say is, vaccines don’t save lives, vaccination saves lives. The vaccine dose that remains in the vial is 0% effective, no matter what the clinical trials hold.” –Walter Orenstein, Distinguished Professor of Medicine, Epidemiology and Global Health, ACP Internist

“We spend a lot of time training medical students on the science behind vaccines.

We don’t spend a lot of time teaching them how to communicate effectively about this.” –Robert Bednarczyk, assistant professor, epidemiology, Rollins, AJC

“We are really in a race between these variants and getting people vaccinated. As an example, people need to get a flu vaccine every year because the flu mutates every year. The only way a virus can mutate is if it has a live host. As this infection continues to spread, it creates more opportunities for it to mutate.” –Kimberly Manning, professor, School of Medicine, PBS News Hour

Emory experts have appeared on public platforms from CNN to Facebook Live to provide science-based information about COVID-19 vaccines. SPRING 2021

”There are so many ethical, operational, health care challenges that we as a country have never had to face before. This is a historic battle.

“This is really as good a response as we could possibly hope for. This puts it in the range of other highly effective vaccines, like measles.”

It’s going to require continued working together to conquer this foe.” –Jon Lewin, CEO Emory Healthcare, Marketplace

–Evan Anderson, Emory professor, infectious diseases, School of Medicine, TIME

“WE ARE CURRENTLY IN A RACE

BETWEEN VARIANTS AND VACCINES.” –Carlos del Rio, distinguished professor of medicine and professor of global health, Facebook Live

“It’s not rocket science, but it is behavioral science, communication science . . . It’s very important the federal government partner not only in getting vaccines to the states but in helping states administer the vaccine.” –Walter Orenstein, NPR

I’m recommending that my pregnant patients get vaccinated. But they should make sure

“In general,

all their questions are answered by their health care provider, and that they’re comfortable before getting vaccinated.” –Denise Jamieson, chair of gynecology and obstetrics at Emory School of Medicine, Newsweek

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“There is a MYTH that you will become sterile if you take the vaccine. This has been propagated on social media, and in one blog in particular. It was supposedly based on a false claim that [one of the COVID-19 vaccines] had a protein that was similar to a placental protein. There is no truth to it, but it just keeps getting circulated.” –Denise Jamieson, Newsweek

“The reality is, every person we turn around and we convince, that go from hesitancy to accepting the vaccine,

is one more person we have on our road to herd immunity.”

“It is critical to assure the public that the vaccine benefits far exceed any risks. To do that, we need the right message, delivered by the right messenger, through the right communication channel.”

– Carlos del Rio, AJC

– Walter Orenstein, CNN

“SO THE REALITY IS, EVEN WITH A VACCINE,

MITIGATION STRATEGIES ARE NECESSARY.” –Carlos del Rio, CNN

“This is all good news, but we can’t rely on vaccinations alone . . . It’s true that cases and hospitalizations have been declining. But the threat of more transmissible variants is real, and we don’t want to squander the gains we’ve made. Now is the time to double down on masking and distancing and not let up.” —Sanjay Gupta, Emory neurosurgeon, associate professor, School of Medicine, CNN Health

“The virus that causes COVID-19 will

continue to circulate but will mostly cause only mild illness, like a routine cold.” —Jennie Lavine, Emory virologist, Science

SPRING 2021

Long COVID For some who contract the novel coronavirus, debilitating symptoms can linger

by Quinn Eastman • illustration by Bryan Christie Design

ONTHS AFTER BECOMING SICK WITH COVID-19, SOME PEOPLE CONTINUE TO HAVE SYMPTOMS SUCH AS SHORTNESS OF BREATH, CHRONIC PAIN, AND DIZZINESS. After the acute infection

seemed to be over, they expected to get back to their previous activities but found that they couldn’t. Jeffrey Siegelman, an emergency medicine specialist at Grady Memorial Hospital, described his experience in a JAMA essay. He was never hospitalized, but found himself still profoundly impacted. “I doubted myself multiple times—thinking if I just pushed myself harder, maybe I could go back to work and to my regular life, to move on,” Siegelman wrote. “Then I would eat something without taste, would feel my heart pounding uncontrollably for hours, or would get so dizzy that I could not even write a simple letter.” Researchers at Emory and other medical centers are beginning to study so-called “long haulers.” Some estimates say that 10 percent of people who’ve had COVID-19 experience lingering, debilitating symptoms. The spectrum of their symptoms is wide, and there isn’t a formal definition of long COVID. While recovery after an illness that puts someone in an intensive-care unit usually takes time, others were sick and miserable at home, and their acute infections may not have seemed so severe. Emory pulmonologist Alex Truong, assistant professor of medicine, started a post-COVID clinic

at Emory’s Executive Park campus with colleague Adviteeya Dixit in the fall of 2020, after seeing the need among patients who had been ill. At first, their clinic was every other Friday, then it moved to every week, and because of demand, Truong and Dixit have been working to recruit additional physicians and expand. “I think there were a lot of people who were suffering at home that we didn’t know about,” Truong says. “They may do OK with a lung function test or six-minute walk test, but they report difficulty breathing or chronic pain.” Truong and other clinicians say one of the most common symptoms is shortness of breath, which may suggest diminished lung function, although other causes such as pulmonary embolism may be contributing. Another commonly reported symptom is postural orthostatic tachycardia syndrome: dizziness or a racing heart when someone stands up after lying down. In addition, a number of post-COVID patients are reporting loss of smell or taste, altered sensations in their

“My concentration and memory have gotten better, but the physical fatigue is worse,” says Adrienne Levesque (above), who started a Facebook group for COVID long-haulers in Georgia. “If I get up, take a shower, and fix my hair, I have to rest afterward.”

