October 2023

OCTOBER 2023

Official Publication of SDCMS

THE GERM ISSUE

The Tuberculosis Elimination Initiative

Celebrating Independent Physicians

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Editor: James Santiago Grisolia, MD Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; William T-C Tseng, MD; Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM Marketing & Production Manager: Jennifer Rohr Art Director: Lisa Williams Copy Editor: Adam Elder OFFICERS President: Nicholas (dr. Nick) J. Yphantides, MD, MPH President–Elect: Steve H. Koh, MD Secretary: Preeti S. Mehta, MD Treasurer: Maria T. Carriedo-Ceniceros, MD Immediate Past President: Toluwalase (Lase) A. Ajayi, MD GEOGRAPHIC DIRECTORS East County #1: Catherine A. Uchino, MD Hillcrest #1: Kyle P. Edmonds, MD Hillcrest #2: Stephen R. Hayden, MD (Delegation Chair) Kearny Mesa #1: Anthony E. Magit, MD, MPH Kearny Mesa #2: Dustin H. Wailes, MD La Jolla #1: Karrar H. Ali, DO, MPH (Board Representative to the Executive Committee) La Jolla #2: David E.J. Bazzo, MD, FAAFP La Jolla #3: Sonia L. Ramamoorthy, MD, FACS, FASCRS North County #1: Arlene J. Morales, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Nina Chaya, MD South Bay #1: Paul J. Manos, DO South Bay #2: Latisa S. Carson, MD AT–LARGE DIRECTORS #1: Rakesh R. Patel, MD, FAAFP, MBA (Board Representative to the Executive Committee) #2: Kelly C. Motadel, MD, MPH #3: Irineo (Reno) D. Tiangco, MD #4: Miranda R. Sonneborn, MD #5: Daniel Klaristenfeld, MD #6: Alexander K. Quick, MD #7: Karl E. Steinberg, MD, FAAFP #8: Alejandra Postlethwaite, MD ADDITIONAL VOTING DIRECTORS Young Physician: Emily A. Nagler, MD Resident: Alexandra O. Kursinskis, MD Retired Physician: Mitsuo Tomita, MD Medical Student: Jesse Garcia CMA OFFICERS AND TRUSTEES Immediate Past President: Robert E. Wailes, MD Trustee: William T–C Tseng, MD, MPH Trustee: Sergio R. Flores, MD Trustee: Timothy A. Murphy, MD AMA DELEGATES AND ALTERNATE DELEGATES District I: Mihir Y. Parikh, MD District I Alternate: William T–C Tseng, MD, MPH At–Large: Albert Ray, MD At–Large: Robert E. Hertzka, MD At–Large: Theodore M. Mazer, MD At–Large: Kyle P. Edmonds, MD At–Large: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM At–Large: David E.J. Bazzo, MD, FAAFP At–Large: Sergio R. Flores, MD At–Large Alternate: Bing Pao, MD CMA DELEGATES District I: Steven L.W. Chen, MD, FACS, MBA District I: Franklin M. Martin, MD, FACS District I: Eric L. Rafla-Yuan, MD District I: Peter O. Raudaskoski, MD District I: Ran Regev, MD District I: Kosala Samarasinghe, MD District I: Thomas J. Savides, MD District I: James H. Schultz, MD, MBA, FAAFP, FAWM, DiMM District I: Mark W. Sornson, MD District I: Wynnshang (Wayne) C. Sun, MD District I: Patrick A. Tellez, MD, MHSA, MPH District I: Randy J. Young, MD RFS Delegate: David J. Savage, MD

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Contents OCTOBER

VOLUME 110, NUMBER 9

FEATURES

4

The Tuberculosis Elimination Initiative

By Ankita Kadakia, MD, Catherine Bender, MPH, Marti Brentnall, MPH, Margarita Santibanez, MBBS, MPH, MD, Jeffrey Percak, MD, Lawrence Wang, MPH, and Wilma Wooten, MD, MPH

10

Rocky Mountain Spotted Fever in the CaliforniaMexico Border Region A Growing Vector-Borne Disease Problem

By Stephen Waterman, MD, MPH, Michael Gracia, MD, and O. Efrén Zarzueta, MD, MPH

14

Environmental Dimensions of Antimicrobial Resistance

By Shira Abeles, MD

4 18

The Role of Telemedicine in Practice of Infectious Diseases

By Javeed Siddiqui, MD, MPH

DEPARTMENTS

2

Briefly Noted: Practice of Medicine • Practice Management

21

Classifieds

14 SANDIEGOPHYSICIAN.ORG

1

PRACTICE OF MEDICINE

CMA and AMA Urge Court to Protect Patient Safety and Uphold Long-Standing Prohibition Against Non-Physicians’ Use of ‘Doctor’ THE CALIFORNIA MEDICAL ASSOCIATION

(CMA) and the American Medical Association (AMA) have filed a joint amicus curiae brief defending California’s long-standing law that prohibits the use of the term “doctor” or the prefix “Dr.” by anyone other than California-licensed allopathic and osteopathic physicians.

In this case, Palmer v. Bonta, et. al., three nurse practitioners with Doctorate of Nursing degrees are suing state officials to block California Business and Professions Code section 2054, so the nurses can call themselves doctors. The nurses claim they are not misleading patients because they use “doctor” and the title “Dr.” in conjunction with their nursing degrees. Such usage, they admit, is not permitted under the law. The lawsuit seeks to invalidate the law on the basis that it violates the nurses’ First Amendment speech rights.

In the brief, CMA and AMA emphasized that courts have repeatedly found a legitimate government interest in California’s 86-year-old statutory rule designed to protect Californians who interface with the healthcare delivery system. “[The] courts have consistently relied upon a readily discernible goal of the legislature to prevent confusion and potential harm to members of the public who may be misled into believing they are dealing with physicians whenever those terms are used by non-physicians,” the brief said. “The original purpose of [this law] remains as relevant and vital today as in 1937 when [it] was enacted.”

Physicians are educated and trained differently and more deeply and robustly than any other professional healthcare practitioner; and industry practice and the law continue to place physicians at the center of medical care. As it was in the early part of the last century, the public continues to view physicians as the pillar of healthcare and closely associates the term “doctor” or “Dr.” with physicians and surgeons.

“It should be no surprise that, in practice and under the law, physicians are placed at the center of the delivery of medical care and that there are special protections for the relationship between patients and their physicians,” the brief said.

2

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“The rigorous requirements for physician education and training aim to not just create practitioners to handle routine issues, but leaders in modern healthcare who are able to coordinate healthcare teams and solve complex medical issues, identify critical diagnoses, and render timely treatment decisions.”

The rigorous education and training regimen allows physicians to have a wider scope of practice than any mid-level practitioner, including specifically nurse practitioners. A misrepresentation of a practitioner’s level of licensing can jeopardize patient safety as a patient may mistakenly believe that the midlevel practitioner possesses the same level of training and qualification as physicians licensed by a California medical board.

With the different focus and requirements in their education and experience, a nurse practitioner’s approach to patient care can provide disparate outcomes from that of a medical doctor. For example, recent studies have found significantly increased levels of prescription of opioids and overprescription of antibiotics by nurse practitioners compared to physicians, especially when the nurse practitioner is not practicing under physician supervision.

When encountering the healthcare system, patients immediately confront an array of practitioners and acronyms that can cause confusion over the practitioner’s level of licensing, education, and training. In a review of over 2,000 primary care providers’ biographies, a published research article found 181 unique combinations of alphabetic acronyms next to the practitioners’ names. A survey found that 45% of adults surveyed did not agree that it was easy to identify who is or is not a licensed medical doctor by reading what services they offer, their title and other licensing credentials in advertising materials.

“Patients want and deserve clarity and transparency in who is providing their care as there are immense differences in the education, training, and qualifications among healthcare professionals.

