San Antonio Medicine February 2021

S A N A N TO N I O

Rodolfo Molina, MD 2021 BCMS PRESIDENT

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COVID-19 VACCINES Development of COVID-19 Vaccinations

By Alan Preston, MHA, ScD ..........................................12 Vaccine Acceptance – An Historical Perspective

By Kelly G. Elterman, MD ..............................................14 Mistrust of the COVID-19 Vaccine in African American Communities: A Problem that Stems Far Back from this Pandemic

By Antonio Webb, MD ..................................................16 Vaccine Implementation

By Bryan Alsip, MD .......................................................18 The Importance of COVID-19 Vaccination for Healthcare Personnel From the CDC, Updated Dec. 15, 2020 ........................20 The Phases of COVID-19 Vaccine Administration From the Centers for Disease Control ...........................20 The COVID-19 Vaccine in Texas The Texas Tribune, Excerpts*, Dec. 23, 2020 ................22 BCMS COVID-19 Vaccine Event in Photos ................24 BCMS President’s Message .....................................................................................................................................8 BCMS Alliance .......................................................................................................................................................10 2021 BCMS Installation of Officers .........................................................................................................................26 Benefits of Social Media for the Physician: How Being on Social Media and YouTube Can Help Supplement a Physician’s Practice By Antonio Webb, MD .....................................................................................................30 Two Characters Can Impact Your Reimbursement: The Importance of Using Modifiers

By Deion Whorton, Sr. ........................................................................................................................................32 The Theft and the Gift By Rajam Ramamurthy, MD.................................................................................................33 BCMS Circle of Friends Physicians Purchasing Directory........................................................................................34 Recommended Auto Dealers .................................................................................................................................39 Auto Review: 2021 Mercedes GLS63 AMG By Steve Schutz ................................................................................40 January article in San Antonio Medicine magazine entitled “Interdependence and Positive Psychology” was co-authored by * The Dr. Jon Courand and Dr. Adriana Dyurich. The printed article mistakenly did not include Dr. Dyurich as the co-author of the article.

Dr. Adriana Dyurich, PhD, LPC is an Academic Success Consultant for Graduate Medical Education at UT Health San Antonio.

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SAN ANTONIO MEDICINE • February 2021

FEBRUARY 2021

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VOLUME 74 NO. 2

San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS). All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement by BCMS. EDITORIAL CORRESPONDENCE: Bexar County Medical Society 4334 N Loop 1604 W, Ste. 200 San Antonio, TX 78249 Email: editor@bcms.org MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org SUBSCRIPTION RATES: $30 per year or $4 per individual issue ADVERTISING CORRESPONDENCE: Louis Doucette, President Traveling Blender, LLC. A Publication Management Firm 10036 Saxet, Boerne, TX 78006 www.travelingblender.com

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BCMS BOARD OF DIRECTORS

ELECTED OFFICERS

Rodolfo “Rudy” Molina, MD, President John Joseph Nava, MD, Vice President Brent W. Sanderlin, DO, Treasurer Gerardo Ortega, MD, Secretary Rajeev Suri, MD, President-elect Gerald Q. Greenfield, Jr., MD, Immediate Past President

DIRECTORS

Michael A. Battista, MD, Member Brian T. Boies, MD, Member Vincent Paul Fonseca, MD, MPH, Member David Anthony Hnatow, MD, Member Lubna Naeem, MD, Member Lyssa N. Ochoa, MD, Member John Shepherd, MD, Member Ezequiel “Zeke” Silva III, MD, Member Amar Sunkari, MD, Member Col. Charles Mahakian, MD, Military Representative Manuel M. Quinones Jr., MD, Board of Ethics Chair George F. “Rick” Evans, General Counsel Jayesh B. Shah, MD, TMA Board of Trustees Stephen C. Fitzer, CEO/Executive Director

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SAN ANTONIO MEDICINE • February 2021

Nichole Eckmann, Alliance Representative Ramon S. Cancino, MD, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Katelyn Jane Franck, Student Alexis Lorio, Student

BCMS SENIOR STAFF

Stephen C. Fitzer, CEO/Executive Director Melody Newsom, Chief Operating Officer Yvonne Nino, Controller August Trevino, Development Director Mary Nava, Chief Government Affairs Officer Phil Hornbeak, Auto Program Director Mary Jo Quinn, BCVI Director Brissa Vela, Membership Director Al Ortiz, Chief Information Officer

PUBLICATIONS COMMITTEE John Joseph Seidenfeld, MD, Chair Kristy Yvonne Kosub, MD, Member Louis Doucette, Consultant Fred H. Olin, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam V. Ratner, MD, Member Antonio J. Webb, MD, Member David Schulz, Community Member Donald Bryan Egan, Student Member Teresa Samson, Student Member Alexis A. Wiesenthal, MD, Member Neal Meritz, MD, Member Stephen C. Fitzer, Editor

PRESIDENT’S MESSAGE

Health Literacy: A Social Determinant of Health

By Rodolfo Molina, MD, 2021 BCMS President

Part 2. Recent Events and Actionable Proposals The purpose of Part 1 of this article was to ground us with a historical perspective and a working definition of health literacy. In this Part 2, I wish to explore recent events and actionable proposals to carry us forward to improve our level of health literacy in the population.

What is San Antonio and Bexar County doing to improve the health of our population? During the COVID-19 pandemic, while being home-bound, we heard daily reports from our local leaders, Mayor Ron Nirenberg and County Judge Nelson Wolff. Aside from giving us local statistics, they repeatedly told us to wear masks, adhere to social distancing and to wash our hands frequently. Good advice the fact that it was so often repeated made it a very clear message to understand. In a letter to the editor, Abel and McQueen used the term “critical health literacy” describing the urgency for the need of every individual to make an effort of understanding facts from fiction in the “exploding market of COVID-19” information. They further stated, “While accepting to sacrifice some part of one’s own individual freedom for the sake of a collective good may be seen as a matter of humanistic social values, in the case of the COVID-19 pandemic there is little time for philosophical rationales.”4 Even before the pandemic, over ten years ago, then Mayor Julian Castro initiated the Mayors Fitness Council. Its primary focus then was to target obesity by educating the population on nutrition and providing spaces for exercise. Recently, the Council has branched out to address mental illness. The council has been working with various business owners and our school districts to promote mental health awareness and have been recognized as a model for other Texas cities.

These are two specific examples of how to improve our population health and each with specific goals in education and community involvement. These examples are an excellent beginning in a path leading towards improved public health for everyone in Bexar County, but we have much more exciting work ahead of us. Through these efforts to improve health education, we are both directly and indirectly targeting and improving health literacy in our community.

Below are some fundamental steps that should be considered by our community, healthcare providers, healthcare mentors, and our politicians.

• Engaging students as early as elementary school, by teaching healthy eating habits in school and providing parents with resources to promote these habits at home • Require schools to provide healthy options for all students at school-provided lunches • Consider offering or requiring a one-semester course on basic healthy living principles including basic human anatomy, simple 8

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medical vocabulary and preventative/primary healthcare concerns for all Texas high school students Dedicated lecture series for our medical students on nutrition and how to counsel patients on lifestyle modification Expanded social services to include adequate follow-up after hospital discharge for all patients, regardless of insurance status, and require insurance companies to provide this service Require insurance companies to contact all their clients and help them with any issues they have encountered after a doctor’s visit Non-politicized platform from the city council (local newspaper clipping, local radio, flyers, commercials, etc.) with which medical providers can provide healthy tips and /or information on resources available locally Appropriate compensation for social work and case management teams within the medical field, and easy access to these services for the general public Mandate limits on pharmaceutical costs on a national level regardless of insurance status, especially for common medications such as those for high blood pressure, high cholesterol, and diabetes

These thoughts and recommendations are neither meant to be allinclusive nor final in their draft, but rather a starting point with which we can begin a conversation to address the much-needed changes in how we view and interact with health and our healthcare system.

It is essential that we maintain a complete understanding and appreciation of the value that health literacy adds to the betterment of all our patients.

References 1. Taylor, R., Rieger, A,. Medicine as Social Science: Rudolf Virchow On The Typhus Epidemic in Upper Silesia. International Journal of Health Services, Vol. 15, No. 4, 1985.

2. Berkman, N. D., DeWalt, D. A., Pignone, M. P., Sheridan, S. L., Lohr, K. N., Lux, L. et al. (2004). Literacy and health outcomes: Summary. In AHRQ evidence report summaries. Agency for Healthcare Research and Quality (US).

3. Kindig, D. A., Panzer, A. M., & Nielsen-Bohlman, L. (Eds.). (2004). Health literacy: a prescription to end confusion.

National Academies Press.

4. Abel T, McQueen D. Health Promotion International, daaa040, https://doi.org/10.1093/heapro/daaa040. 02 April 2020.

Rodolfo (Rudy) Molina, MD, MACR, FACP is a Practicing Rheumatologist and 2021 President of the Bexar County Medical Society.