Alex Truong, Emory pulmonologist, assistant professor of medicine

SPRING 2021

“I was so used to hearing: ‘I don’t know what to tell you.’ My first pulmonologist said COVID would have killed me if I’d had it this long,” Levesque says. “Dr. Truong told me: ‘We’re going to work hard on this together.’ ”

limbs, and/or brain fog (problems with memory, concentration or word finding). “My concentration and memory have gotten better, but the physical fatigue is worse,” says Adrienne Levesque, a patient of Truong’s who started a Facebook group for those with long COVID in Georgia. “If I get up, take a shower and fix my hair, I have to rest afterward.” An accountant for a family-owned business, she is currently able to work only a few hours a day. She experiences sudden swings in blood pressure, making her dizzy, and has measured shifts in her body temperature of several degrees Fahrenheit. SYSTEMATIC AND QUANTITATIVE

Frances Eun-Hyung Lee, Emory allergist and immunologist, associate professor of medicine

Ignacio Sanz, Emory rheumatologist, Mason I. Lowance Professor of Medicine

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Truong is collaborating with several others at Emory to better understand the mechanisms behind long COVID. The goal is to characterize the clinical manifestations and match those up with laboratory findings as much as possible. “We’re trying to figure out why this happens in some people and not others,” Truong says. “And we plan to follow patients over time to know if their symptoms get better or not.” “There is a tremendous need to identify and define what long-haul COVID consists of clinically,” says Frances Eun-Hyung Lee, an Emory allergist and immunologist who is collaborating with Truong. “Not everyone has all of the symptoms. We want to be very systematic and quantitative about this.” The Emory research team is collecting blood samples from post-COVID patients and establishing a biorepository to store them. In addition, they are conducting detailed interviews and neurocog-

nitive tests to assess symptoms. The researchers have examined about 100 post-COVID patients. Initially, Truong says the group of patients he and his colleagues saw were mostly people who were sick at home and had not been hospitalized for COVID-19. More recently, that balance has shifted toward more people who had been hospitalized. Often they need help managing corticosteroids or blood-thinning drugs they had initially been prescribed, he says. As one example, Levesque suspects she was initially infected in March, but the virus hit with full force in August. Before COVID, she had been managing rheumatoid arthritis with medication and believes that may have weakened her immune system’s ability to fight off the virus. The feeling of not being able to breathe arrived a couple of weeks after the fever and headaches. Monitoring her oxygen saturation and seeing it drop to alarmingly low levels, she took inhaled corticosteroids to stave off the inflammation in her lungs every four hours. Based on previous experience, she was wary of corticosteroids because they have unpleasant side effects ranging from weight gain and high cholesterol to weakened connective tissue and eyesight. After the worst of the lung inflammation was over, Levesque tried several times to wean herself off corticosteroids. She eventually discontinued them with Truong’s help, but had encountered skepticism from some doctors when she reported her persistent symptoms. “I was so used to hearing: ‘I don’t know what to tell you.’ My first pulmonologist said COVID would have killed me if I’d had it

this long,” she says. “Dr. Truong told me: ‘We’re going to work hard on this together.’ ” The doctors coordinating the post-COVID clinics are gathering a diverse group of specialists beyond their own areas of expertise who can investigate patients’ specific issues and provide guidance on best care, including cardiologists, neurologists, psychiatrists, rheumatologists, otolaryngologists, and rehabilitation specialists. THE AUTOIMMUNE HYPOTHESIS

Like everything with COVID, longhaul may seem new. But Lee thinks she’s seen something like it before in autoimmune diseases such as lupus (systemic lupus erythematosus) and rheumatoid arthritis. In those diseases, immune cells are abnormally activated and avoid the checks and balances that usually constrain them. That leads to production of antibodies, which are normally directed against foreign invaders like the coronavirus but instead react against cells in the body. People with lupus and rheumatoid arthritis report many of the same symptoms experienced by long-haulers, like fatigue, joint pain, and skin rashes. Lee and her colleagues are examining whether long-COVID symptoms can be explained by the persistence of coronavirus in the body and continuing inflammation or by the immune system staying in battle mode even after the virus is gone from the body. Other autoimmune disorders, such as Guillain-Barre syndrome, can be triggered by viral infection when the immune system attacks the nerves. The virus that causes hand, foot, and mouth disease, Coxsackie virus, is usually considered

a childhood nuisance, but infection can have the rare complication of autoimmune myocarditis, Lee points out. “This is not new,” she says. “These are mechanisms the medical community has seen before. The difference is now one virus was able to cause such severe infections in so many adults at the same time.” A team led by Lee and her husband, rheumatologist Ignacio Sanz, observed that immune cells in hospitalized COVID-19 patients display signs of indiscriminate activation. The results were published in Nature Immunology in October. Their team went on to confirm the presence of autoantibodies in the hospitalized patients, with tests that are performed in patients with autoimmune diseases like lupus and rheumatoid arthritis. While autoimmunity triggered by viral infection is an attractive theory for explaining long-haul, Sanz and Lee say that the appearance of autoantibodies during COVID-19 may be a transient phenomenon. In the ongoing Emory study, participants’ blood samples will be examined in a series of follow-up visits, both for an ongoing immune response to the coronavirus and for the persistence of autoantibodies. Can doctors intervene and divert the immune system away from overactivation? For systemic inflammation, we don’t know yet, Lee says. But in the lungs, it may be possible. Pulmonologist Thanushi Wynn became involved with post-COVID clinical care at Emory after following up with patients she had seen in the intensive care unit. While they were in the hospital, some of them seemed stuck clinically—they