In healthcare settings, patients find it increasingly difficult to identify who is or isn’t a physician. The

PRACTICE MANAGEMENT

potential for confusion is especially heightened when non-physician health care professionals use terms that are customarily understood to refer to a physician, including ‘doctor’ or ‘Dr.,’” said AMA President Jesse M. Ehrenfeld, MD, MPH. “Truth-inadvertising laws have helped prevent this confusion, as well as potential harm to patients, who may be misled into believing they are being treated by a physician when they are not. It is imperative that we follow precedent and keep these laws in place to ensure patients have the basic information they need to make informed decisions about their healthcare.”

Research and empirical evidence based on medical practice today confirm the legislature’s concerns that there is great likelihood for public confusion given the strong, widespread association between “doctor” or “Dr.” and physicians.

“While the laws delineating who can use the term ‘doctor’ have been on the books for decades, the public’s understanding of the physician-patient relationship goes back much further than that,” said CMA President Donaldo Hernandez, MD. “Patients understand and have longstanding expectations of who they are talking to when they’re speaking to their doctor. By ignoring that precedent, we risk deceiving or confusing our patients.”

DHCS Implements System Fix to Allow Claims for Pfizer Bivalent COVID-19 Vaccine for Small Children LAST MONTH, THE CALIFORNIA DEPARTMENT

of Health Care Services (DHCS) informed providers that its system was not yet able to appropriately process claims for the bivalent booster dose for children six months to 4 years, and urged Medi-Cal providers to hold such claims until the claims adjudication system was prepared to appropriately adjudicate submitted claims.

The California Medical Association (CMA) has learned that the DHCS system fix is being implemented this week and an Erroneous Payment Correction (EPC) will be initiated to automatically reprocess the impacted claims.

No action is required on the provider’s part at this time. However, physicians may elect to resubmit their claims vs. waiting for the EPC, if they so choose.

PHYSICIANS NURSE PRACTITIONERS PHYSICIAN ASSISTANTS LOCUM TENENS PERMANENT PLACEMENT P H O N E : 8 0 0-919-9141 OR 8 05 -641-9141 FAX: 8 0 5 -641-914 3 EM A I L : J N GUY EN@ T R ACYZWEIG.COM TR ACYZW EIG.COM

SANDIEGOPHYSICIAN.ORG

3

INFECTIOUS DISEASES

The Tuberculosis Elimination Initiative: Why It Matters Now 175,000 San Diegans have latent tuberculosis infection (LTBI). Most do not know it and could get sick with active tuberculosis without screening and treatment.

Introduction: TB and Health Disparities Tuberculosis (TB) is an infectious disease spread from person to person through the inhalation of airborne particles in shared spaces. TB has been around for at least 150 million years [1] though formally identified by Robert Koch in 1882.

Despite advances in TB treatment, TB remains a disease of severe complications that can lead to permanent disability or death. Annually, at least 2,000 Californians are diagnosed with TB with half being hospitalized [2,3]. One in six dies within five years of receiving a TB diagnosis [3]. The World Health Organization (WHO) estimates a 15% TB death rate globally with TB being the second leading infectious cause of death worldwide following COVID-19 [4].

TB has a predilection for vulnerable populations. Groups disproportionately affected by TB include immunosuppressed patients, including those with diabetes, kidney failure, cancer, and HIV infection. TB can also have a negative impact for people that live or work in congregate settings, such as persons experiencing homelessness, incarcerated persons, and residents of long-term care facilities [5]. During infectious periods, individuals with TB are at risk for loss of income, homelessness, and isolation from family and friends due to illness and workplace exclusion. Efforts to prevent contagion further disrupt existing social supports. In California, persons with TB who experience homelessness are 30% more likely to die with TB than those not experiencing homelessness [6].

Health disparities related to race, ethnicity, and socioeconomic status that exist for TB have become even more apparent after the COVID-19 pandemic. Among 2,210 California residents diagnosed and reported with TB dis-

ease during September 2019–December 2020, and 3,402,804 residents diagnosed and reported with COVID-19, through February 2021. Ten percent had previous or current TB and COVID-19 co-infection.

Also, 91 cases had less than 120 days between TB and COVID-19 diagnoses. Among the 91 people with TB and COVID-19 co-infection, 60% were Hispanic and 45% resided in low health equity census tracts, highlighting health disparities in both COVID-19 and TB. People with TB and COVID-19 had higher mortality than those with either disease alone [7,8]. The early phases of the COVID-19 pandemic disproportionately affected racial and ethnic minority groups in the U.S., with rates of disease compared to Whites higher for Asian (1.53), Black (2.46), and Hispanic/

By Ankita Kadakia, MD, Catherine Bender, MPH, Marti Brentnall, MPH, Margarita Santibanez, MBBS, MPH, MD, Jeffrey Percak, MD, Lawrence Wang, MPH, and Wilma Wooten, MD, MPH 4

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Latino (3.87) populations.

While these disparities are unquestionably devastating and unacceptable, the relative disparity is even more dramatic for TB. All racial and ethnic minority groups experience higher rates of TB compared to Whites, but analyzing by race and country of birth reveals even more stark differences. non-U.S.-born Latinos (10.1), non-U.S.-born Blacks (16.9), and non-U.S.born Asian Californians (23) develop active TB at rates higher than U.S.-born Whites [9].

Nationally, at the state level, and locally, non-USborn individuals develop active TB at higher rates than US-born individuals. The Centers for Disease Control and Prevention (CDC) report in 2022 that 73% of TB cases reported in the United States occurred in non-US-born individuals [9].

In California, TB case rates in each non-U.S.-born racial and ethnic group were higher than among U.S.born persons in the same group. Nearly half (49%) of California’s TB cases occurred in Asian persons, and 41% of cases occurred in Hispanic persons [7].

TB Can Be Prevented: Recommendation to Assess Risk, Test, Treat for Latent TB Infection Most people infected with TB harbor the undetected bacteria in their bodies, which is referred to as latent tuberculosis infection

100%

180,000

120,000 100,000 80,000 60,000

25%

40,000

15%

tion compared with state (4.5) and national (2.4) averages 0 [7]. LTBI In 2022, San Diego reported prevalence Aware of County LTBI Treated for LTBI 208 new active TB cases, compared to 201 in 2021.

20,000

Figure 2: Number and incidence of new active TB cases, San Diego County, 2013–2022

250

206

220

234

258

237

12.0

264 226 193

200

201

208

10.0 8.0

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0

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2018 2019

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300

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(LTBI). LTBI cannot be transmitted to others. However, CDC reports that without treatment, individuals with LTBI have a 5–10% risk of reactivation and progression to infectious TB disease in their lifetimes. The California Department of Public Health (CDPH) reports that 87% of people who develop active TB began as LTBI and therefore these illnesses could have been prevented [10].

The US Preventive Task Force Grade B recommendation updated in May 2023 recommends screening for LTBI for populations at risk, and states that, to achieve the benefit of screening, it is important that persons who screen positive for LTBI receive follow-up and treatment. A risk assessment tool has been developed locally to address the challenges of identifying people who may be at risk for TB in our unique community [11,12]. Risk factors include: • Non-U.S.-born; • U.S.-born and visits country with elevated TB rate, eats queso fresco outside the U.S.; • Current or planning immunosuppression; and • History of homelessness, incarceration, or drug abuse.

LTBI diagnosis and treatment is critical to achieve TB elimination goals in San Diego County: Approximately 175,000 San Diego County residents have LTBI (Figure 1). Among those residents with LTBI, an estimated 25% are aware of their infection and only 15% receive treatment [13,14].