BCMS ALLIANCE

Better Together

By Nichole Eckmann, 2021 BCMS Alliance President

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Founded in 1917, the Bexar County Medical Society Alliance has been serving the medical community of San Antonio for over 100 years! BCMSA began as a group of physician spouses sewing surgical gowns, rolling bandages & knitting mufflers for WWI soldiers. We sure have grown as an organization since then! Our members now are physician spouses with various skills and passions, who are also dedicated to their families and supportive of the physician’s rigorous schedule and frequent absenteeism from the household. The organization has evolved from spouses being home taking care of the family 100% of the time to being business owners and professionals, putting equal amounts of work into their careers, a balancing act that is often challenging.

When I first joined this organization around 4 years ago, I wasn’t really sure what to expect. I was newly married to my husband Dr. Maxim Eckmann, and I had no idea what it was like to live the medical life. I was adapting to that and to our new blended family of 6 boys! I had moved to San Antonio about a year before we were married and I didn’t have many friends. I was looking for a supportive group with like-minded individuals who could give me pointers on juggling this life and who understood the complexities of being married to medicine. I was at a birthday party one day and the wife of one of my husband’s co-workers, Dr. Lori Boies, asked me if I knew about the Bexar County Medical Society Alliance. I said no I did not, but I was interested in hearing more about it. She did a great job of explaining what the Alliance was all about, and when I left that birthday party, I told my husband I was really going to think more about joining, because I felt it was important for me to meet new people. A few weeks later I joined the organization, and I was welcomed with open arms.

I quickly made friends that I still have today, and I had an instant support system.

So why do I spend my time sitting on boards like the BCMSA with my often-crazy schedule of making breakfast for 6 kids every morning, taking time for exercise, managing a real estate business, keeping up with school functions and trying to make dinner every night? The answer is simple: camaraderie and a way to give back to the community. The medical life is one of a kind, one that you don’t understand unless you are living it. When I attend a board meeting or an event, I always connect with a member that “just gets it.” As President this year, that is, in a nutshell, what I’m hoping to achieve with my amazing Board in 2021. I want us to continue to make connections with other physician spouses and welcome them with open arms into this supportive group the way I was welcomed four years ago. Although times are challenging and have been a bit uncertain, we as an organization can be there for one another and continue to work together to give back to the community.

Danielle did a fantastic job in 2020 keeping the organization moving forward despite the fact we have not been able to have in-person events or meetings since March. We, as an organization, realized that the best way to deal with the uncertainty and worry was to continue to do what we do best — reach out to the community and give back. We continued to meet and create ideas for reaching out to our members and the community while setting an example of masking and social distancing.

One example of this has been working with The Mitchell Chang Foundation to provide masks to low-income families and health care workers, specifically families in zip codes with the highest COVID-19 rates and economic need.

For decades we’ve provided scholarships for students pursuing healthcare careers. Our Scholarship Committee met virtually this past Spring, awarding 5 allied health scholarships and we established two new medical student scholarships. In March, BCMSA created a “we come to you” PPE Drive with volunteers spanning the county to pick up donations in their area of town. Nearly 2,000 items of personal protective equipment were collected and donated to the University of Texas Health Science Center at San Antonio whose physicians and other medical team members staff our county hospital.

The goal is to continue creating ideas in 2021 that will allow us to stay connected with each other as members and with our community as well. If anything, the truth is we ARE better together!

Thanks so much to my presidential advisors and friends Dr. Lori Boies, Jenny Shepherd, Jennifer Lewis and past President Danielle Henkes for your continued support, and to my husband Dr. Maxim Eckmann for always bringing out the best in me and encouraging me to continue to fulfill my goals in life even if they sometimes seem out of reach. If anything, 2020 has shown us that if we stay connected, even if it is virtually, we can get through this! So, here is to 2021 and adapting to the unexpected!

SAN ANTONIO MEDICINE • February 2021

COVID-19 VACCINES

Development of COVID-19

Vaccinations

By Alan Preston, MHA, ScD

Operation Warp Speed has resulted in the creation of two, soon to be three or more, COVID-19 vaccinations. This is excellent news for all who are anxious to get back to normal without the restrictions imposed on small businesses and individuals. Operation Warp Speed's goal is to have private industry develop a vaccine and quickly allow the supply chain to deliver 300 million doses of safe and effective vaccines. Many people are, however, skeptical as to the safety of the vaccinations. Even with a vaccine for H1N1, only 50% of the population decides to take a vaccine to prevent the disease.

The FDA has created the gold standard for the approval of prescription drugs. The objective of all clinical trials is two-fold; one to assure safety to the patients, and the second to ensure the intervention works as intended. The last goal is what we call efficacy.

Efficacy can be thought of in two ways for a vaccine: 1. Efficacy can attempt to prevent the disease and the transmission of such.

2. In the rare case someone gets COVID-19, does the vaccine protect against severe symptoms?

To test the hypothesis as to whether the trial is both safe and effective, four study phases are required for approval from the FDA: 1. The pre-clinical phase is the animal studies to determine safety and efficacy 2. Phase-1: Small human trials to assure safety and no adverse side effects (usually less than 100 subjects)

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a. The proper dosage of the vaccine is tested at this phase to find the correct dosage 3. Phase-2: Moderate sample size of 100 to over 1,000 a. Trying to match the demographics of the target population who will receive the vaccine 3. Phase-3: Testing vaccine on humans a. Large sample size (30,000 to 60,000) b. The sample matches the demographics of the population c. Monitor how effective the vaccine is d. The population will have both the active and placebo vaccine If all goes well, the trial goes to approval for the Emergency Use Authorization (EUA) from the FDA. Once the EUA is achieved, then the distribution of the vaccination is cleared. There is a lot of confusion at this step. Our country is based on a republic that separates the federal government's roles from that of the States and local municipalities. The federal government can set "guidelines" as to what the priorities should be as to who gets the vaccination first; however, it is up to each state and local officials to work with the private community to coordinate the vaccination of patients, frontline caregivers and the vulnerable.

The early distribution of the vaccinations has been smooth in some communities and a disaster in others. Blaming the federal government for the local municipalities' inadequacies will not make the process easier or more effective.

The two vaccinations that have EUA from the FDA are Pfizer and Moderna. Both companies use a similar approach to the development of the vaccination. Both locate the Messenger RNA from one of the many found on the COVID-19 virus proteins and use that protein, which contains the messenger RNA, to introduce it to the human host. The objective of vaccination is to have the host create antigens to attack the COVID-19 protein. Then the human host will develop antigens to fight off the foreign RNA, and by producing antigens to fight off the m-RNA, your body is one step ahead if you encounter the real COVID-19. How does this work?

Here is how it works. The scientist takes a lipid nanoparticle to introduce the m-RNA into a protective casing. To maintain the integrity of the lipid nanoparticle, the manufacture must keep it very cold; otherwise, the efficacy is lost in a few days of the vial of the vaccine. This creates a transport vehicle to introduce to the human hosts. The COVID-19 S-Protein is contained in the lipid nanoparticle. Once it gets into the host cell, the good news is that it does not enter into the cell's nucleus, where the cell's DNA is located.

COVID-19 VACCINES

The mRNA will begin making proteins using the cell's ribosomes. The ribosomes help decode the message. The process of making proteins from the mRNA is called translation. The new proteins get expressed on the cell membrane on two types of proteins. One of the existing cells' proteins is called MHC-2 protein, which is only found on antigen-presenting cells. The MHC-2 protein is only found on B-cells and Dendritic Cells, which act as messengers between the innate and the adaptive immune systems.

The body's response to attract is to attack the S-protein. But how does that work? The Thelper cell and the T-cell become activated, which begins to release a lot of cytokines. Interleukin 2 and 4, and 5 are created. It tells the B-cells to proliferate and to differentiate and have the plasma cells to make antibodies. The antibodies go after any virus that has an S-protein. It also stimulates the T-cells to produce memory antibodies.

How long will the antibodies stick around?

We don't know yet. It may be six months or nine months or longer, but time will tell. What we do know based on the clinical trials is that it is effective, over 95% for Moderna and 94.5% for Pfizer. Again, there are two ways to look at efficacy. One is against getting the disease, and the other is stopping the severity of the disease.

As an example, Moderna tested nearly 30,000 patients. They were divided into two groups; one group had the vaccine injected, the other had saline (the placebo) injected. For those who had symptoms and tested positive, this is what they found. For the placebo group, about 185 tested positive. For the vaccine group, only 11 tested positive; but in the vaccine group none had severe symptoms of COVID-19.

In the placebo group, about 30 were severe cases. Therefore, Moderna’s efficacy against getting the disease is 185-11=174/185= 94%. Moderna vaccine’s efficacy for preventing severe symptoms of COVID-19 was 100%!

The challenge of keeping the vaccination cold is a real challenge to many communities throughout the USA. To store the vaccines and be viable, it needs to be -4 Fahrenheit for the Moderna, and it needs to be – 94 degrees Fahrenheit for Pfizer. And therein lies part of the problem with the distribution system. Which providers have the necessary freezers to keep the vaccine vials at such a low temperature?