were on a ventilator or were receiving highflow supplementary oxygen. When she performed a CT scan on their lungs, the dense, pneumonia-like images also looked like something Wynn had seen before: interstitial lung disease, a progressive scarring of the lungs. Interstitial lung disease is also thought to be an autoimmune disorder. It is sometimes an exacerbation of another condition such as rheumatoid arthritis but can also be caused by toxins or radiation. It can be treated with high doses of corticosteroids—higher than the doses used for COVID-19—but timely intervention is key, Wynn says. Patients sometimes feel okay when they’re ready for discharge, but their breathing problems may return. Tapering off corticosteroids requires careful management, she says. As Levesque’s experience indicates, it can be a matter of trading off some symptoms versus others. With intense treatment, some patients were able to turn around their conditions. One of Wynn’s SPRING 2021

“The next time I care for someone with

patients, a former chaplain intern at Emory Saint Joseph’s Hospital, was on a ventilator for weeks and required a tracheostomy. Later when the chaplain came to see her in the clinic, Wynn was surprised at how well she looked. A repeat CT scan of her lungs looked almost normal. “It’s not a traditional success story,” Wynn says. “For some people, COVID-19 may be like a stroke—they may face permanent issues afterward.”

vague abdominal pain, or fatigue, or paresthesia, or any of the myriad conditions that are uncomfortable on the inside but look fine on the outside,” says physician Jeff Siegelman, who has experienced long COVID, ”I will remember that

PSYCHOLOGICAL SUPPORT

People dealing with long COVID face challenges besides their persistent symptoms. Doctors may not detect a specific physical abnormality and may be skeptical or even dismissive. Some became sick before SARS-CoV-2 testing was widely available and don’t have documented evidence of viral infection. Many feel alone and

don’t know who to turn to for advice. “They feel so overwhelmed,” Levesque says about the people in her Facebook group. “When they find out someone else has been going through the same thing, they can get a lot of encouragement and support.” In its uncertain status, long COVID may resemble ME/CFS (myalgic encephalomyelitis/chronic fatigue syndrome), which was long neglected by mainstream medicine. Leaders at the National Institutes of Health, including presidential adviser Anthony Fauci, have said that they want to avoid repeating the same mistakes. At Emory, immunologist Lee says she intends to continue research on long COVID. “I wasn’t planning on becoming a champion for this,” she says. “But there’s a real need.” EHD

these symptoms are

real and impactful for patients.”

Caring Communities, a group of Emory mental health professionals, is hosting a support group for health care workers associated with Emory Healthcare, Grady Health System, and Children’s Healthcare of Atlanta experiencing long COVID. Health care workers who have had symptoms for more than four weeks, are struggling to manage symptoms, or are distressed about the impact of their ongoing illness are welcome to join this free weekly group to pro-

Thanushi Wynn, Emory pulmonologist and assistant professor of medicine

cess these challenges with supportive colleagues. Another support group is planned for other members of the Emory community who are experiencing long COVID. If you are a patient and believe you are experiencing long COVID, contact your primary care physician.

EMORY HEALTH DIGEST

After experiencing long COVID himself, emergency physician Jeff Siegelman (with his wife, Melissa) says he views his patients in a different light.

PHOTO COURTESY OF THE SIEGELMANS

SPRING 2021

STRAIGHT TO THE

heart, lungs, kidney, or brain by Quinn Eastman

The broad category of long COVID could include people who have sustained damage from SARS-CoV-2 infection to specific organs in the body such as the heart, lungs, kidney, or brain.

Sometimes it is not crystal clear how someone’s symptoms are directly related to coronavirus infection. Jennifer Fagan, a scientist and mother of two, caught what she now assumes was COVID-19 in March 2020, just as testing was becoming available at Emory. She developed a mild fever, and that’s when she went in for a test, which was negative. But a few days later, her fever intensified, up to 104 degrees. Several years ago, while working in West Africa as a public health scientist, Fagan had malaria—but this was worse, she says.

EMORY HEALTH DIGEST

Along with painful breathing and chest pain lasting a month, she had a skin rash, diarrhea, and eye irritation (conjunctivitis). However, Fagan did not come to the point of needing to go to the hospital. Her primary care physician, Matthew Marchal, diagnosed her with COVID-19 based on her symptoms and their severity. “In April, we had many patients that were ‘test negative, presumed positive,’ ” Marchal says. What happened to Fagan developed insidiously then manifested suddenly. In pre-COVID times, she practiced yoga and enjoyed running three times a week, at one point completing a half marathon. That fall, if she tried to go for a jog, she would feel dizzy and her heart would race, and yoga felt impossible. She assumed that part of what she experienced was deconditioning: being out of shape after so much time not exercising. But along with episodic dizziness and dramatic changes in her heart rate, she noticed other