140,000

0.0

Rate

Although we saw a decline in active TB cases during the COVID-19 pandemic, which was similar to the state and na42.8 45 tional declines, this was most likely due to pandemic related 40 33.4 35 factors rather than to a true reduction in disease incidence.

30 With the decrease in COVID-19 mitigation strategies that 21.8 25 20.3 20 were protective against TB, a return to pre-pandemic levels 5 of TB is 10occurring [16].

2.5 5 As indicated earlier, TB is a disease of health disparities; 0 US Outside the Mexico local data indicates higher rates ofPhilippines diseaseVietnam in neighborhoods US that are most adversely affected by social determinants of health (Figure 3). The highest incidence and case counts Cases per 100,000

Number of Persons

160,000

Figure 1: Approximate estimates of LTBI prevalence, awareness and treatment, San Diego County, 2020 Figure 3: County of San Diego tuberculosis rates by zip code 2017–2021

100%

180,000 Number of Persons

160,000 140,000 120,000 100,000 80,000 60,000

25%

40,000

15%

20,000 0 LTBI prevalence

Aware of LTBI

Treated for LTBI

Estimated using methodology from the California TB Control Branch Report of Tuberculosis in California, 2020 and associated data tables, applying national level data from the National Health and Nutrition Examination Survey, 20112012, to the San Diego County population.

Case Count

12.0 201

208

10.0 8.0 6.0 4.0 2.0

2021

2022

Cases per 100,000

Number of Cases

TB in San Diego County San Diego County300 has a unique geography with its proxim264 258 234 237 ity to the border with which is one of the226 busiest 220 250 Mexico, 206 193 border crossings in the world [15]. With the diversity of the 200 county and the number of individuals who live and work on 150 both sides of the border, San Diego County sees higher rates 100 of active TB with 6.3 cases per 100,000 persons in 2022 (Fig50 ure 2) and is considered a high burden county with TB case 0 2013 2014 2015 2016 2017 2018 2019 2020 rates greater than or equal to 4.5 cases per 100,000 popula-

0.0

Rate

SANDIEGOPHYSICIAN.ORG

5

2013

2014

2015

2016

2017

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2018 2019

2020

2021

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INFECTIOUS DISEASES

Figure 4: TB incidence by birth country, San Diego County, 2018–2022 42.8

45

Cases per 100,000

40

33.4

35 30 25

20.3

20

21.8

5 10 5 0

2.5 US

Outside the US

Mexico

Philippines

Vietnam

Rates calculated with 2018-2021 American Community Survey Population Data

occur in the South and Central regions of San Diego County.

Many zip codes in these regions were identified during the COVID-19 pandemic as having lower Healthy Places Index (HPI) scores, indicating that these areas had community conditions that negatively impact life expectancy [17,18].

The majority (67%) of TB cases in San Diego County occurred in persons who were born outside the United States (U.S.). Of the 69 cases born in the U.S., 78% (54 cases) were Hispanic. The TB rate among persons born outside the U.S. was more than 8 times higher than the rate among U.S.-born persons and varied by birth country (figure 4).

The highest proportion of active TB cases in the County for 2022 occurred in Hispanics (66% [137 cases]) and Asian/ Pacific Islanders (25% [52 cases]). Non-Hispanic Blacks accounted for 2% (4 cases) and non-Hispanic Whites, 6% (12 cases). Of the 137 cases in Hispanics, more than half (83 cases) were born outside the U.S. Rates among Asian/Pacific Islanders and Hispanics were more than 10 times that of non-Hispanic Whites.

The Cost of TB Prevention of TB infection is more cost effective compared with diagnosing and treating TB disease. The cost to prevent TB for one person is low ($857) compared with the costs of diagnosing and treating one person with active TB disease ($43,900) [19,20]. The burden of TB is not just in morbidity and mortality but also in cost to the patient and healthcare system.

People with TB disease can often experience social and 6

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physical isolation related to their illness and absence from their workplace during the contagious period.

The latter can lead to loss of income, inability to pay for housing, food, and necessities, which creates a significant financial hardship for the patient and their families.

The cost to hospital systems is exorbitant and often related to additional hospital days due to isolation, complications of TB disease, and discharge requirements for a person with infectious TB. The median length of stay for TB hospitalizations in California was 12 days compared to three days for other hospitalizations. TB hospitalizations are twice as expensive and four times longer than hospitalizations for other condi-

tions [3]. The direct medical expense of TB in California was $76 million in 2020 and, together with the costs of premature death due to TB, the disease cost California more than $180 million [21].

TB Elimination through Public-Private Partnership — a Call to Action Approved by the San Diego County Board of Supervisors (Board), the San Diego County TB Elimination Initiative (TBEI) is a public-private partnership launched in January 2020 to establish a coordinated TB elimination framework that serves San Diego County’s diverse population. The initiative focuses on effective TB prevention, including risk assessment, testing, and treatment of people with LTBI to prevent progression of latent infection to active TB disease.

To develop this framework, the Tuberculosis Control and Refugee Health Branch within the County of San Diego Health and Human Services Agency (HHSA), Public Health Services convened stakeholders from over 25 unique agencies in addition to State and CDC representatives to serve on seven committees from January 2020 until June 2021. Committee members identified recommendations (Table 1) and supporting activities to address disparities and barriers to TB elimination

Table 1: Recommendations for TB elimination in San Diego County developed by the County TB Elimination Initiative committee members

The TBEI committees developed and approved the following six key recommendations, outlined in the TBEI Recommendations Report:

1

Improve LTBI care cascade outcomes

2

Promote awareness of LTBI as a major public health concern that is preventable and curable

3

Develop a LTBI surveillance system to describe the burden of LTBI and monitor improvement of the LTBI cascade of care

4

Implement TB screening in educational systems

5

Improve access to treatment for LTBI and active TB

6

Secure sufficient resources for implementing TBEI strategies

for populations at highest risk for TB in San Diego County, including non-U.S.-born persons and underserved communities. These strategies are outlined in the TBEI Implementation Plan.

In July 2021, the TBEI transitioned from community planning to community implementation. HHSA and over 70 community partners have made substantial progress in planning and implementing activities related to the recommendations listed above, overseen by an Advisory Task Force, and organized into four main areas of work: a Community of Practice, TB Prevention in Schools, and Community Outreach and Education. [14,22].

The TBEI Community of Practice (CoP) convenes primary care, infectious disease, and pulmonary medicine providers, epidemiologists, health systems, health plans, universities, and State and County stakeholders from over 14 organizations, including Federally Qualified Health Centers, health systems and community-based organizations, including at least 35 contributing members.

The goal of the CoP is to educate providers about LTBI care best practices and electronic health record enhancements that support LTBI quality improvement; encourage the development and use of a LTBI care cascade by healthcare organizations in the county; and to enhance capacity for LTBI care cascade measurement. A LTBI care cascade describes the steps from initial screening to diagnosis and treatment completion for LTBI. Measuring the LTBI care cascade highlights points of attrition and opportunities for intervention [18].)

This group also addresses misconceptions about the BCG vaccine and promotes best practices recommended by the CDC, including adoption of blood tests (interferon gamma release assays) to diagnose LTBI to reduce false positives, and newer short-course rifamycin-based LTBI treatment regimens, such as daily rifampin for four months, that are now recommended over historically used isoniazid and that increase the likelihood of treatment being completed by patients. [23].

TBEI Schools work engages partners from K-12 and higher education institutions in implementing TB prevention strategies that include TB peer education programs, as well as events that promote education and access to TB risk assessment, testing and LTBI linkage to care on school campuses. The goal is to prevent TB transmission in schools.

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INFECTIOUS DISEASES

Figure 5: Steps in the Latent TB Infection care cascade. [24]

local clinics and healthcare systems adopting strategies to improve their LTBI care cascade outcomes.