Additionally, each vial can administer about ten patients. One of the issues is making sure that all ten doses are give to patients who show up at the same time to receive the vaccination. Another challenge is making sure that once patients receive the first injection, they return

about 21 days later (Pfizer) or 28 days later (Moderna) for the second injection. The first injection is only about 57% efficacious and requires to have the second vaccination to become 95% effective. Managing this population to assure compliance with these parameters will be a challenge for the doctor's offices and other institutions that administer the vaccine.

What will it take to get to “herd immunity”?

There is not a definitive answer to that question; however, the consensus is about 75% of the population vaccinated can substantially mitigate the transmission of COVID-19. And of course, if the vaccine is administered to the vulnerable population in more significant percentages, the COVID-19 death rate should plummet. The other tremendous benefit of a vaccine is that it should mitigate the impact on hospitals and, in particular, the ICU beds. I suspect there is a significant population that needs attention to many other diseases that are not being addressed during this pandemic. If we continue to scare people from getting the necessary care they need, far more of those individuals will die from not being vaccinated than from those who actually get the COVID-19 disease.

Let's hope that these and other vaccines put an end to the COVID19 pandemic. We need to be patient and understanding as the local infrastructure evolves to manage the vaccines' dispensing. It is time to get the country opened up again and allow people to get back to work.

The nature of people is to socialize; isolation is never good for a healthy society.

Alan Preston, MHA, Sc.D. works in the area of Population Health Management and has a doctorate in Science in Epidemiology and Biostatistics from Tulane University and has spent his entire career in the healthcare space.

Visit us at www.bcms.org

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COVID-19 VACCINES

Vaccine Acceptance –

An Historical Perspective

By Kelly G. Elterman, MD

With the much-awaited arrival of the COVID-19 vaccine in December 2020, vaccination has become a frequent topic of conversation – discussed in hospitals, pharmacies, on social media, and around the dinner table. Everyone has questions, concerns, and opinions. Despite the ongoing pandemic and known risks of COVID-19 infection to both individuals and society, vaccine acceptance appears neither universal nor outright, even among healthcare workers.

In a recent JAMA study, scientists found that only 51%-61% of Americans would accept a COVID-19 vaccine if offered, depending on vaccine efficacy; 51% would accept a vaccine with 50% efficacy and 61% would accept one with 90% efficacy. The Lancet published a similar study, demonstrating a 67% acceptance rate. Internationally, vaccine acceptance varied depending on the country’s trust of its government, but was still less than the 70% needed to achieve herd immunity.

The reluctance or refusal to accept vaccination when it is available has been termed “vaccine hesitancy,” by the World Health Organization and has been identified in 90% of countries worldwide. In 2019, the WHO listed vaccine hesitancy as a top ten global health threat.

While this phenomenon may seem a product of the modern age fueled by the spread of misinformation on the internet, it has actually afflicted society for centuries.

Vaccination has a long and complicated history. The first precursor to modern day vaccination appears to have occurred as early as 1000 AD in China, where smallpox sores were ground and inhaled. In the 1700s, small pox variolation – the practice of deliberate infection using dried smallpox scabs from an afflicted individual – was practiced in Asia, India, and the Ottoman Empire. The practice was promoted in England by Lady Mary Wortley Montagu, who variolated her son in Turkey, and in the colonies by Boston clergyman Cotton Mather, both of whom were heavily criticized despite evidence than only 2-4% of those variolated died, compared to 20-30% of those who became ill naturally.

Smallpox continued to kill many in Europe and the colonies throughout the 1700s. In 1796, Edward Jenner successfully demonstrated prevention of smallpox using vaccination with cowpox material. Four years later, Benjamin Waterhouse, a Harvard physician, introduced the practice to the United States when he performed the first vaccinations on his own children. Within a matter of years, the term “vaccination” emerged and the first U.S. Vaccine Agency established.

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By the middle of the 19th century, vaccination of schoolchildren against smallpox became mandatory in the United Kingdom and in Massachusetts, the first US state to pass a vaccination law. Less than thirty years later, in 1882, a group known as the Anti-Vaccination League held its first meeting in New York at which speakers propagated the notion that smallpox was spread by filth, rather than contagion. Much like in modern-day, this idea spread successfully despite evidence to the contrary.

Another historical parallel to modern-day vaccine hesitancy is the 1905 case of Jacobson v. Massachusetts, in which the defendant argued that the Massachusetts law requiring smallpox vaccination violated his individual rights to decide what was best for his own body. The Supreme Court determined, however, that individual rights must fit within a framework of what is best for society as a whole, particularly during an epidemic. Interestingly, this case was settled in favor of public health over 100 years ago, yet the same argument persists a century later amidst a global pandemic.

Since smallpox, other diseases plaguing humankind have been successfully controlled if not eliminated through vaccination. In 1917, little more than a decade after Jacobson v. Massachusetts, the influenza pandemic began in the United States. Then, as now, public health measures such as masking were instituted with mixed acceptance, and scientists raced to develop a vaccine as the virus claimed the lives of more than half a million Americans. Unlike current times, however, it was 20 years before scientists could successfully isolate the virus and develop a vaccine, then another decade before the vaccine could be publicly available. Fortunately, vaccine development science has advanced such that we need not wait decades to find the tools to successfully prevent similar tragedies.

Various childhood diseases that previously resulted in death or disability are another example. Prior to vaccination, polio resulted in 15,000 cases of paralysis annually in the United States. Measles caused 3 to 4 million cases of illness, 48,000 hospitalizations and 500 deaths

COVID-19 VACCINES

each year. Through wide-spread vaccination, polio was eliminated from the United States in 1979 and measles in 2000. Ironically, it is this success that has allowed vaccine hesitancy to flourish. As time passes, disease prevalence declines and the public forgets the disease, the proven risks of illness become unrealistically compared to the perceived risks of vaccination. Measles illustrates this phenomenon well: after elimination in 2000, cases peaked in 2019, with the majority occurring in unvaccinated communities where many fear vaccine-related autism more than measles despite scientific evidence that the concern is unfounded.

While some vaccination fears are born from misinformation, others are based on actual, albeit minute, risk. Historically, smallpox variolation carried a risk of death. In 1955, a manufacturing error resulted in 11 deaths and hundreds of cases of paralysis among children vaccinated with the injected, killed poliovirus. More prominent in the public’s eye, however, are the cases of influenza that occur each year despite vaccination. With such events scattered throughout history, it is not difficult to understand why vaccine hesitancy exists.

In sharp contrast to those who refuse vaccines are the scientists and volunteers who accept risk for the sake of societal benefit. These too, are found throughout history. Centuries ago, it was those subjecting themselves and their children to variolation. More recently, it was Dr. Mikhail Chumakov and his wife, Dr. Marina Voroshilova, a pair of Russian scientists who tested Dr. Albert Sabin’s live-attenuated polio vaccine on themselves and their children to prove its safety and efficacy when neither the United States nor the Soviet Union would conduct trials of a live vaccine on children. Their confidence and bravery ultimately led to the development of trials and the approval of the oral polio vaccine, which subsequently benefited countless children worldwide. Today, it is the COVID-19 vaccine trial volunteers and the frontline workers willing to take the vaccine immediately despite the concerns of their families, friends, and colleagues.

Vaccination, its acceptance and refusal have an interesting history that appears, as all unstudied history, to repeat itself. Over time, the diseases change but the arguments remain the same. Despite many forms over the centuries, it is still the spread of misinformation, little of which is fact-based, that is responsible for fear and mistrust leading to vaccine hesitancy and the resultant public health consequences.

Nonetheless, the facts and numbers remain: throughout history and in modern day, vaccination results in the decline of disease and illnessrelated death.

We are fortunate to live in a time where our scientific advances allow us to forget the scars of childhood diseases and to develop tools to fight new viral foes within a matter of months. If only we could fight vaccine hesitancy as quickly.

References: 1. Kreps S, Prasad S, Brownstein JS, et al. (2020). Factors Associated With US Adults’ Likelihood of Accepting COVID-19 Vaccination. JAMA Network Open, 3(10), e2025594. https://doi.org/10.1001/jamanetworkopen.2020.25594 2. Malik AA, McFadden SM, Elharake J, Omer SB. (2020). Determinants of COVID-19 vaccine acceptance in the US. EClinicalMedicine, 26, 100495. https://doi: 10.1016/j.eclinm.2020.100495.

3. Lazarus, J.V., Ratzan, S.C., Palayew, A. et al. (2020). A global survey of potential acceptance of a COVID-19 vaccine. Nat Med, 1-4. https://doi.org/10.1038/s41591-020-1124-9 4. MacDonald, N. E. (2015). Vaccine hesitancy: definition, scope and determinants. Vaccine 33(34), 4161-4164. https://doi.org/10.1016/j.vaccine.2015.04.036.

5. World Health Organization. (2019). Ten threats to global health in 2019. The World Health Organization. https://www.who.int/news-room/spotlight/ten-threats-toglobal-health-in-2019 6. The Lancet Child & Adolescent Health. (2019). Vaccine hesitancy: A generation at risk. The Lancet Child & Adolescent Health, 3(5):281. https://doi.org/10.1016/S23524642(19)30092-6.