The cardiologist examined her heart with symptoms—persistent skin irritation and patches ultrasound and she underwent a stress test, in of hair loss (alopecia). “Just working up to being able to go for a walk which her heart rhythms were monitored. She also visited a pulmonologist, who had took a while,” she says. her breathe into a tube to test her lung function. She was slowly able to get back to jogging a Nothing stuck out. few miles again. But in December, Fagan was only diagnosed while sitting on a couch having later with myocarditis based breakfast, Fagan went into cardiTHAT FALL, IF FAGAN on cardiac MRI, which is more ac arrest. TRIED TO GO FOR A sensitive than other tests. Her She was in North Carolina JOG, SHE WOULD FEEL experience may be an outlier. with her family, and survived DIZZY AND HER HEART Emory cardiologist Jonathan partly because her husband had Kim, who advises Atlanta sports taken a course in CPR. He startWOULD RACE. teams, has concluded that amaed performing chest compresteur athletes can generally return sions, while her teenage daughto exercise safely after having COVID-19—if they ter called an ambulance. “My husband initially thought I was having don’t experience cardiac-related symptoms— a seizure,” she says. “He told me that my face without undergoing a cardiac MRI. He adds, howturned yellow. After a while, my eyes popped ever, that “all athletes post-COVID-19 infection open, and I started breathing again.” should have a slow and gradual return to training In the emergency department of a North with close monitoring of persistent symptoms, Carolina hospital, doctors could see that she had regardless of the severity of infection.” abnormal heart rhythms. They diagnosed her Still, a postinfection inflammation of the with myocarditis, inflammation of the heart musheart, possibly exacerbated by an autoimmune recle, and implanted a defibrillator. action, could explain a slowly developing problem Afterward, at home in Georgia, Fagan felt like Fagan’s. “It’s a plausible mechanism,” says unsteady and unable to work. Emory cardiology researcher Ahsan Husain, who On clear days this winter, she would occastudies cardiomyopathy. sionally go walking in her neighborhood, asking a Meanwhile, Fagan is left with more questions friend to come with her just in case. “I’ve got my than answers. “How do you know what’s relevant babysitter with me,” she would say ruefully. and how it fits together?” she asks. Fagan consulted a cardiologist, who Indeed, say Emory clinician researchers, performed several diagnostic tests, looking much more about long COVID and its impact on for abnormalities. the body remains to be discovered. EHD

Jennifer Fagan (top left, with her family; above, in the hospital; right, after recovery) had a heart attack after recovering from COVID symptoms. SPRING 2021

INSIDE

Emory’s COVID-19 Vaccination Clinic by Shannon McCaffrey PHOTOS STEPHEN NOWLAND

EMORY HEALTH DIGEST

n a cold and blustery February morning, care’s vice president for pharmacy services. “Launching this so quickly was an incredible a small, handicap-accessible bus pulls undertaking. But rising to a challenge like this— up to Northlake Mall in Atlanta. Slowly, where the public’s health is stake—is in Emory’s a lift descends and Lula Jordan steers her electric DNA. Every day we’ve learned and improved.” wheelchair onto the sidewalk. The 77-year-old retiree rolls into what was once a Kohl’s department store. Thanks to Emory A MALL TRANSFORMED Healthcare, which opened the clinic December 17, A few hours before Jordan arrives at Northlake, it is one of the busiest COVID-19 vaccination sites Ray Snider pulls into the empty parking lot. A registered nurse, Snider is director of medical in Georgia. intensive care units at Emory University Hospital. Inside the sliding glass doors, a masked Since late December, he’s been running operavolunteer scans Jordan’s forehead with a digital tions at the Northlake Clinic. thermometer. She is there to receive her second The morning light is only starting to color the dose of the Pfizer COVID-19 vaccine. sky when Snider unlocks the doors, reviews the Jordan is one of 1,653 people the Emory day’s schedule and turns to a large whiteboard Northlake clinic will vaccinate that day, most of that tracks a dizzying array of numbers: schedthem elderly and among the most vulnerable to uled doses, volunteers, and COVID complications. By April, all the other metrics that will more than 100,000 health care gauge the day’s work. “The workers and patients had been To run its Northlake biggest challenges involve vaccinated there. vaccine clinic, Emory keeping people moving,” SnidHealth leaders are fond of Healthcare relies on er says. “You plan and plan but saying that vaccines don’t save a dedicated cadre of then people may arrive hours lives, vaccinations do. So, Emhundreds of health care ahead of their appointment ory’s aim is to get shots in arms professionals and voluntime. That leads to surges in as quickly and efficiently as the teers. The effort requires volume and you have to adapt.” supply chain allows. precise planning to That Emory has a site this To do so, Emory Healthcare ensure not a single dose large, with ample parking to relies on a dedicated cadre of vaccine is wasted. accommodate a growing numof hundreds of health care ber of people seeking vaccinaprofessionals and volunteers. The effort requires precise planning to ensure not tions is a blend of planning and luck. Northlake Mall first opened its doors in the early 1970s and a single dose of vaccine is wasted and that strict was an early star in Atlanta’s shopping scene. But, rules of masking, social distancing, and proper like other once-bustling malls, it saw business hygiene are followed. At the same time, it needs plummet in recent years as consumers moved to be flexible enough to evolve and adapt rapidly to online shopping. Kohl’s shut its doors in 2016 as the largest vaccination campaign in modern and Sears, another of the mall’s anchor stores, memory ramps up. followed suit in 2018. The clinic’s early success as one of the first Meanwhile, Emory Healthcare was in need of centralized vaccine clinics in Georgia hasn’t gone space, and in the fall of 2019, inked a deal to take unnoticed. The Emory team has advised federal, over 224,000 square feet—roughly four football state, and local officials as well as private entities fields’ worth of space—at the struggling mall. on best practices. Now, of course, mass vacciPlans were to house 1,600 employees at the site, nation clinics are springing up around Georgia, including at the Delta Flight Museum near Harts- and construction had to convert the stores into field Jackson-International Airport and Mercedes office space. Then COVID struck. Hospital space Benz Stadium in Atlanta. “The important thing was needed to treat the rising number of sick is to get as many people vaccinated as quickly as patients. So, Emory pivoted and began to use the possible,” says Christy Norman, Emory Healthvacant stores for COVID testing. SPRING 2021