Continuing to educate providers on how to screen, diagnose, and treat LTBI, particularly providers serving patients from high incidence zip codes and from communities disproportionately impacted by TB, is an important strategy to decrease the burden of active TB in San Diego County.

TBEI Community Outreach and Education Committee convenes stakeholders from organizations that serve communities that are at high risk for TB. The goal is to promote TB prevention through community outreach events and activities that educate about TB, and improve awareness and access to LTBI risk assessment, testing, and follow-up care.

Public-private partnership in TB prevention activities can achieve a reduction in TB incidence in San Diego County through education and engagement of the healthcare system, stakeholder involvement in the care and education of vulnerable populations, and the community, especially in areas affected by health inequalities.

Conclusion: Now Is the Time to Focus on TB Elimination TB cases have started to rise again. It is important for providers in San Diego County to help find and treat the estimated 175,000 San Diegans with LTBI, especially since a majority of active TB cases develop only after long-standing LTBI. Though a substantial decrease in TB cases was observed in the first year of the COVID-19 pandemic in San Diego County, likely due to multiple factors reflecting the impact of the pandemic, including restrictions to decrease COVID-19 transmission, fewer patients seeking care, and delayed or missed diagnoses in the healthcare system, this decline in TB cases has ended.

Now is the time to leverage the momentum created by (1) the foundation work to improve public awareness of 8

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infectious diseases and the need to address health disparities identified after COVID-19, (2) the TBEI partnership which lays the groundwork for collaboration in making TB elimination a priority in San Diego County. Providers and healthcare systems now have tools and education from COVID-19 that can be applied to another deadly airborne infection, TB. Moreover, the increased adoption of blood tests (IGRAs) to diagnose LTBI reduces false positives and new short-course LTBI treatment regimens now recommended by CDC increase the likelihood of treatment being completed by patients. Additionally, the LTBI education and practice transformation work in the Community of Practice has led to more

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2. California Department of Public Health TB Control Branch. Report on Tuberculosis in California, 2018. 2019.

3. Readhead A, Cooksey G, Flood J, Barry P. Hospitalizations with TB, California, 2009-2017.

Int J Tuberc Lung Dis. 2021;25(8):640-7.

4. Global Tuberculosis Report 2022, World Health Organization, 27 October, 2022.

5. California Department of Public Health TB Control Branch. Costs and Consequences of Tuberculosis in California, 11 June, 2021.

6. Pascopella L, Barry PM,

Flood J, DeRiemer K. Death with tuberculosis in California, 1994-2008. Open Forum Infect Dis. 2014;1(3):ofu090.

7. California Department of Public Health TB Control Branch. Report on Tuberculosis in California, 2021. 2022.

8. Nabity SA, Han E, Lowenthal P, Henry H, Okoye N, Chakrabarty M, Chitnis AS, Kadakia A, Villarino E, Low J, Higashi J, Barry PM, Jain S, Flood J. Sociodemographic Characteristics, Comorbidities, and Mortality Among Persons Diagnosed With Tuberculosis and COVID-19 in Close Succession in California, 2020. JAMA Netw Open. 2021 Dec 1;4(12):e2136853. Doi: 10.1001/jamanetworkopen.2021.36853. PMID: 34860244; PMCID: PMC8642782.

9. Van Dyke ME, Mendoza MC, Li W, et al. Racial and Ethnic Disparities in COVID-19 Incidence by Age, Sex, and Period Among Persons Aged <25 Years — 16 U.S. Jurisdictions, January 1–December 31, 2020. MMWR Morb Mortal Wkly Rep 2021;70:382–388. DOI: http://dx.doi. org/10.15585/mmwr.mm7011e1external icon 10. California Department of Public Health TB Control Branch. TB in CA: 2021 Snapshot, February 2022.

11. The County of San Diego Tuberculosis Control and Refugee Health Branch. TB Risk Assessment (sandiegocounty.gov).

12. The County of San Diego Tuberculosis Control and Refugee Health Branch. For Health Care Providers (sandiegocounty.gov) 13. County of San Diego Tuberculosis Control and Refugee Health Branch. Tuberculosis in San Diego County: By the Numbers, 2023 edition.

14. County of San Diego Tuberculosis Control and Refugee Health Branch. San Diego County TB Elimination Fact Sheet, 2023 edition.

15. Bureau of Transportation Statistics. Crossings by Rank.

2022. Workbook: Border Crossing Data (dot.gov) 16. Schildknecht KR, Pratt RH, Feng PI, Price SF, Self JL. Tuberculosis — United States, 2022. MMWR Morb Mortal Wkly Rep 2023;72:297–303.

17. Healthy Place Index (HPI) (healthyplacesindex.org) 18. Census-Tracts-HPI-Quartile-ZIP-Code.pdf (sandiegocounty.gov) 19. A systematic synthesis of direct costs to treat and manage tuberculosis disease applied to California, 2015. BMC Res Notes. 2017;10(1):434.

20. Cost from Shephardson et al. inflated to 2020 dollars.

Shepardson D, Marks SM, Chesson H, et al. Cost-effectiveness of a 12-dose regimen for treating latent tuberculous infection in the United States. Int J Tuberc Lung Dis. 2013;17(12):1531-1537. Doi:10.5588/ijtld.13.0423 21. Oh P, Pascopella L, Barry PM, Flood JM. A systematic synthesis of direct costs to treat and manage tubercu-

losis disease applied to California, 2015. BMC Res Notes.

2017;10(1):434 22. Alsdurf H, Hill PC, Matteelli A, Getahun H, Menzies D. The cascade of care in diagnosis and treatment of latent tuberculosis infection: a systematic review and metaanalysis. Lancet Infect Dis. 2016 Nov;16(11):1269-1278. Doi: 10.1016/S1473-3099(16)30216-X. Epub 2016 Aug 10. PMID: 27522233.

23. Sterling TR, Njie G, Zenner D, et al. Guidelines for the Treatment of Latent Tuberculosis Infection: Recommendations from the National Tuberculosis Controllers Association and CDC, 2020. MMWR Recomm Rep. 2020;69(1):111. Published 2020 Feb 14. doi:10.15585/mmwr.rr6901a1 TB Free California Initiative. Preventing Tuberculosis in Your Clinical Setting: A Practical Guidebook. Richmond, CA. April 2022.

The authors are the County TB Elimination Initiative (TBEI) staff who work with local community and healthcare providers on TB elimination through the TBEI. Dr. Kadakia is deputy public health officer for the County of San Diego and president of the California Tuberculosis Controllers Association. She is a board-certified internal medicine and infectious disease physician. Dr. Percak is an adult infectious disease specialist and has served as the medical director and chief of tuberculosis control and refugee health for the County of San Diego since June 2022.

Catherine Bender is an experienced healthcare professional leading the San Diego County TB Elimination Initiative for the tuberculosis control and refugee health branch of the County Health and Human Services Agency. Marti Brentnall has worked more than 14 years in tuberculosis prevention, focusing on education, outreach, and program development. She has been the outreach and education coordinator for the San Diego County tuberculosis control and refugee health branch since 2015. Dr. Wooten is the public health officer, and Catherine Bender is the TBEI program coordinator, Marti Brentnall is the outreach and education coordinator, Lawrence Wang is our TB epidemiologist, and Dr.Santibanez is the assistant medical services administrator for the County’s tuberculosis control and refugee health. Together they run the internal initiative planning, coordination, and activities for TB elimination but partner with healthcare professionals, schools, and the community on programs/events/education to eliminate TB. SANDIEGOPHYSICIAN.ORG

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Rocky Mountain Spotted Fever in the California-Mexico Border Region

A Growing Vector-Borne Disease Problem By Stephen

Waterman, MD, MPH, Michael Gracia, MD, and O. Efrén Zarzueta, MD, MPH Introduction/Background Rocky Mountain Spotted Fever (RMSF), first described in western Montana in 1900, is a life-threatening rickettsial disease spread by ticks. Rickettsia rickettsii infects vascular endothelial cells of small blood vessels. Endothelial cell injury causes increased capillary permeability with localized hemorrhage and edema. Small vessel thrombosis results in peripheral ischemia, which can lead to gangrene of extremities. The clinical course often involves progressive ischemic damage of all major organs and tissues (e.g., pulmonary edema, brain infarcts, elevated liver enzymes). Illness is characterized by sudden onset of moderate to high fever with malaise, headache, muscle pain, and conjunctival infection. A maculopapular rash usually appears on the extremities on the third to fifth day, soon involving the palms and soles and rapidly extends to much of the body (Photo 1). A petechial rash appears in about half of patients around the sixth day. Because of nonspecific initial symptoms, diagnosis of RMSF is missed on initial evaluation in 60–85% of patients. Without timely specific antibiotic treatment with doxycycline within the first five to six days of illness, the case fatality rate can be 25% or higher.