7. The College of Physicians of Philadelphia. (2020). The History of Vaccines – An Educational Resource. https://www.historyofvaccines.org/multilanguage/timeline 8. Edwards KM & Hackell JM. (2016). Countering Vaccine Hesitancy.

PEDIATRICS, 138(3):e20162146. https://doi.org/10.1542/peds.2016-2146.

9. Centers for Disease Control and Prevention. (2020). Measles.

Centers for Disease Control and Prevention. https://cdc.gov/measles 10. Centers for Disease Control and Prevention. (2020). Global immunization. Centers for Disease Control and Prevention. https://cdc.gov/polio 11. Kramer, A. (2020 June 24). Decades-Old Soviet Studies Hint at Coronavirus Strategy. The New York Times. https://www.nytimes.com/2020/06/24/world/europe/vaccine-repurposingpolio-coronavirus.html

Kelly G. Elterman, MD is a board-certified anesthesiologist and independent contractor in San Antonio and is a member of the Bexar County Medical Society.

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Mistrust of the COVID-19 Vaccine in African American Communities: A Problem that Stems Far Back from this Pandemic

By Antonio Webb, MD

With thousands of front-line workers and other members of our society already receiving the first round of COVID-19 vaccinations around the world, there is a subset of our population that still have doubts and hesitancy surrounding it: African Americans.

The Issue at Hand This hesitancy and lack of trust is multifactorial, stemming way back to the 1800s. During this time, James Marion Sims, a national and renowned doctor who later became known as the “Father of Gynecology,” performed medical experiments on enslaved women. These women, who by his definition of their position in society, could not provide informed consent. During this time he performed experimental operations, many times without anesthesia. This was in part because he didn't believe black women experienced pain in the same way that white women did. Between 1930 and 1970, 65% of the 7,600 plus sterilizations ordered by the state of North Carolina were carried out on black women.1 For nearly half of the 20th century, black women were forcibly sterilized often without their knowledge. Some of these women were sterilized during cesarean sections and were never told; others were threatened with termination of welfare benefits or denial of medical care if they didn’t “consent” to the procedure; others received unnecessary hysterectomies at teaching hospitals as practice for medical residents. In the south, it was such a widespread practice that it had a euphemism: a “Mississippi appendectomy.”

The US Public Health Service began the Tuskegee study in 1932.

Black males in Macon County, Alabama, who had already contracted syphilis, were recruited to participate in the study.2 These men were told that the purpose of the trial was to study and understand whether syphilis progressed differently in black people as compared to white people. Although a novel treatment at the time, penicillin became widely available a few years later in 1943, but these black males were intentionally not treated. Unfortunately, many of these black males died from untreated syphilis by the time the study was halted in 1972.

Many others went on to infect their wives, some of whom then transmitted the disease to their children.

Fast forward to 2021, there are a lot of similarities between Dr. James Sims’ experimental operations in the mid 1800s, the unconsented sterilizations of black women and Tuskegee experiments in the 1930s, and disparities in COVID-19 - all which highlight the system16

SAN ANTONIO MEDICINE • February 2021

atic and structural discriminations that have and currently exist in the United States. It is well known that black and minority patients are more likely to die of preventable diseases such as heart disease and stroke. They also have higher rates of cancer, asthma, influenza, pneumonia, diabetes, and HIV/AIDs. For many of them, structural racism and unequal treatment remain a contributing factor to disease and death. There is an abundance of literature also showing that racial and ethnic minority groups are being disproportionately affected by COVID-19.3-5 It is said that black Americans are infected with COVID-19 at nearly three times the rate of white Americans and are twice as likely to die from the virus. This is due to many of the inequities in social determinants of health. These include discrimination, lower rates of health insurance coverage, barriers to accessing healthcare, educational inequalities, income and wealth gaps, and limited access to quality housing to name a few. These factors and others are associated with more COVID-19 cases, hospitalizations, and deaths in areas where racial and ethnic minority groups live, learn, play, and worship.6 Beyond these factors, research shows that historic and widespread abuse and mistreatment of communities of color by the medical system and ongoing racism and discrimination drive disparities in healthcare. This contributes to lower quality of care, distrust of the healthcare system along with stress and trauma.7 Dr. Susan Moore, an African American physician, is just one example. She died in Dec 2020 following multiple hospitalizations for complications from COVID-19. Acutely aware of her deteriorating condition, she repeatedly asked for medications to treat her pain; imaging studies to assess her dyspnea and routine checks while admitted to the hospital, all while under the care of a white physician. She noted on widely shared social media posts that her pain was dismissed during her stay and that she didn't trust the hospital system. She expressed being treated like a drug addict and was reportedly told to be discharged home from the hospital despite her reported symptoms. She publicly cried for help by stating, "I put forth and maintain, if I was white, I wouldn’t have to go through that. This is how black people

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get killed, when you send them home and they don’t know how to fight for themselves.” Despite being a physician herself and saving countless lives during her medical career, her outcry for adequate and fair treatment could not save her own. This highlights the fact that even being an educated physician in our country does not exclude one from the systemic and structural racism.

A recent pew research report highlighted the fact that black Americans are less inclined to receive the COVID-19 vaccination than other racial and ethnic groups: 42% would do so compared to 63% of hispanics and 61% of white adults. Another recent report from UnidosUS, the NAACP, and COVID collaborative revealed that just 14% of Black Americans and 34% of Latino Americans say they have trust in the safety of a new COVID-19 vaccine. The study also found that 18% of Black and 40% of Latino respondents trust the COVID19’s vaccine effectiveness.8 The unfortunate reality is that Black people in this country have been trained, over many centuries, to distrust both the government and medical community on the issue of healthcare and hence the hesitation and lack of trust of the COVID-19 vaccine.

physicians were more likely to engage with them, and even consent to preventive services like cardiovascular screenings and immunizations. They found that the effects were most pronounced for men who have little experience obtaining medical care and among those who mistrust the medical system.10 To those points, we must work directly with our community leaders and amplify the voices of people of color to ease fears, build trust and disseminate factual evidencebased information about the vaccines. Only then will we be able to start healing and recovering from the mistrust, physical, and psychological damage imparted on the black race and culture for hundreds of centuries in the past.

Our Roles as Clinicians As clinicians, our job is to first assimilate knowledge about various conditions, treatments, medications and then impart this information to our patients in a shared decision-making manner. To date (as of this writing), 300,000+ people have lost their lives to this deadly virus.9 Black Americans have been disproportionately affected by pandemic morbidity and mortality, and this experience is reflected in hesitancy attitudes and behavior towards the COVID-19 vaccine. As leaders in our communities, we must first build trust. Having healthcare providers from diverse backgrounds that are of the same race and gender is critical. Studies show that black patients have better outcomes when treated by black doctors. For example, a Stanford University study looked at black men in Oakland, California and paired them with either Black or non-Black doctors. The men seen by Black

REFERENCES 1. Stern AM. Sterilized in the name of public health: race, immigration, and reproductive control in modern California. Am J Public Health. 2005;95(7):1128-1138. doi:10.2105/AJPH.2004.041608 2. https://www.cdc.gov/tuskegee/timeline.htm 3. Stokes EK, Zambrano LD, Anderson KN, et al. Coronavirus Disease 2019 Case Surveillance — United States, January 22–May 30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:759–765.

4. Killerby ME, Link-Gelles R, Haight SC, et al. Characteristics Associated with Hospitalization Among Patients with COVID-19 — Metropolitan Atlanta, Georgia, March–April 2020. MMWR Morb Mortal Wkly Rep. ePub: 17 June 2020.

5. Gold JA, Wong KK, Szablewski CM, et al. Characteristics and Clinical Outcomes of Adult Patients Hospitalized with COVID19 — Georgia, March 2020. MMWR Morb Mortal Wkly Rep 2020;69:545–550.

6. https ://www.cdc.g ov/coronavir us/2019ncov/community/health-equity/race-ethnicity. html#fn2 7. Institute of Medicine. 2003. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/12875.

8. https://static1.squarespace.com/static/5f85f5a15 6091e113f96e4d3/t/5fb72481b1eb2e6cf84 5457f/1605837977495/VaccineHesitancy_BlackLatinx_Final_11.19.pdf 9. https://coronavirus.jhu.edu/ 10.https://siepr.stanford.edu/research/publications/does-diversity-matter-health-experimentalevidence-oakland

Dr. Antonio Webb is an Orthopedic Spine Surgeon located in San Antonio, Texas with the South Texas Spinal Clinic.

To contact Dr. Webb, please email toniowebb@gmail.com or more information about Dr. Webb can be found at www.antoniowebbmd.com or www.youtube.com/antoniowebbmd. Dr. Webb is a member of the Bexar County Medical Society.

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Vaccine Implementation

By Bryan Alsip, MD

On December 11, 2020, the U.S. Food and Drug Administration (FDA) issued the first emergency use authorization for the PfizerBioNTech COVID-19 vaccine for the prevention of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). From a public health standpoint, this represented a significant turning point in our war against COVID19, marking a deliberate shift in strategy from defense to offense. Having been on the defensive for over a year, that was a refreshing change.