people will be left waiting, slowing down the Within days, the former Sears Auto Center flow; too many vaccines and extra doses may be was retrofitted as a drive-through testing site; wasted at day’s end. tall cubicle-like bays were built inside Kohl’s to Michael Stuckey, an Emory Healthcare pharprovide tests for patients. After the Pfizer and macist, picks up a thimble-sized vial of the Pfizer Moderna COVID vaccines received emergenvaccine and inserts 1.8 ccs of saline. Using a finecy-use authorization from the US Food and gauge syringe, he gently coaxes six doses out of Drug Administration in December, Emory the vial. Each dose is just 0.3 ccs— transformed the Kohl’s site six drops. Early on, pharmacists yet again, this time into a Michael Stuckey, an Emowere only getting five doses out of vaccination hub. ry Healthcare pharmacist, the Pfizer vials but they quickly Little is left to suggest picks up a thimble-sized learned they could get an extra the site’s former life as vial of the Pfizer vaccine dose per vial using slimmer tools. a retail store except an and inserts 1.8 ccs of saAmit Shah, assistant director escalator, unmoving, at its line. Using a fine-gauge of pharmaceutical services at center. Here, in the syringe, he gently coaxes Emory Healthcare, is supervising early morning hours, six doses out of the vial. the team. He spends a lot of time the cavernous space is Each potentially asking questions: What is the mostly quiet. lifesaving dose is just patient no-show rate? How fast 0.3 ccs—six drops. are things moving? THE VACCINE “We’re always trying to As Snider runs through his anticipate what the needs are,” he says. Shah early morning preparations, an Emory Unipreviously worked as an injector, administering versity police officer drives vaccine doses the vaccines to health care workers. “People cried,” seven miles from an ultra-cold freezer at Emohe says. “The level of emotion was intense. I ry University Hospital. They will arrive at the wasn’t expecting that.” site’s customized pharmacy, hidden away behind a series of partitions. The distribution of both the Pfizer and Moderna vaccines—which THE VOLUNTEERS use a new mRNA technology—requires rigorous At a little after 8:00 a.m., the volunteers begin planning. The operation is somewhat akin to to trickle in. Some have become regulars, falling air traffic control, with carefully timed arrivals into roles as greeters or wayfinders. Others are and departures. Once the vaccines are removed first-timers. They all slide on fluorescent yellow from deep freeze, they require up to 15 minutes vests and mill about waiting for instructions. to thaw. Within two hours, the “Welcome,” says Cynthia Fallon, assistant nurse Pfizer doses must be mixed with saline. manager at Emory Healthcare. “We are so glad Both vaccines need to be used within six you could join us. Thank you. All right, today hours after they are drawn into a syringe or we will be giving the Pfizer vaccine only, so that they can spoil. Too few vaccines prepared and should make things a little easier.”

EMORY HEALTH DIGEST

On any given day at Emory’s Northlake COVID vaccine clinic, there will be roughly 100 volunteers from across the Emory community over two shifts.

Gurtu watches for bottlenecks. She is constantly Volunteers run the gamut from retirees, to running scenarios, sometimes sketching them Emory health care workers donating their time, out on paper. How can they shave off a minute to students and faculty. Emory senior Jackie at the registration desk? Is there a way to set Burke, a finance major, will spend about eight arrival patterns more efficiently? Solutions that hours directing patients to the area where they prove successful are absorbed into the daily can fill out consent forms. “My sister is a nurse routine. “Everyone here has been accepting and and she’s immunocompromised,” Burke says. wanting to do this,” Gurtu said. “When I heard about this, I “It makes a huge difference.” thought it would be a good “Welcome,” said way to do my part.” Cynthia Fallon, assistant Eddie Lai, an administrative HALLELUJAH nurse manager at Emory fellow at Emory Healthcare in Meanwhile, Lula Jordan, the Healthcare. “We are so the Office of Quality and Risk, woman who rolled off the glad you could join us. is directing this small army of MARTA bus in her electric Thank you. All right, tovolunteers. wheelchair, is winding her day we will be giving the “When we started, we realway through the clinic. She is Pfizer vaccine only, so ly didn’t know what to expect,” welcomed by volunteer Christhat should make things Lai says. “It’s been gratifying topher Williams, a patient a little easier.” to see the Emory community advocate in the neurology ICU come together like this to help.” at Winship, and ushered to Outside the clinic a line has Vaccine Bay 5, where nurses begun to form, like a Black Friday sale. Snider is ask a few questions before she gets her shot. keeping an eye on the time as he troubleshoots Jordan barely winces. last-minute issues. Then he gives the signal. Because she has a food allergy, Jordan must “9 o’clock,” Snider says. “Roll ’em.” sit in the monitoring area for 30 minutes, rather The doors open. than the typical 15. Adverse reactions to the vaccine are rare but the stay is a necessary precaution. LEAN IN Living in a high rise that houses senior Monica Gurtu, an industrial engineering major, citizens in Atlanta’s East Lake neighborhood, began her career in manufacturing, where she Jordan’s past year has been a struggle. She became intrigued by process—how a seemingly misses group activities and church. This vaccine small change in one part of an assembly line gives her hope, she says. could make a huge difference in overall efficienAfter her waiting time is up, she rolls toward cy. She studied lean, a strategy made popular the exit. The sliding glass doors open to a gust by the Japanese automaker Toyota, and ended of cold air. up applying it to health care. After COVID hit, “Praise God and hallelujah,” she says as the Gurtu came to the Northlake clinic to volunteer. doors close behind her. EHD From an unobtrusive perch near the entrance, SPRING 2021