Half of all deaths occur within the first eight days after illness onset. Laboratory diagnostic testing typically includes nucleic acid detection and serology (1).

Epidemiology/ Ecology The majority of RMSF reports in the United States are sporadic cases in south central and southeastern states transmitted by Dermacentor ticks in wooded or grassy areas. However, RMSF has emerged in the southwest United States and reemerged in northern Mexico over the last 20 years spread by a different tick species: the brown dog tick, Rhipicephalus sanguineus, with a different ecology (Photo 2). Outbreaks and hyperendemic RMSF have occurred in American Indian reservations in Arizona and states in northern Mexico such as Baja California and Sonora. RMSF in northern Mexico has disproportionately affected children in 2

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poor neighborhoods with high case fatality rates of 30–40%. These outbreaks are associated with an abundance of free-roaming dogs, high tick infestation rates, and rickettsial antibody prevalence in the dog populations (2,3, Photos 3).

Due to the close relationship between people and domesticated dogs, brown dog ticks can also be found in and around people’s homes in these communities. Case rates are highest during the spring and summer months, but transmission can occur year-round. The incubation period after a tick bite is three to 14 days.

Recent Surveillance Data Baja California Mexicali, Baja California’s capital with a population of about 700,000 and which borders the city of Calexico in Imperial County, California, has been the epicenter of RMSF in Baja California since an outbreak was first reported in December 2008.

From 2009 to 2019, 779 laboratory confirmed cases were reported in Mexicali with 140 deaths, a case fatality rate of 18% (4, 5). Case numbers are likely higher due to many probable cases with inadequate confirma-

tory testing. While Mexicali continues to have the highest case numbers, the disease has spread to all the major health jurisdictions of Baja California: Tijuana (which includes Tecate and Rosarito), Ensenada, and more recently the agricultural jurisdiction of San Quintin, 100 miles south of Ensenada.

From 2020 to 2022, laboratory confirmed cases alone for the jurisdictions of Tijuana, Ensenada, and San Quintin were 33, 20, and 10, respectively (Figure 1). The overall case fatality rate in Baja California during 2020–2021 was 32%.

San Diego and Imperial Counties The County of San Diego communicable disease surveillance data reports show 1 confirmed and 3 probable RMSF cases from 2021 to July 2023; two of the cases were in children and all cases were white race; one probable case was Hispanic ethnicity. County reportable disease surveillance data includes only San Diego County residents. However, since 2021 two binational RMSF non-resident cases in children referred from border Baja California cities have been treated in San Diego. One of these binational cases was an Imperial County resident. Two additional San Diego RMSF pediatric cases were diagnosed by next-generation sequencing only and thus do not meet the nationally reportable disease definition for RMSF. None of these RMSF patients died. Other San

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Figure 1. Confirmed cases of rickettsiosis, Tijuana, Baja California, Health Jurisdiction, 2022

Diego County vector-borne confirmed and probable case numbers during this time period include: 26 Lyme disease; 19 imported dengue; and 6 West Nile virus.

The San Diego County Vector Control Program has detected Rickettsia rickettsii and another rickettsial species in Dermacentor ticks collected along county hiking trails. A UC Davis tick and rickettsiae surveillance partnership during 2021–2022 found brown dog ticks broadly present across San Diego and Imperial Counties in shelters and kennels including during winter months.

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Prevention and Control Primary prevention efforts for brown dog tick-associated RMSF center on tick population reduction using environmental and on-host acaracides (pesticides for killing ticks).

Pesticides, predominantly pyrethroids, are typically applied outside of the home. An integrated pest management approach combining community-wide application of long lasting (approximately 8 months) acaricidal collars placed on dogs together with environmental mitigation and education has been shown to prevent cases and deaths and reduce tick infestation rates in Northern Mexico and Arizona studies (6,7). Educational efforts, including information on tick prevention and RMSF diagnosis and early treatment, targeting both community members and healthcare workers are crucial for minimizing mortality rates. Travelers to endemic areas can protect against tick bites by wearing protective clothing and using EPA-approved repellants such as DEET, permethrin, and picaridin, and should perform tick checks after spending time in these areas. Research is ongoing to develop RMSF vaccines for dogs and humans (8).

Case Report A 4-year-old boy from Alpine, a small town in the Cuyamaca Mountains of San Diego County, presented to a pediatric hospital in the California-Mexico border region with a sevenday history of high fevers and after developing a macular rash that started on his thighs and spread inwardly. He also exhibited worsening fatigue, decreased appetite, peripheral edema, and non-purulent conjunctivitis. He complained of migratory abdominal, hip, and leg pain. At times, he appeared listless and confused; the boy’s mother reported several episodes of somniloquy. There was no history of tick bite or cross border travel. On his third day of fever, he was briefly prescribed an otic antibiotic given concern for otitis externa.

He was admitted to the pediatric intensive care unit.

Initial laboratory testing showed an elevated C-reactive protein, leukopenia, thrombocytopenia, hyponatremia, elevated liver enzymes, and elevated prothrombin time. Radiographs of the chest revealed diffuse, interstitial lung disease with bilateral opacities, and transthoracic echocardiography revealed low-normal left ventricular systolic function and a pericardial effusion.

The child was in cardiorespiratory failure and required positive pressure ventilation, inotropic support, and multiple rounds of albumin and diuretics for stabilization. He was empirically started on vancomycin and cefepime. Pediatric infectious disease specialists were consulted, and they initiated a broad infectious workup that included next-generation sequencing of plasma cell-free DNA (cfNGS).

Shortly after admission the patient’s rash became petechial with a distribution that included the palms and soles.

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Given local epidemiological trends, the clinical presentation garnered suspicion for rickettsial disease. Thus, on hospital day three the child was started on intravenous doxycycline.

Two days later, he began to defervesce and was weaned from all pressor, colloid, and respiratory support. He eventually made a complete recovery and was discharged on hospital day eight to complete a 10-day course of oral doxycycline.

After discharge, serological testing and cfNGS confirmed the presence of Rickettsia rickettsii.

Summary and Conclusions RMSF spread by the brown dog tick is an important ongoing public health problem in Baja California, causing significant morbidity and mortality. The tick vectors and pathogen are present in San Diego County; but despite hyperendemicity of RMSF in Baja California including border cities like Mexicali, Tecate, and Tijuana, relatively few RMSF cases have been identified in California border counties. Nevertheless, clinicians should be aware of the significant presence of this potentially fatal vector-borne disease in the region and maintain a high index of suspicion for RMSF in acutely febrile patients. When RMSF is in the differential diagnosis, clinicians should solicit travel and tick/insect bite history in acutely febrile patients, especially those with a rash, and initiate early treatment with oral or intravenous doxycycline without waiting for diagnostic laboratory results.