The authorization of the Pfizer-BioNTech vaccine also brought its own challenges. Although praised for early data which suggest the vaccine is safe and effective, it has strict storage and handling requirements. Specifically, vials of vaccine must be kept frozen between -112ºF and -76ºF, which requires an ultra-low temperature freezer not readily available to most immunization providers. As federal and state governments made decisions regarding allocation, only those organizations that had enrolled as vaccine providers and had indicated they could meet the ultra-low temperature storage requirements were des18

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ignated to receive the Pfizer-BioNTech vaccine. Therefore, week 1 allocations of the COVID-19 vaccine in Texas went almost exclusively to hospitals.

Those hospitals and health systems began immunizing their staff as recommended by both the CDC’s Advisory Committee on Immunization Practices (ACIP) and the Texas Expert Vaccine Allocation Panel (EVAP), but the supply of vaccine did not initially meet the demand. Some hospitals did not receive enough doses, or even any vaccine. Furthermore, Health Care Workers, as defined by the Texas EVAP for Phase 1A, includes an extensive range of staff and providers working both inside and outside of the hospital setting.

As we have seen throughout this pandemic, our community found ways to collaborate. Several organizations that received initial allocations began to share vaccine and to immunize others. University Health partnered with the Southwest Texas Regional Advisory Council (STRAC), the City of San Antonio, Bexar County, and other healthcare providers, to offer vaccinations to EMS providers who en-

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gage in 9-1-1 emergency services like pre-hospital care and transport, staff in outpatient care settings who interact with symptomatic patients, and healthcare workers in corrections and detention facilities.

On December 18, 2020, the FDA issued an emergency use authorization for the Moderna COVID-19 vaccine, which demonstrated similar safety and efficacy as the Pfizer-BioNTech version with some logistical advantages. Although it is shipped frozen (between -13ºF and 5ºF), the Moderna vaccine does not have the same ultra-low temperature storage requirements. The Moderna vaccine also does not require dilution and, after being thawed, can stay refrigerated for up to 30 days prior to use. This makes the vaccine easier to store and administer, which enables more organizations to play a role in offering the vaccine. Week 2 allocations of the COVID-19 vaccine in Texas included the Moderna product and were shipped to a larger group of immunization providers including physician offices, urgent care clinics, and pharmacies. Unfortunately, many of these allocations were very small, with several locations receiving only the minimum supply of 100 doses.

During the same week, the Texas Department of State Health Services (DSHS) published their recommendations for Phase 1B COVID19 vaccine allocation. As with several other states, these guidelines differed from those published by the CDC’s Advisory Committee on Immunization Practices (ACIP), by not recommending the vaccine

next for frontline essential workers, but rather focusing “on people for whom there is strong and consistent evidence that COVID-19 makes them more likely to become very sick or die.” Although this extensively broadened the population for which the COVID-19 vaccine was indicated, it also further exacerbated the COVID-19 vaccine supply and demand inequity.

COVID-19 vaccines offer great promise in our battle against the adverse health effects of this pervasive disease, but we still have several immediate needs: we need more vaccine supply; we need more organizations to enroll as vaccine providers to administer the vaccine; and we need more clear communication regarding where those who are recommended to receive the vaccine can do so. I have the privilege of working with many dedicated leaders and professionals in our community who are committed to addressing these issues.

As of this writing, University Health has begun to offer the COVID-19 vaccine to individuals in the Phase 1B category through a large vaccination setting and other organizations are also finalizing plans to provide immunizations to this vulnerable population. The state of Texas is communicating that if vaccine providers administer the vaccine they will get more, and so is strongly encouraging that no doses be held in reserve. With the timing of the second dose of approaching for those who were immunized early, and a larger eligible population, we need a consistent and growing supply of vaccine to be provided.

Just recently, the COVID-19 vaccine developed by the University of Oxford and AstraZeneca was authorized by regulators in the U.K. and in India, bringing yet another weapon to the global fight against this novel coronavirus. It is the most logistically forgiving of the three major vaccines to date since it only requires refrigeration for storage, which opens up supply to a vast network of existing immunization infrastructure. However, researchers are estimating that FDA authorization of the Oxford AstraZeneca vaccine may not come until April 2021. Until then, we must maximize the availability and administration of both the Pfizer-BioNTech and Moderna vaccines in the coming months.

As more organizations in Bexar County enroll to become immunizers, more vaccine is provided by the state and federal governments, and more venues become available to our community residents, we can protect more people against symptomatic COVID-19 disease. At a time when hospitalizations for COVID-19 patients in Texas are at an all-time high, this is more important than ever. If you or your organization traditionally offers immunizations, please become a part of this endeavor. Enroll as a COVID-19 vaccine provider with the Texas Department of State Health Services (DSHS) at https://enrolltexasiz.dshs.texas.gov/emrlogin.asp and immunize your staff and eligible patients as guidelines recommend. We need more community contributors to expand our vaccination efforts and help make 2021 the year we turn the tide on this historic pandemic.

Bryan Alsip, MD MPH FACPM is Executive Vice President and Chief Medical Officer for the University Health System and is a member of the Bexar County Medical Society.

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The Importance of COVID-19 Vaccination for Healthcare Personnel Updated Dec. 15, 2020 (CDC) Based on recommendations from the Advisory Committee on Immunization Practices (ACIP), an independent panel of medical and public health experts, CDC recommends healthcare personnel be among those offered the first doses of COVID19 vaccines.

Healthcare personnel include all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials. This recommendation pertains to paid and unpaid healthcare personnel working in a variety of healthcare settings—for example, acute care facilities, long-term acute care facilities, inpatient rehabilitation facilities, nursing homes and assisted living facilities, home health care, mobile clinics, and outpatient facilities, such as dialysis centers and physicians’ offices.

Examples of healthcare personnel include: Emergency medical service personnel, nurses and nursing assistants, physicians, technicians, therapists, dentists, dental hygienists, and assistants.

Who is included under the broad term “healthcare personnel”? Phlebotomists, pharmacists, students, and trainees, contractual staff, dietary and food services staff, environmental services staff, and administrative staff. Healthcare personnel are at risk of exposure because they are on the front line of the nation’s fight against this deadly pandemic. Healthcare personnel’s race and ethnicity, underlying health conditions, occupation type, and job setting can contribute to their risk of acquiring COVID-19 and experiencing severe outcomes, including death.

By providing critical care to those who are or might be infected with the virus that causes COVID-19, healthcare personnel have a high risk of being exposed to and getting sick with COVID19. As of December 3, the day CDC published these recommendations, there were more than 249,000 confirmed COVID-19 cases and 866 deaths among healthcare personnel. View more recent numbers on the toll COVID-19 has taken on healthcare personnel by visiting the CDC website.

Vaccinating healthcare personnel protects healthcare capacity.

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The Phases of COVID-19 Vaccine Administration

By Centers for Disease Control (CDC) The first vaccines for prevention of coronavirus disease 2019 (COVID-19) in the United States were authorized for emergency use by the Food and Drug Administration (FDA) (1) and recommended by the Advisory Committee on Immunization Practices (ACIP) in December 2020.* However, demand for COVID-19 vaccines is expected to exceed supply during the first months of the national COVID-19 vaccination program. ACIP advises CDC on population groups and circumstances for vaccine use.† PHASES On December 1, ACIP recommended that 1) health care personnel§ and 2) residents of long-term care facilities be offered COVID-19 vaccination first, in Phase 1a of the vaccination program (2).

On December 20, 2020, ACIP recommended that in Phase 1b, vaccine should be offered to persons aged ≥75* years and frontline essential workers (non–health care workers), and, In Phase 1c, persons aged 65–74 years, persons aged 16–64 years with high-risk medical conditions, and essential workers not recommended for vaccination in Phase 1b should be offered vaccine.** These recommendations for phased allocation provide guidance for federal, state, and local jurisdictions while vaccine supply is limited. In its deliberations, ACIP considered scientific evidence regarding COVID-19 epidemiology, ethical principles, and vaccination program implementation considerations. ACIP’s recommendations for COVID-19 vaccine allocation are interim and might be updated based on changes in conditions of FDA Emergency Use Authorization, FDA authorization for new COVID-19 vaccines, changes in vaccine supply, or changes in COVID-19 epidemiology.

Following ACIP’s interim recommendation for vaccine allocation in Phase 1a (2), the Work Group proposed vaccine allocation for Phases 1b and 1c. A description of the population groups in these phases, supporting scientific data, consideration of ethical principles, and considerations for vaccination program implementation are presented in this report, and supporting evidence is available at https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/covid-19/evidencetable-phase-1b-1c.html.

Phase 1b Approximately 49 million persons, including frontline essential workers (non– health care workers) and persons aged ≥75* years are recommended to receive vaccine in Phase 1b of the COVID-19 vaccination program (Table). Essential workers perform duties across critical infrastructure sectors and maintain the services and functions that U.S. residents depend on daily. The Cybersecurity and Infrastructure Security Agency (CISA) of the U.S. Department of Homeland Security has developed a list intended to guide jurisdictions in identifying essential critical infrastructure workers, who may be exempted during stay-at-home-orders (3). ACIP used CISA guidance to define frontline essential workers as the subset of essential workers likely at highest risk for work-related exposure to SARS-CoV-2, the virus that causes COVID-19, because their work-related duties must be performed on-site and involve being in close proximity (<6 feet) to the public or to coworkers.