Virtual Immersion ENVISIONING THE FUTURE OF NURSING

by Pam Auchmutey

Nurses have come a long way from practicing injections on oranges and each other. Emory nursing students will soon be able to practice treating realistic, complex wounds on mannequins, delivering a baby in a car, and setting up a COVID-19 testing center. 40

EMORY HEALTH DIGEST

Nursing education has employed simulation as a key mode of training for many decades, though in far less sophisticated ways as today. According to the American Nurses Association, in 1911 the first nursing mannequin was a life-sized doll named “Mrs. Chase,” which students used to learn how to dress, turn, and transfer patients. The new Simulation and Clinical Skills Lab that will be housed in the Emory Nursing

patient mannequins, as well as a re-creation of an operating room, where nurse anesthesia doctoral students will train. All of the spaces in the lab will immerse students in clinical realism—psychological, physical, and conceptual. An integrated audiovisual system will broadcast and record students during their simulated sessions with mannequins and standardized patients. “We’ll be able to capture and record video in real time and then faculty can use it as a teaching-learning strategy, or as a debrief tool, and students can use it to assess their skills,” Swan says. High-fidelity operating room Virtual technology is also planned to be a key part of the lab, enabling students to don goggles to immerse themselves in a patient scenario. Computerized overlays can be placed on a patient mannequin to show, for instance, a more complicated type of wound.

PHOTO: WOMEN’S COLLEGE HOSPITAL ARCHIVES

Learning Center (ENLC) will be a far cry from what Beth Ann Swan experienced as an undergraduate nursing student in Pennsylvania some years ago. Swan, executive director of the center for the Nell Hodgson Woodruff School of Nursing, says her school had a skills lab with hospital beds. Nursing students practiced on each other, conducting assessments and giving injections to oranges. “We certainly didn’t have anything like the technology we have today,” says Swan. In the 1990s, medical companies began catching up by developing affordable, high-fidelity patient mannequins that were precursors to the ones that medical and nursing educators use today. When it opens in May 2022, not only will the ENLC’s Simulation and Clinical Skills Lab be the largest in Georgia, but it also will be one of the most advanced. The facility will include several simulated hospital rooms populated with high-tech

“Mrs. Chase,” the first nursing mannequin.

SPRING 2021

“When you have high-fidelity spaces that simulate real-world clinical experiences, students are able to have hands-on practice in a safe environment,” Swan says. “When students walk into a simulated learning environment, they have the opportunity to practice critical skills in an immersive and dynamic space.” For Swan, the ENLC is about leveraging space and technology to optimize learning. Swan is eager for students and faculty to take full advantage of the new space. “The School of Nursing,” she says, “has an unprecedented opportunity to lead and reimagine the future for nursing education, research, practice, and lifelong learning, ultimately to advance

EMORY HEALTH DIGEST

health care delivery for individuals, families, and communities.” The terrace level of the ENLC will provide plenty of clinical skills space—open rooms with several hospital beds occupied by low-fidelity mannequins. Four of the rooms will be used by undergraduate students; a larger fifth lab will be dedicated to advanced skills training for graduate students. Other teaching spaces include patient exam rooms, procedure rooms, a nurses station, observation rooms, and debriefing rooms where students and faculty can replay videos and use an interactive white board to drill further into a scenario or concept. While spaces in the Simulation and Clinical Skills Lab will

have definite uses, they will also allow for flexibility to inspire innovation and pop-up activities on the terrace level and on the second floor, so that students can practice delivering a baby in a car, assessing meal preferences at a homeless shelter, or setting up a COVID-19 testing center. “One of the beautiful things about our new space is that it will enable our faculty to be even more innovative,” says Carolyn Clevenger, associate dean for clinical and community partnerships. “I fully expect to see a shift in their teaching practices.” Simulating home care A highlight of the Emory Nursing Learning Center will be a home lab where nursing

Nursing students will get high-tech, hands-on experience in the Nursing Simulation Lab. Spaces will allow for the flexibility to inspire innovation and pop-up activities.

students can get a more realistic feel for what it’s like to care for a senior in assisted living, a mother at home with a new baby, or an older child who has asthma. The home lab, on the second floor of the ENLC, will resemble a small apartment, with a living room, kitchen, bedroom, and bathroom. Currently, undergraduate nursing students do “home visits” in the Charles F. and Peggy Evans Center for Caring Skills at Emory’s School of Nursing. Faculty and staff have transformed a hospital room into an apartment by bringing in furniture, rugs, lamps, and other home accessories. In one home-visit scenario, students visit a man, portrayed by a standardized patient, who has recently had open heart surgery. He lives alone and is not taking his

medication. His apartment is cluttered and not well lit. In another scenario, students witness the death of a cancer patient in hospice. “With the new home lab, students will be able to experience home visits, telehealth visits, home-based primary care, and learn about social determinants of health,” says executive director Swan. The home lab, and other spaces in the ENLC, will also be an incubator for nursing science. “It will provide a place where faculty and students—whether they’re undergraduates, PhD students, or postdocs—can be inventors,” Swan adds. “They can explore the notion of creating a smart apartment or experiment with improving quality of life for the person or population they are working with.” EHD

Beth Ann Swan,

executive director of the Emory Nursing Learning Center.