The American Academy of Pediatrics recommends doxycycline for RMSF treatment in children and cites evidence that tooth staining does not occur with appropriate dosing regimens. Efforts are ongoing by public health authorities to improve the prevention and control of the disease in affected communities, but challenges remain.

Acknowledgments The authors are grateful to Drs. Christopher Paddock and Maureen Brophy, CDC Rickettsial Diseases Branch, Dr. Janet Foley, UC Davis School of Veterinary Medicine, Dr. Seema Shah, County of San Diego Public Health Services Epidemiology and Immunizations Services Branch, Irais Estrada, Imperial County Public Health Department, Theodore Efthemeou, California Office of Binational Border Health, and Dr. Nikos Gurfield, County of San Diego Department of Environmental Health and Quality, for their assistance with this report.

References 1. CDC. Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain Spotted Fever and other spotted fever group rickettsioses, ehrlichiosis, and anaplasmosis – United States: a practical guide for health care and public health professionals. MMWR Recommendations and Reports 65(2); May 13, 2016

2. Drexler NA, Yaglom H, Casal M et al. Fatal Rocky Mountain Spotted Fever along the United States – Mexico border, 20132016. Emerg Inf Dis 2017;23:1621-26 3. Kjemtrup AM, Padgett K, Paddock CD et al. A forty-year review of Rocky Mountain spotted fever cases in California shows clinical and epidemiologic changes. PLoS Negl Trop Dis 2022;16(9):e0010738 4. Zazueta OE, Armstrong PA, Márquez-Elguea A et al. Rocky Mountain Spotted Fever in a large metropolitan center, Mexico- United States border, 2009-2019. Emerg Inf Dis 2021;27:1567-1576 5. Foley J, Tinoco-Gracia L, Rodriguez-Lomeli M et al. Unbiased Assessment of abundance of Rhipicephalus sanguineus sensu lato ticks, canine exposure to spotted fever group Rickettsia, and risk factors in Mexicali, Mexico. Am J Trop Med Hyg 2019; 101(1):22-32 6. Alvarez-Hernandez G, Drexler N, Paddock CD et al.

Community-based prevention of epidemic Rocky Mountain spotted fever among minority populations in Sonora, Mexico, using a One Health approach. Trans R Soc Trop Med Hyg. 2020 Apr 9;114(4):293-300. doi:10.1093/trstmh/trz114.

7. Drexler N, Miller M, Gerding J et al. Community-based control of the brown dog tick in a region with high rates of Rocky

Mountain spotted fever, 2012-2013. PLoS ONE 9(12): e112368. doi:10/1371/journal.pone.0112368 8. Walker DH, Blanton LS, Laroche M et al. A Vaccine for Rocky Mountain spotted fever: An unmet health need. Vaccines 2022 Oct; 10 (10);1626. doi:10.3390/vaccines10101626

Dr. Waterman is a medical epidemiologist formerly with the Centers for Disease Control and Prevention, and now health sciences clinical professor at UC San Diego’s Herbert Wertheim School of Public Health and Human Longevity. He has worked extensively on US-Mexico border infectious disease issues. Dr. Gracia is a pediatric infectious disease fellow at UC San Diego. He is dedicated to sustained cross-border global health and medical efforts to combat infection diseases of public health significance (e.g., RMSF, tuberculosis). Dr. Zarzueta is the former state epidemiologist of Baja California, Mexico. He is pursuing a doctoral degree in epidemiology at the Harvard School of Public Health. His research interests focus on improved understanding including social determinants of emerging infectious diseases in developing countries.

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Environmental Dimensions of Antimicrobial Resistance

By Shira Abeles, MD

ANTIMICROBIALS ARE A CORE ASSET OF MODERN

medicine, and as clinicians we have focused on stewarding their use as best we can — giving the right dose of the right drug at the right time for the right duration. We support antimicrobial stewardship programs in medical settings to preserve their potency, and we have learned about how every time a person is exposed to antimicrobials, there are a myriad of ways these drugs impact the patient. Each exposure alters one’s microbiome, selects for resistant organisms, and runs the risks of any number of common side effects.

We strive for each clinical use to be for a good reason — to save organ, limb, or life. When we prescribe antibiotics, we have calculated the benefits to outweigh the risks of the unintended consequences for the patient. The benefits of antimicrobial stewardship have been demonstrated clearly in prescribing patterns in healthcare settings, and are a required part of health institutions.

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Despite these efforts in healthcare, antimicrobial resistance rates are increasing, and what’s more, it has been noted that infections due to resistant microbes are diagnosed more often in community acquired infections than they are in healthcare acquired infections. So the question is, why? What is happening? To understand what is driving antimicrobial resistance (AR) in our community, we need a broader perspective of the multiple factors contributing to the antimicrobial resistance threat we face.

Antimicrobials are not only used in healthcare, and microbes important to our health are not limited to the human body. Microbes are ubiquitous: in the food we eat, in the environments we occupy, and even in the air we breathe.

Antimicrobials and antiseptics are used broadly in our food systems, homes, and work environments. The microbes and antimicrobial resistance in our ecosystems continually interact with our microbiomes. The United Nations published

a report in February 2023 describing the multiple ways in which the environment plays a key role in AR, highlighting the importance of considering a One Health approach to the AR threat to human health.

A major use of antimicrobials that deserves immediate attention is in our food systems. Significantly more antimicrobials are used among animals raised for food compared with those used in humans. In the US, approximately 6 million kilograms of medically important antibiotics were purchased for livestock in 2021, along with approximately 5 million kg of “non-medically important” antibiotics, for a total of over 11 million kg of antimicrobials used for livestock, according to a 2021 FDA summary report. This is compared to what has been estimated to be about an annual 3.3 million kilograms used for human health as of 2019. So right off the bat, we see the majority of antimicrobial use is not under the oversight of healthcare providers. Nevertheless,

this widespread use of antibiotics in food systems ultimately impacts the health of our food systems and contributes to the antimicrobial resistant threat we face.

The antimicrobials used in livestock impact animal microbiomes – just as occurs in humans. However with livestock, the animals defecate on the ground, so any selection for AR in their guts interacts with the soil, and then can be transported in runoff, and then further downstream and into the surrounding environment. Antimicrobials used in aquaculture (fish farms) have a much more direct entry into the environment as antimicrobials in fish farms are placed directly into our waters. Antimicrobial resistant microbes can disseminate from agriculture into humans in multiple ways: when handling meat harboring some AR bacteria, via contact with colonized animals, from contamination of produce, and through contact with contaminated soil or water.

There are even studies demonstrating that being close to animal farms was associated with an increased risk for being colonized with MRSA as well as other AR organisms.

Antimicrobials are even being sprayed on crops, which can accelerate selection of AR among plants and the soil, and contaminate water sources during runoff. Some antimicrobials actually work by being taken up by the plant, thus resulting in being incorporated into the food itself and ultimately consumed. The scope of use of antimicrobials in our food systems is vast. While their impact on human health is less direct, the scale of antimicrobials in the environment has the same unintended consequences as when they are used in medicine and deserve the same scrutiny as those we use in humans.