ACIP has classified the following non–health care essential workers as frontline workers: first responders (e.g., firefighters and police officers), corrections officers, food and agricultural workers, U.S. Postal Service workers, manufacturing workers,

COVID-19 VACCINES ditional interim considerations for phased implementation of COVID-19 vaccines are available at https://www.cdc.gov/vaccines/ covid-19/initialpopulations.html and https://www.cdc.gov/vaccines/covid-19/phased-implementation.html.

grocery store workers, public transit workers, and those who work in the education sector (teachers and support staff members) as well as child care workers.§§ A tiered approach for essential workers builds on the occupations identified by the National Academies of Science, Engineering and Medicine for early vaccination (4).

Persons aged ≥75 years are at high risk for COVID-19–associated morbidity and mortality. As of December 20, 2020, the cumulative incidence of COVID-19 among persons in this age group was 3,839 per 100,000 persons, with a cumulative hospitalization rate of 1,211 per 100,000, and a mortality rate of 719 per 100,000 (7–9). The overall proportion of persons aged ≥75 years who live in a multigenerational household is 6%; the proportion among non-Hispanic White persons is 4%, and the proportion among racial or ethnic minority groups is higher (non-Hispanic Black persons, 10%; Hispanic or Latino persons, 18%; non-Hispanic persons of other races, 20%).*** Phase 1c In Phase 1c, vaccine should be offered to persons aged 65–74 years, persons aged 16–64 years††† with medical conditions that increase the risk for severe COVID-19, and essential workers not previously included in Phase 1a or 1b.

Based on ongoing review of the literature, CDC has identified medical conditions or risk behaviors that are associated with increased risk for severe COVID-19.§§§ The risk for COVID-19–associated hospitalization increases with the number of high-risk medical conditions, from 2.5 times the risk for hospitalization for persons with one condition to 5 times the risk for those with three or more conditions (10). According to a recent analysis of 2018 Behavioral Risk Factor Surveillance System data, at least 56% of persons aged 18–64 years report at least one high-risk medical condition (CDC COVID-19 Response Team, Division of Population Health, personal communication, December 2020). Essential worker sectors recommended for vaccination in Phase 1c include those in transportation and logistics, water and wastewater, food service, shelter and housing (e.g., construction), finance (e.g., bank tellers), information technology and communications, energy, legal, media, public safety (e.g., engineers), and public health workers.**** Implementing vaccination programs to reach essential workers will pose challenges. Use of multiple strategies is recommended to reduce barriers to vaccination,†††† such as providing vaccination opportunities at or close to the workplace. State and local health authorities will need to take local COVID-19 epidemiology and demand for vaccine into account when deciding to proceed to the next phase or to subprioritize within an allocation phase if necessary. A flexible approach to allocation will facilitate efficient management and ensure that COVID-19 vaccine is administered equitably and without delay. Ad-

Phase 2 Phase 2 includes all other persons aged ≥16 years not already recommended for vaccination in Phases 1a, 1b, or 1c. Currently, in accordance with recommended age and conditions of use (1), any authorized COVID19 vaccine may be used.

References *65 years or greater in Texas 1. Food and Drug Administration. COVID-19 vaccines. Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration; 2020. https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/covid-19-vaccinesexternal icon 2. Dooling K, McClung N, Chamberland M, et al. The Advisory Committee on Immunization Practices’ interim recommendation for allocating initial supplies of COVID-19 vaccine—United States, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1857–9. CrossRefexternal icon PubMedexternal icon 3. Cybersecurity and Infrastructure Security Agency. Guidance on essential critical infrastructure workers: version 4.0. Washington, DC: US Department of Homeland Security, Cybersecurity and Infrastructure Security Agency; 2020. https://www.cisa.gov/publication/guidance-essential-critical-infrastructure-workforceexternal icon 4. National Academies of Sciences, Engineering, and Medicine. Framework for equitable allocation of COVID-19 vaccine. Washington, DC: National Academies of Sciences, Engineering, and Medicine; 2020. https://www.nationalacademies.org/our-work/a-framework-for-equitable-allocation-of-vaccine-for-th e-novel-coronavirus#sectionPublicationsexternal icon 5. Bui DP, McCaffrey K, Friedrichs M, et al. Racial and ethnic disparities among COVID-19 cases in workplace outbreaks by industry sector—Utah, March 6– June 5, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1133–8. CrossRefexternal icon PubMedexternal icon 6. Waltenburg MA, Victoroff T, Rose CE, et al.; COVID-19 Response Team.

Update: COVID-19 among workers in meat and poultry processing facilities— United States, April–May 2020. MMWR Morb Mortal Wkly Rep 2020;69:887–92. CrossRefexternal icon PubMedexternal icon 7. CDC. Coronavirus disease 2019 (COVID-19): CDC COVID data tracker.

Atlanta, GA: US Department of Health and Human Services, CDC; 2020. https://covid.cdc.gov/covid-data-tracker 8. CDC. COVID-NET: laboratory-confirmed COVID-19–associated hospitalizations. Atlanta, GA: US Department of Health and Human Services, CDC; 2020. https://gis.cdc.gov/grasp/COVIDNet/COVID19_3.html 9. CDC. Weekly updates by select demographic and geographic characteristics: provisional death counts for coronavirus disease 2019 (COVID-19). Atlanta, GA: US Department of Health and Human Services, CDC; 2020. https://www.cdc.gov/nchs/nvss/vsrr/covid_weekly/index.htm#AgeAndSex 10. Ko J, Danielson M, Town M, et al. Risk factors for coronavirus disease 2019 (COVID-19)–associated hospitalization: COVID-19–Associated Hospitalization Surveillance Network and Behavioral Risk Factor Surveillance System.

Clin Infect Dis 2020. E-pub September 18, 2020. CrossRefexternal icon PubMedexternal icon 11. McClung N, Chamberland M, Kinlaw K, et al. The Advisory Committee on Immunization Practices’ ethical principles for allocating initial supplies of COVID-19 vaccine—United States, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1782–6. CrossRefexternal icon PubMedexternal icon 12.CDC. COVIDView: a weekly surveillance summary of U.S. COVID-19 activity.

Atlanta, GA: US Department of Health and Human Services, CDC; 2020. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html Visit us at www.bcms.org

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The COVID-19 Vaccine in Texas The Texas Tribune – December 23, 2021 (Excerpts*)

Doses of the COVID-19 vaccine began arriving in Texas in mid-December, marking a significant milestone in the battle against the virus.

But it will be months before vaccine doses are widely available, and the rollout is leaving eligible Texans with more questions than answers.

For now, the limited supply is prioritized for front-line health care workers and certain high-risk populations.

Who is eligible for the COVID-19 vaccine in Texas?

Front-line health care workers and long-term care facility residents and staff are the prioritized groups to receive doses of the vaccine as part of Phase 1A of distribution.

Phase 1B prioritizes Texans who are 65 years and older, and people who are at least 16 and have qualifying health conditions that put hem at an increased risk for severe illness from COVID-19. According to the Texas Department of State Health Services, some of these conditions are: • Cancer.

• Chronic kidney disease.

• Chronic obstructive pulmonary disease.

• Heart conditions, such as heart failure, coronary artery disease or cardiomyopathy.

• Solid organ transplantation.

• Obesity and severe obesity.

• Pregnancy.

• Sickle cell disease.

• Type 2 diabetes mellitus.

Why is my provider saying they don’t have a vaccine available?

As thousands of Texans have come to discover in recent weeks, doses of the coronavirus vaccine have remained in short supply.

Shipments of the vaccine first began arriving at Texas hospitals on Dec. 14. Under Phase 1A of the state’s rollout, the limited supply was reserved for front-line health care workers, as well as residents and staff members of nursing homes and other long-term care facilities, which have been decimated by the virus.

On Dec. 21, Dr. John Hellerstedt, commissioner of DSHS, announced that Texans 65 and older, and people who are at least 16 with certain medical conditions, would be next in line. This group is referred to as 1B.

How is Texas keeping track of who’s gotten the first dose?

The Texas Department of State Health Services has a map that tracks where doses of the coronavirus vaccines are going and how many people are receiving them. The state’s dashboard also separates the numbers by the phase — either 1A or 1B. But the state’s numbers could lag up to two days behind what's happening on the ground. Providers have 24 hours to report their vaccination statistics to the agency, which updates its numbers each afternoon with data reported by midnight the day before.

Who decides who is eligible to receive doses of the vaccine?

Decisions on how doses of the vaccine are allocated are made by a state panel of advisers — including lawmakers, state and local health officials, and medical experts and researchers. The group, known as the Expert Vaccine Advisory Panel, provides recommendations for final approval by Hellerstedt.

Is the COVID-19 vaccine safe?

Yes. Although some Texans have expressed hesitancy toward the vaccine, health experts and public officials widely agree that the vaccine is safe. The two currently approved developers — Pfizer and Moderna — reported their vaccines are 95% and 94% effective, respectively.