SPRING 2021

PAT I E N T P O V

My Experience with Long COVID TWO-HUNDRED THIRTY DAYS. It’s a long time to have COVID-19, but it’s also seven months of not being able to play soccer with my kids, seven months of watching my wife single-handedly keep our home afloat (while working full time), and seven months of not being able to taste or smell. This is in addition to seven months of not being able to work on the front lines as an emergency physician. The news focuses on the more than 18,000 Georgians who have died from COVID-19, and rightly so. On the opposite end of the spectrum, many focus on the fact that the majority of COVID-19 infections result in mild or asymptomatic reactions—a fact for which we are all grateful. However, in the middle are thousands of people like me, suffering from months of debilitating symptoms with no end in sight. My story, like so many others, belies the either/or perception. And, it is a very real outcome for more than a third of young, healthy individuals who get COVID-19 and aren’t hospitalized. I ask you to consider the fact that, while you may not die, your COVID outcome could easily be as uncertain and difficult as mine. You could get “long COVID,” suffering from persistent symptoms for months, which cannot easily be cured. On August 3, I awoke with

44 EMORY HEALTH DIGEST

a headache and a few hours later found I had a low-grade fever. The ensuing weeks added a barrage of ever-changing symptoms—chills, muscle aches, headaches, loss of taste and smell, and insomnia. As the weeks wore on, I kept waiting for the day when I would wake up feeling better, but instead my symptoms continued morphing. Chills and aches became heart palpitations, high blood pressure, and fatigue so profound that I could not get off the couch for hours after just walking a half of a mile. My thoughts clouded, “brain fog” hampering my concentration. Dizziness and headaches continued, worsened by all manner of activity. Even something as simple as eating a meal would increase my symptoms. Now, more than seven months in, these ongoing symptoms have also resulted in feelings of guilt. I still cannot be an equal partner in our household. I still cannot be active with my kids. I still cannot work full time, leaving my colleagues in the emergency department to work mandatory overtime at a moment when every shift is so stressful as to push emergency physicians to the precipice of burnout. Complicating this is that I appear healthy, as do many with long COVID. When I meet someone outside, they often as-

sume I am better as they remark how good I look, only for me to explain that the short walk I am taking is all the exertion I can muster for the day. Symptoms of long COVID vary widely and can affect almost every system in the body. While many long COVID patients experience the same symptoms I do, others suffer with cough, shortness of breath, chest pain, and more. Some people have one or two of these symptoms that linger, others have so many

PHOTO COURTESY OF THE SIEGELMANS

Emergency physician Jeff Siegelman has had months of prolonged, debilitating symptoms from COVID-19. Activities like bike riding with his family (below, a f amily outing pre-COVID) are not yet possible for him due to profound fatigue.

that they are unable to return to work or normal activities. Frustratingly, treatment for these symptoms is an exercise in trial-and-error, with the National Institutes of Health and others only just beginning to call for research on understanding the many forms of long COVID and how to treat them. So, what are the chances you’ll end up like me? To be sure, reports vary about how many people with COVID-19 go on to have long COVID, but it is clear that the number is sig-

nificantly higher than with other viruses and could be as high as 1 in 3. Even using a more conservative estimate of 10% means that of Georgia’s more than 1 million confirmed COVID cases, almost 100,000 people don’t get better within three to four weeks. Could you afford to be out of work that long? How would that affect your colleagues and your family? I know that 2020 was a long and difficult year. I know that we all want to be with friends and family, especially after a year

of quarantine. And yet, I ask you to please join my call to action. The task is simple: mask up, stay physically distant, and help everyone get through this. The vaccine that we’ve waited for is finally here, but it might not make a difference if you’re already disabled from long COVID. Jeff Siegelman is an associate professor of emergency medicine at Emory School of Medicine and works as an emergency physician at Grady Memorial Hospital in Atlanta. SPRING 2021

POLICY WISE

‘Think Boldly’ We must shore up trust in science and public health by K.M. Venkat Narayan, James Curran, William Foege

EMORY HEALTH DIGEST

ILLUSTRATION BY JING JING TSONG

ith the advent of the 21st century, science and technology were expected to be formidable forces that would improve population health and well-being. These forces would drive a rapidly changing and interconnected world, with communities and nations sharing common rewards (e.g., economic development, health, and welfare) and facing common risks (e.g., pandemics, chronic diseases, nuclear weapons, climate change). Effective governance and communications were to be cornerstones for this new era. Yet the response to the coronavirus disease 2019 (COVID-19) pandemic in the US, one of the world’s science and technological powerhouses, has not realized these hopes. Instead, the pandemic has exposed critical weaknesses in the institutional systems specifically intended to protect and harness science and technology to promote personal and public health. History suggests that major crises such as wars, natural disasters, and pandemics can serve as a tipping point for proactive collective action. For example, reflection and lessons in the aftermath of World War II led to

the creation of progressive institutions for that time, such as the United Nations and the World Health Organization (WHO). The current moment presents an opportunity to think boldly and to imagine a better world beyond the tragedy of the COVID-19 pandemic. Despite enormous scientific and technological accomplishments, such as the rapid development and testing of diagnostics, therapeutics, and vaccines, the response to the pandemic unveiled vulnerabilities in society and in the scientific independence of public health institutions.