A warming climate itself places evolutionary pressures on microbes to cope with heat stress in ways that can result in both emergence of new pathogens as well as cross resistance to antimicrobials. This is particularly concerning with fungi and in fact, the origins of the drug-resistant Candida auris are hypothesized to be from the combined pressures of climate change and the associated increased environmental application of fungicides on crops. There are estimated to be about 1.5 million fungal species, of which only a few are common pathogens for humans. In addition to immune factors, some of why few fungi infect humans is thought to be due to body temperature because most fungi thrive from 12–30°C. As fungi evolve to a warmer climate, adaptations such as cell wall thickening, changes in nutrient utilization and enhanced detoxification processes and other adaptations will allow for emergence of new pathogens, and increased resistance to antifungals. Furthermore, as heat increases due to climate change, farmers are driven to use more fungicides, further spiraling pressures for AR. Once concentrated in the environment, resistant microbes can become more widespread, and of course with climate SANDIEGOPHYSICIAN.ORG

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change, we are having more concentrated episodes of rainfall, flooding, and strong winds. The devastating Category V Hurricane Maria in Puerto Rico in 2017 was shown to likely have resulted in a significant rise in AR genes in water sources downstream from a wastewater treatment plant, likely due to flooding related to the extreme storm. Not only does stormwater runoff spread AR genes, but it also contains contaminants such as antimicrobials, antiseptics, and heavy metals that foster further evolution of AR. And finally, AR microbiota can likely even disseminate via the air. And here we see another overlap of environmental health and AR: in August 2023, a study reported an association of AR with particulate matter (PM)2.5 air pollution, and it has been associated with smog. Thus, as air quality is compromised due to the effects of human-caused climate change, dissemination of AR becomes more widespread.

AR in the environment interacts with plastics and microplastics, which further promote AR. The full scope of health consequences from ubiquitous microplastics is unclear, but they have been shown to become colonized with microorganisms and serve as a substrate for biofilm formation, allowing microbes to persist and, of course, travel. They also absorb chemical contaminants and floating genetic materials including AR genes, and within the biofilms the resistance genes can exchange with other bacteria.

This demonstrates, again, how the degradation of the environment has cascading consequences on the environment and human health.

What We Can Do Learning about the intersections between health and the environment is a first step in combatting these existential crises. This concept is referred to as One Health, which has been defined by the WHO One Health High-Level Expert Panel as the following: • One Health is an integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals, and ecosystems.

• It recognizes the health of humans, domestic and wild animals, plants, and the wider environment (including ecosystems) are closely linked and interdependent.

• The approach mobilizes multiple sectors, disciplines, and communities at varying levels of society to work together to foster wellbeing and tackle threats to health and ecosystems, while addressing the collective need for clean water, energy and air, safe and nutritious food, taking action on climate change, and contributing to sustainable development.

In considering what we’ve learned about antimicrobials, the microbiome, and AR, we must broaden our perspective and recognize how intertwined our food systems and 16

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ecosystems are to our own health. Our microbes afford us health. The food we eat impacts our health, and how we treat the food/soil/plants/animals in our food supply ultimately circles back and impacts health outcomes. We can start connecting diseases we see among patients to the exposures experienced in life, enriching our understanding of social and environmental justice.

Understanding the environmental dimensions of AR should not discount the value of the antimicrobial stewardship we practice within healthcare — in fact, it should heighten the importance of our day-to-day antimicrobial stewardship because every dose of antibiotics disrupts the equilibrium of the microbiome more significantly, leaving patients more vulnerable to being colonized with virulent and resistant organisms increasingly present in our environment. We must continue to steward the antibiotics we control, but also advocate for more sustainable food systems with less reliance on antimicrobials in a warming planet.

And we can do more. We can act locally on these global problems and unite as healthcare providers to prioritize One Health. We can ensure our health systems are moving toward locally sourced plant-forward food options and antibiotic-free meats and as outlined in the Cool Food Pledge. We should be engaging in conversations to decrease single-use plastics in our medical practices in favor of reusable products. Consider the benefits of a plant-forward diet for your patients’ health too, which has co-benefits for the planet. Get engaged with your Sustainability and Green Committees to learn about what more you can do and understand the infrastructure, and work together to find and invest in more sustainable practices.

It was not too long ago that my role as a clinician seemed removed from planetary health, but now I realize that in fact healthcare providers are front and center in managing consequences of the environment, and have a duty to engage as part of the solution.

Dr. Abeles studied ecology and evolutionary biology at Princeton University before attending medical school at Columbia College of Physicians and Surgeons. She came to San Diego for the ocean, the sunshine, and medical residency at UCSD. The field of infectious diseases ties ecology with human health and was a natural fit, and she completed her ID fellowship at UCSD. She is currently an associate clinical professor of medicine at UCSD, specializing in infectious diseases. She is the medical program director of Antimicrobial Stewardship, the inaugural medical director of Sustainability, and the associate medical program director of Infection Prevention and Clinical Epidemiology at UCSD Health.

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The Role of Telemedicine in Practice of Infectious Diseases

By Javeed Siddiqui, MD, MPH

WHAT IS TELEMEDICINE? PRIOR TO THE SARS-COV-2

pandemic the majority of people would not necessarily know the answer to this question. However, in a post-COVID world, the majority of individuals not only know what telemedicine is but have experienced the delivery of healthcare using real-time audio video technologies for their own care, or the care of loved ones.

Simply stated, telemedicine is a tool to increase access to care and enhance the convenience of healthcare delivery, which will continue to become more commonplace into our ever-expanding Internet-connected world.

As the awareness and increase utilization of telemedicine, so has the increased awareness and the value of the field of infectious diseases. Throughout history, the world has been shaped by the impact of a myriad of infectious diseases from malaria to plague to polio to yellow fever to tuberculosis, and now COVID-19.

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It is not by happenstance that in our current world, where every aspect of life occurs online, that we not ask why healthcare has been so recalcitrant to adopting new technologies. In the United States, the healthcare industry has been a world leader in terms of diagnostics.

However, we have been reluctant to look at new methods of simplifying and increasing access to healthcare.

Thus, the delivery of

infectious diseases care through the utilization of telemedicine now plays a critical role in the diagnosis and management of lifethreatening diseases, and has the potential to play a critical role in disease prevention and public health.

There are a number of applications for telemedicine-based infectious diseases, both in the outpatient as well as the inpatient settings of healthcare.

With regards to outpatient medicine, telemedicinebased infectious disease healthcare delivery allows for the access of specialty care to local community clinics. Whether we live in a rural environment or in an urban environment, access to healthcare is complex, time consuming, and at times frustrating.

With the utilization of telemedicine, an individual can go to their local clinic and get access to specialty care from specialists, regardless of geographic distance in an easy, efficient, and effective manner.

One such example is the treatment of hepatitis C. As many are aware, there has been a significant increase in the number of individuals infected with the hepatitis B virus as a result of the opioid crisis. Hepatitis

C is a blood-borne infectious disease that can be effectively treated and clinically cured. With the appropriate evaluation, an infectious disease physician can prescribe medications that in little as eight weeks can result in 98% clinical cure.

Many of the hepatitis C patients receive their care in local community clinics and are often reluctant to go to specialty clinics due to concerns of being ostracized and judged by the community at large. Through telemedicine, infectious disease physicians alongside their primary care colleagues can effectively diagnose hepatitis C patients, complete their evaluation, and, when appropriate, prescribe medications that can lead to a clinical cure. All of this can and has been done effectively through telemedicine, which allows the patient to remain in their community, to be comfortable in the healthcare setting that they are in, and which increases access to care.

Hepatitis C is but one example of a disease state that benefits tremendously through the application of telemedicinebased infectious disease healthcare delivery. Other disease states such as HIV medicine, hepatitis B, tuberculosis, and the evaluation and management of respiratory viruses can all be effectively accomplished through delivering infectious diseases care via telemedicine. This does not require the development of new technologies, the purchasing of new equipment, or the installation of new hardware, but rather this requires the healthcare industry to become more comfortable with in innovative forms of healthcare delivery, and for the public to become more comfortable with receiving care in a nontraditional manner.

When considering hospital-based medicine, it is essential that a patient be evaluated, properly diagnosed, and started on appropriate treatment in the shortest timeframe possible.