While no vaccine is without side effects, clinical trials for both Pfizer and Moderna show serious reactions are rare.

Abbott received his first dose of the vaccine last month, telling reporters, “I will never ask a Texan to do something I’m not willing to do myself.”

Do I need to get the vaccine if I already had the virus?

The short answer is yes. Health experts still don't know how long natural immunity lasts after someone gets COVID-19, but there has been evidence suggesting it does not last very long. The vaccine can offer you protection against the coronavirus even after you've had it.

When will Texas get more COVID-19 vaccine doses?

New doses of the vaccine will continue to arrive in Texas over the coming months. Public health experts estimate it will take between six and nine months for the vaccine to be widely available to everyone who wants it.”

*The Texas Tribune, SHAWN MULCAHY and ELVIA LIMÓN, Dec. 23, 2020 22

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BCMS COVID-19 Vaccination Event January 10, 2021 at the Bexar County Medical Society Building

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COVID-19 VACCINES

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Benefits

of Social Media for the Physician: How Being on Social Media and YouTube Can Help Supplement a Physician’s Practice

By Antonio Webb, MD

Internet and social media use has sky-rocketed in the past 15 years. According to a Pew Study in 2005, 68% of American Adults used the internet. In 2019, that number grew to 90%.1 In the same study, 80% of US internet users looked up health information online.

That translates to 59% of the American adult population using the internet, with 13% of them going online to find information about their health condition. Also, 7% of all adults have used social media to gather healthcare information.

This staggering growth demonstrates the changing times we are facing as physicians. In the face of stifling competition, patients are more often seeking medical information and providers online. This highlights the absolute necessity of meeting the needs of our patients. Patients are searching online and on social media sites to find information about their health conditions and to learn about the various treatment options; then they are seeking out providers for care.

Whether it is Facebook, Twitter, Instagram, Snapchat, TikTok or YouTube, most people are using at least 1-2 social media platforms these days. A certain portion of these individuals are also using social media to market their business and, in the case of physicians, marketing their practice with the use of professional social media pages and/or websites. However, a majority of physicians lack an online presence. A study in 2017 by 30

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Lander et al, used the Pediatric Orthopaedic Society of North America (POSNA) directory to review each active member's presence on social media using an internet search.6 Their study showed that of the 987 POSNA members, 95% had a professional webpage, but only 14.8% had a professional Facebook page, 2.2% a professional Twitter page, 36.8% a Linked-in profile, and 33% were on YouTube. This study suggested that Pediatric Orthopedic Surgeons may be underutilizing their potential social media presence.

Video is one of the most powerful tools in marketing. According to Google, 64% of consumers use video to research healthcare professionals (doctors, dentists, etc.) and 56% watch videos to learn about specific health treatments or problems, such as dental procedures or spinal ailments. YouTube is one of the most popular social media sites in the world with over 2 billion active users. It is localized to more than 90 countries and is accessible in 80 different languages. YouTube makes it possible to create and post videos for all of the world to see. It is one of the most powerful social media sites because of the ability of patients to see you before they come visit your practice. It’s the “try before you buy” form of marketing that allows patients to feel comfortable with you before they even step foot in your office. Here are several reasons why every doctor should be on social media, specifically YouTube.

To create educational videos for your patients Some services offered by your practice may be more complex than others. For example, with spine surgery medical procedures and conditions can be daunting and intimidating for a lot of patients. Conditions and procedures like isthmic spondylolisthesis, diffuse idiopathic skeletal hyperostosis, diastematomyelia, or extreme lateral interbody fusion may be hard for patients to understand and follow, especially when trying to explain them during short and rushed office visits. Educational videos that explain certain conditions that are focused on “pre” or “post” treatment instruction can be helpful for patients to understand their diagnosis and serve as a step-by-step guides to reference before and after an office visit. Sharing videos on YouTube that detail the process from startto-finish helps patients gain a better understanding, putting them at ease while also bringing more patients into your practice.

These videos can be sent to patients as links to watch before their appointment, played during the office visit while they are waiting to see you, and/or can be used as a reference by patients to review after their visit. By doing this, patients can learn more about their condition or upcoming procedure and therefore they can be more informed.

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To advance your passion Being on camera and producing video content allows you to speak more about what you are passionate about. Whether this is a certain condition in your specialty or the latest technology in your field, creating content for YouTube allows you to share this excitement with your viewers. Doing so shows your viewers and potential future patients that you may be passionate about that same condition or technology that interests them.

To build your brand and promote your practice If your medical practice marketing strategy doesn’t include video, it’s time to rethink your approach. A physician can create educational videos for YouTube on conditions related to their specialty or create content relating to a subject they are passionate about, while also building their brand and marketing their practice.

Unlike written content like blog posts, video literally speaks to your target audience. A short video explaining your thoughts on the recent influenza outbreak, COVID vaccine, or a video of you reacting to an NBA player's recent ankle fracture, can go viral within minutes of upload thus bringing your name, brand, and practice to viewers all over the world. Promotional videos for your office can include office tours, meet the staff videos and patient reviews which can all give insight into your life as a physician and give followers the opportunity to engage with your

practice. In addition, this newly generated traffic to your social media pages and/or website can lead to higher patient reviews online. A recent study in the hand surgery literature showed that physicians with a personal website received higher Healthgrades scores than those without one17. This demonstrates that physicians are capable of impacting patient perceptions simply by having a presence online.

For professional education: The use of social media and online, webbased services has grown substantially during the COVID-19 pandemic. The transition to online learning continues to be a necessity and allows physicians, medical students and trainees to attend courses, journal clubs, lectures, and other events that would not normally be accessible to them. In addition, there has been an explosion of social media accounts by various orthopedic residency and fellowship programs with content generation including discussions on interesting cases and dissemination of newly published research. Even after the COVID pandemic settles, training programs and academic institutions will continue to use social media and the online web to provide access to educational content in a digital format.

Summary Having a presence on social media, a professional website for your practice, and creating videos for YouTube can benefit a physician’s

practice. Creating content on YouTube not only allows one to educate their patients, but also promote their medical practice because marketing is more effective when video is involved. Sharing your videos on YouTube is an easy way to highlight both your personality and expertise, making patients feel more comfortable putting their health in your hands.

Therefore, if you’re not already on social media or creating content for YouTube, it’s time to get in front of the camera to promote your practice and share your passions with the world.

Dr. Antonio Webb is an Orthopedic Spine Surgeon located in San Antonio, Texas with South Texas Spinal Clinic, PA. He has a passion for videography and cinematography with 215,000 subscribers on YouTube and more than 25 million views. More information about Dr. Webb can be found at www.antoniowebbmd.com or www.youtube.com/antoniowebbmd. Dr. Webb is a member of the Bexar County Medical Society.

REFERENCES

1. https://www.pewresearch.org/internet/factsheet/internet-broadband/ 2. Lander ST, Sanders JO, Cook PC, O'Malley NT. Social Media in Pediatric Orthopaedics. J Pediatr Orthop. 2017;37(7):e436-e439. doi:10.1097/BPO. 0000000000001032 a. doi:10.1097/BPO.0000000000001032 3. Hanauer DA, Zheng K, Singer DC, Gebremariam A, Davis MM. Public awareness, perception, and use of online physician rating sites. JAMA. 2014;311:734–735. a. doi:10.1001/jama.2013.283194 Visit us at www.bcms.org

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BUSINESS OF MEDICINE

Two Characters Can Impact Your Reimbursement:

THE IMPORTANCE OF USING MODIFIERS

By Deion Whorton, Sr.

It is important for physicians and their staffs to know when it is applicable to append a modifier to a CPT or HCPSS code. Using the correct modifier is crucial in order to be reimbursed at the correct rate. Failure to append a modifier to a code can also delay payment.

Modifiers are used to supply additional information or to report an adjustment to a procedure or service provided by a medical professional. Depending on the situation, modifiers can increase or decrease the reimbursement rate for services rendered.

There are two types of modifiers associated with medical billing. The first type of modifier used in medical billing is CPT modifiers. These modifiers, in numeric format, were adopted by the American Medical Association. The second type that is used in medical billing is HCPCS modifiers. Unlike CPT modifiers, there are hundreds of HCPCS modifiers and they are in alpha or alpha numeric format. These modifiers are often used when reporting a surgical procedure.

It is important to report a HCPCS modifier when the procedure is not performed bilaterally (this will be discussed later in this article). There are HCPCS codes that are used to indicate a provider’s credentials and the location where services are rendered. Government insurance carriers typically require providers to append these modifiers, if applicable. Every insurance carrier is different regarding the use of HCPCS modifiers. It is imperative that the billing and coding team knows when it is appropriate to append the appropriate modifier.

Below are examples of the commonly used CPT & HCPCS modifiers, along with examples of when it is appropriate to use these modifiers: Modifier 24- Unrelated Evaluation and Management Service by the same physician or other qualified healthcare professional during a postoperative period- This modifier should be used for a visit that has occurred 32

SAN ANTONIO MEDICINE • February 2021

during the postoperative period that is not related to a surgery. This modifier should be used if a patient sees a medical provider after contracting nasopharyngitis within a few weeks after an appendectomy.