There have been escalating attacks on science and expert opinion, an intrusion of partisan politics into public agencies, especially the Centers for Disease Control and Prevention (CDC) and the US Food and Drug Administration (FDA), and an absence of national coordination. An added problem has been the spread of misinformation on social media, which has also undermined public trust in science and public health communication. It is concerning that large sections of society have displayed vulnerability to this

erroneous information. There have been warnings about this possibility, as the US and other countries built a societal order based on science and yet ignore broader science education of the population. The US must enhance knowledge and understanding of science and the scientific method to repair public trust in science and relevant institutions. Public understanding of science, along with effective communication from trusted sources, are critical to the implementation of evidence-based interventions to promote health and prevent disease. More immediate measures are needed to strengthen nonpartisan political commitment for public health and to protect the scientific independence and voice of public health institutions. The following questions (and some recommendations) need thoughtful deliberation: n Scientific discoveries must be understood and respected by the public. The remarkable cultural diversity in the US will require context- and culture-specific messaging and engagement. How can public communication be enhanced so that interventions supported by science are acted upon? How can education be improved to promote deeper understanding, knowledge, and trust in scientific principles? n Processes are in place to strengthen science, such as peer reviews of studies and of the recommendations of expert committees. Nevertheless, it is critical that the public appreciates that knowledge is ever changing and new questions can emerge. n What is needed for public policy and society to embrace this scientific temperament, and for science and the humanities to constructively embrace one another? n Public health needs protection

from the vagaries of partisan politics. What model of funding and governance can help to insulate public health institutions from short-term political concerns and position them to best serve the public, including anticipating and responding to public health emergencies? n Scientific agencies need to be free and unfettered to reveal full scientific and public health information. For example, the director of the agency (e.g., CDC) and the senior scientists should be expected to share uncensored scientific information and data with the public and to discuss facts with the media without constraints. What mechanisms can protect these functions? n A public health system oriented toward prevention and proactive measures will be best equipped to encounter a pandemic and respond to other ongoing health challenges. n Greater international engagement is paramount to ensure public health cooperation. There is increasing interconnectedness between science and public health and international economics, politics, and policy. Helping other countries prevent and control contagious diseases and promote health not only benefits those nations but also contributes to US domestic health security, well-being, and global leadership. How can we foster greater global collaboration in science and in public health? The CDC and FDA were created 75 and 115 years ago, respectively, each in response to a local health threat. The world is a far smaller place today than 100 years ago, with climate change and pandemics as global problems. To deal with these problems will require changes to the

governance structures of public health institutions and a rebuilding of public trust. EHD This essay first appeared in JAMA Network online. This version has been shortened for length. To read the full article, visit jamanetwork.com/journals/jama/fullarticle/2776207

Venkat Narayan, Emory professor of medicine and Hubert Professor of Global Health and Epidemiology at Rollins

James Curran, dean of Emory’s Rollins School of Public Health and professor of epidemiology

William Foege, Emory Presidential Distinguished Professor Emeritus of International Health at Rollins SPRING 2021

Plan big. Big changes can come from the smallest places. Like the tip of a needle delivering a lifesaving vaccine.

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SOCIETY

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W H AT ’ S Y O U R F A V O R I T E V A C C I N E ? From smallpox eradication to HPV vaccines that prevent cervical cancer, vaccines have saved millions of lives globally. Find out which vaccines Emory experts claim as their favorites. This 1966 photograph depicted two public health technicians in the process of carrying out a vaccination campaign inside a Dekalb County, Georgia, elementary school. In this view, a young girl was receiving two vaccinations simultaneously by way of a Ped-O-Jet® jet injector in each upper arm. In this case, these children were receiving both, a measles vaccine, and an immunity boosting, gamma globulin injection. Page 22 EMORY HEALTH DIGEST

PHOTO COURTESY OF CDC PUBLIC HEALTH IMAGE LIBRARY

Across the State and Around the Corner

Emory Healthcare in Georgia Emory Healthcare is the most comprehensive health system in the state, with locations all over Georgia, including 11 hospitals, 142 outpatient locations in 25 counties, and 19 regional affiliate hospitals in 17 counties. Winship Cancer Network has three locations.

5 4

9 7

8 6

2 1

The Clifton Corridor . . . and Beyond 2. Emory Clinic (multiple buildings)

7. Woodruff Health Sciences Center Administration Building

3. Winship Cancer Institute

8. Rollins School of Public Health

4. Emory Rehabilitation Hospital

9. Nell Hodgson Woodruff School of Nursing

5. Yerkes National Primate Research Center

10. Emory University Hospital Midtown

6. Emory School of Medicine (education and research buildings)

11. Executive Park (Emory Healthcare clinics in brain health, orthopaedics, and sports medicine)

1. Emory University Hospital