Modifier 25- Significant, Separately Identifiable Evaluation and Management by the same physician or other healthcare professional on the same day of a procedure or another service. This modifier is only appended to an E/M code when another service is provided during a visit. This modifier is likely to trigger an audit with the insurance carriers if used in excess. Insurance carriers are known to pend these claims and request medical records. This modifier should be used if the original purpose of the encounter was for evaluation and management. If an OB/GYN requests an ultrasound during the office visit, the provider can bill for the office visit and the ultrasound. Modifier 25 must be appended to the evaluation and management code. If the purpose of the visit is strictly for an ultrasound, you should not bill an office visit.

Modifier 33- Preventative Service- This modifier is appended to services that are considered preventative care. The payer will pay 100% of the allowable when used appropriately. Internal and family medicine providers will append this modifier to well visits and any immunizations that are recommended. A gastroenterologist provider may use this modifier if they perform a colonoscopy due to family history or age.

Modifier 50- Bilateral Procedure- This modifier is appended to a procedure code when the procedure is performed on matching organs. Examples of a matching organs are ears. If a pediatric patient has recurrent episodes of otitis media in both ears, the patient may require tympanostomy tubes to prevent fluid from accumulating around the ear drums. The modifier should be appended to the appropriate code describing the insertion of the tympanostomy tubes. There may be additional codes reported if there is fluid prior to the tubes being inserted. If so, the

applicable modifier should be used based on the documentation. Some insurance payers may require you to append the code twice and append RT and LT modifiers.

Modifier 57- Decision for Surgery- This modifier is appended to an E/M code when a physician decides the patient needs surgery. The surgery is generally done within 24 hours after evaluation. This modifier is typically appended to emergency room and initial hospital care evaluation and management codes. If a patient presents to the emergency room and it is determined that he or she has appendicitis, the patient will need emergency surgery. The patient will more than likely be admitted based on this finding. The reported codes on the claims will be the appropriate E/M code with the appended modifier and the applicable CPT code for the appendectomy.

Deion Whorton Sr. is the CEO of PCS Revenue Cycle Management. He is passionate about helping physicians and healthcare professionals increase profitability within their organization. PCS Revenue Management is a member of the BCMS Circle of Friends.

SAN ANTONIO MEDICINE

The Theft & The Gift

By Rajam Ramamurthy, MD

It is a dreary wet day, December 24, 2020. Little difference does that make; nowhere to go anyway. The year will end soon; the year stolen from me. Why does it have to happen to me? It was not my creative moment; my head fell on the desk and the pen rolled out of my hand on to the note pad.

The Theft It was the year before Christmas when all through the world Nothing was moving not even the planes I am told.

Children spent hours in front of the screen What ever happened, why does mom not scream.

Some weary troubled eyes peaked over the masks, Whiles others spue the poison and go about their tasks.

Humanity receded into their homes and bolted the doors What of the millions with no roof nor doors or floors?

While patients crowd the over filled hospital, Argument abound that this is a hoax, in the capital.

News from far and near of kith and kin dying, The mind numbs with zoom gatherings unable to silence the crying.

By summer, no, Thanksgiving, for sure Christmas, I concede bereft, A year when no memories were made, just lament the grand theft.

I woke up with a stiff, sore neck; the outside was ablaze with the winter sun. I felt that someone had come into the room.

I picked up the pen and it danced on the page as though it had a mind of its own.

The Gift It was days after Christmas when all through the world Weariness descended and the sprit curled.

When in the news papers arose such a chatter It spread like a storm in Facebook and Twitter.

There was a little man brilliant and bossy At once I knew it had to be the straight talking Fauci Now Pfizer, now Novavax, now Glaxo and Moderna, On Johnson, on Sanofi, on Astra and Zeneca.

To the bench, to the lab, brilliant minds reach tall Sweat and slog to answer the clarion call.

Chimneys were cooled to an unbelievable freeze Down came St. Nicolas and let out a big sneeze.

With a twinkle in his eyes and nod of his head He opened the freezer and the laid the little vial on the box of gingerbread.

He flew up the chimney, and jumped onto a strange looking sleigh It had UPS painted on it and it took off with a sway.

Hear now! Hear now! Neighbors and friends Have you checked your freezer; it is all good what the New Year portends?

I woke up with a jolt and ran to the window, the glass of milk was empty, and the cookies were gone.

I looked up and saw two red dots rapidly fading in the distant sky. I turned around and made my way to the freezer.

Rajam Ramamurthy, MD was the 2004 President of the Bexar County Medical Society and is Professor Emeritus, Department of Pediatrics/Neonatology at UTH San Antonio.

Visit us at www.bcms.org

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AUTO REVIEW

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SAN ANTONIO MEDICINE â&#x20AC;¢ February 2021

AUTO REVIEW

2021 Mercedes GLS63 AMG

By Stephen Schutz, MD

The 2021 Mercedes GLS63 AMG is a powerful and sporty full size SUV for people who want luxury, space, speed, and quickness.

Oh, and a loud exhaust sound. Combining all those attributes is not easy—or cheap, more on that later—but Mercedes has done it.

The Tuscaloosa, Alabama-built GLS SUV has been around since 2006, and it has evolved in a good way over the years. The packaging is very similar to what it was when it was introduced (as the GL), but the luxury part of things has been turned up, if not to 11, then at least to 9.

For example, the dashboard is now one big screen. Previously, there was a gauge cluster in front of you with a mini iPad-like screen above the center stack. No more, and now the whole thing is one rectangular screen, including the gauges in front of you.

With this beautiful big screen providing all the information you could ever want, plus better materials than I experienced when I tested a first-gen Mercedes back in 2008, I found that sitting in the GLS63 was a very pleasant experience. In fact, the GLS has now reached the point where it gives you S-class luxury with a higher seating position and extra utility. It’s that good.

The exterior of the GLS has similarly evolved, mostly by rounding out the sharp edges of the original GL design, but also by shrinking the taillights and enlarging the grille. It all works, and the newest GLS looks like the top shelf contemporary luxury SUV that it is, albeit with some sinister elements when spec'd in GLS63 AMG guise, which is what I tested.

For 2021, the GLS comes in three variants, the in-line six-cylinder GLS450, V8 GLS580, and high performance V8 GLS63 AMG. The 450 and 580 come with a 48-volt “mild hybrid” system that uses an electric motor to boost low speed acceleration and increase fuel efficiency, while the 603HP 63 AMG is all about using brute force to achieve speed and quickness.

All GLS SUVs come standard with AWD, three rows of seats, 4zone climate control, and 20in wheels among other amenities. The GLS450 starts at just under $80,000, but as with many Mercedes models, a myriad of stand-alone options and option packages can push that number well up into six figures, especially if you choose the GLS63 AMG with its base price of $133,000.

I had a thought early on during my week with the GLS63 that I kept coming back to: if the GLS580 is the corporate CEO who’s polished, confident, and reassuring, then the GLS63 AMG is the VP of sales who’s always on edge and constantly working the phones.

He makes his stretch numbers but makes people wonder, “he’s so

jumpy and twitchy, is he on something? Could it be Adderall or even coke?” He moves the needle but seems perpetually to be one urine test or IRS audit away from losing everything. That’s the GLS63 AMG. You start it, and it’s loud. You accelerate to merge into traffic, and it’s even louder. And in no time you’re where you want to be. Like Right Now. Needless to say, passing slow pokes on the interstate is a total joke it’s so easy. It handles surprisingly well, too.

Naturally, driving this car is lots of fun, but expect periodic speeding tickets. You’ll buy a lot of gasoline too (fuel economy figures were not available at the time of this report but are likely to be poor).

I hope I’m painting a picture: the GLS63 AMG is luxurious, fast, and loud; and expensive. But it has character galore and will never bore you.

Ok, a few more mundane aspects of the GLS63 AMG. It uses the new MBUX Mercedes touch-screen user interface that famously answers to, “Hey Mercedes” and works surprisingly well. The HVAC system, audio/media, and a myriad of other vehicle settings are easily controlled with MBUX and that aforementioned screen.

This is the future, by the way. If your present car doesn’t use something like MBUX, your next vehicle almost certainly will. Voice control and touch screens are where we’re headed, like it or not. (MBUX is undeniably nice, but am I the only one who thinks MBUX sounds like points you earn if you buy enough oil changes at your Mercedes dealership?)

The GLS63 AMG is a luxurious and very fast full-size SUV that will satisfy your need to speed no matter how intense that need is.

It’s expensive, but if a lot of space plus all of the other AMG extras mentioned above are your thing, this is an SUV that will make you happy.

As always, call Phil Hornbeak, the Auto Program Manager at BCMS (210-301-4367), for your best deal on any new car or truck brand. Phil can also connect you to preferred financing and lease rates.

Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the US Air Force. He has been writing auto reviews for San Antonio Medicine since 1995.

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Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of January 22, 2021.

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SAN ANTONIO MEDICINE â&#x20AC;¢ February 2021