In addition, it is the reality of medicine that unexpected complications occur in patients despite all the efforts put forth by a clinical care team. Hospitalized patients need to have access to specialists. In the United States, there is currently a positive of access to medical specialists, and in particular a positive of access to an infectious disease specialist.

Telemedicine has and continues to be a force multiplier for infectious disease physicians. Through the effective application of telemedicine and telehealth technologies, world hospitals, community hospitals, and even tertiary care centers contain access to infectious disease specialists in a timely and effective manner. We currently see the applications of telemedicine in ICU patients and cancer treatment centers with complex infections that occur secondary to immunosuppression and in specialized hospitals, such as orthopedic hospitals when a patient develops an unexpected complication. Telemedicine allows infectious disease physicians to go to multiple hospitals regardless of geography in an efficient manner, while delivering effective and compassionate care.

Increasingly the reality of care delivery at home has

become popular, but also efficient and effective in a post-COVID world. While Congress discusses permanently removing restrictions regarding healthcare delivery to the home, currently under the expansion of the public health, emergency legislation, physicians and their patients are able to utilize telemedicine and telehealth technologies to deliver healthcare to the home. In a world of frequent respiratory viruses that can be highly contagious, the application of telemedicine and infectious diseases allows patients to be evaluated at their homes, utilize homebase diagnostic tests, and have medication sent directly to the patient’s home. Not only is this convenient and effective, but from a public health standpoint, this reduces the risk of transmission to others. Without the utilization of telemedicine, an individual who has a potentially contagious respiratory tract infection would then travel to a clinic or emergency department using a number of transportation modalities that could expose others, then sit in a waiting room that clearly exposes others in order to obtain an evaluation and diagnosis, then needing to travel to pharmacy in order to obtain medications to finally return home to rest and take their treatment. In the case of COVID or influenza viruses, to evaluate patients in their homes not only makes sense for the convenience standpoint but from a public health standpoint.

As telemedicine-based infectious diseases care occurs on a daily basis in the United States, we need to continue to ask the healthcare industry why it has not become more commonplace. The effectiveness of telemedicine-based infectious diseases care has been evaluated and documented in numerous peer review medical journals. With the unprecedented increases in healthcare costs, we know that increasing access to care is an effective strategy in getting care to our patients when and where they need it. My hope is that by sharing this information with you, patients will ask: Can I see my provider through telemedicine?

We know the consumer plays a vital role in changing behaviors in organizations and an industry and the public needs to continue to understand that they have a strong voice in the healthcare industry. A teenager I saw the emerging cable industry constantly say, “I want my MTV.” Now as a practicing telemedicine based infectious diseases physician, I hope the general public will now say, “I want my telemedicine!”

Dr. Siddiqui is an infectious diseases physician and a pioneer in the field of telemedicine and telehealth technologies. Dr Siddiqui has been 100% telemedicinebased since 2010 and currently serves as chief medical officer of TeleMed2U, a telemedicine-based multispecialty clinic practice.

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Ample waiting room area. Can accommodate any specialty or Internal Medicine. Multiple days per week and full use of the office is available.

If interested please email drphilipw@gmail.com.

CHAMPIONS FOR HEALTH - PROJECT ACCESS SAN DIEGO: Volunteer physicians are needed in the following specialties: endocrinology, rheumatology, vascular surgery, ENT or head and neck, general surgery, GI, and gynecology.

These specialists are needed in all regions of San Diego County to provide short term pro bono specialty care to adults ages 26-49 who are uninsured and not eligible for Medi-Cal. Volunteering is customized to fit your regular schedule in your office. Champions for Health is the foundation of the San Diego County Medical Society. Join hundreds of colleagues in this endeavor: Contact Evelyn.penaloza@ championsfh.org or at 858-300-2779.

with additional waiting area outside of the X-ray room.

Orthopedic surgery centric office space. Includes access to a kitchenette/indoor break room, exterior break room and private physician workspace. Open to other MSK physician specialties and subspecialties. Building occupancy includes specialty physicians, physical therapy/occupational therapy (2nd floor), urgent care, and 5 OR ambulatory surgery center (1st floor). For inquiries contact kdowning79@gmail.com and mgamboa@ortho1.com for more information. Available for occupancy projected as February 2024.

OFFICE SPACE IN EL CENTRO, CA TO SHARE: Office in El Centro in excellent location, close to El Centro Regional Medical Centre Hospital is seeking Doctors of any specialty to share the office space. The office is fully furnished. It consists of 8 exam rooms, nurse station, Dr. office, conference room, kitchenette and beautiful reception. If you are interested or need more information please contact Katia at (760) 427-3328 or email at Feminacareo@gmail.com.

LA JOLLA/UTC OFFICE TO SUBLEASE OR SHARE: Modern upscale office near Scripps Memorial, UCSD hospital, and the UTC mall. One large exam/procedure room and one regular-sized exam room. Large physician office for consults as well. Ample waiting room area. Can accommodate any specialty or Internal Medicine. Multiple days per week and full use of the office is available. If interested please email drphilipw@gmail.com

MEDICAL OFFICE SPACE WANTED IN HILLCREST/ BANKERS HILL AREA. Mercy Physicians Medical Group (MPMG) specialist is looking for office space near Scripps Mercy Hospital. Open to lease or share office space, full time needed. Please respond to rjvallonedpm@sbcglobal.net or (858) 945-0903.

ENCINITAS MEDICAL SPACE AVAILABLE: Newly updated office space located in a medical office building. Two large exam rooms are available M-F and suitable for all types of practice, including subspecialties needing equipment space. Building consists of primary and specialist physicians, great for networking and referrals. Includes access to the break room, bathroom and reception. Large parking lot with free parking for patients. Possibility to share receptionist or bring your own. Please contact coastdocgroup@gmail.com for more information.

UROLOGY OFFICE CLOSING 6/2023—EQUIPMENT AVAILABLE: Six fully furnished exam rooms including tables (2 bench, 3 power chair/table, 1 knee stirrup), rolling stools, lights, step stools, patient chairs. Waiting room chairs, tables, magazine rack. Specialty items—Shimadzu ultrasound, SciCan sterilizer, Dyonics camera with Sharp monitor, Medtronic Duet urodynamics with T-DOC catheters, Bard prostate biopsy gun with needles, Cooper Surgical urodynamics, Elmed ESU cautery, AO 4 lens microscope.

RICOH MP-3054 printer with low print count. For more information contact: r.pua@cox.net.

PHYSICIAN POSITIONS WANTED PART-TIME CARDIOLOGIST AVAILABLE AFTER 7/4/23: Dr. Durgadas Narla, MD, FACC is a noninvasive cardiologist looking to work 1-2 days/week or cover an office during vacation coverage in the metro San Diego area. He retired from private practice in Michigan in 2016 and has worked in a San Marcos cardiologist office for the last 5 years, through March 2023. Board certified in cardiology and internal medicine.

Active CA license with DEA, ACLS, and BCLS certification.

If interested, please call (586) 206-0988 or email dasnarla@ gmail.com.

PSYCHIATRIST AVAILABLE! Accepting new patients for medication management, crisis visits, ADHD, cognitive testing, and psychotherapy. Out of network physician servicing La Jolla & San Diego. Visit hylermed.com or call 619-707-1554.

PRACTICE FOR SALE GASTROENTEROLOGY GI PRACTICE FOR SALE: Looking to expand or move? Established 25+ years Gastroenterology GI office practice for sale in beautiful San Diego County, California. 500 active strong patient relationships and referral streams. Consistent total gross income of $600,000 for the past couple years; even through pandemic. Located in a professional-medical building with professional contract Staff.

All records and billing managed by a professional service who can assist with insurance integration. Office, staff & equipment are move-in ready. Seller will assist Buyer to ensure a smooth transition. Being On-Call optional. Contact Ferdinand @ (858) 752-1492 or ferdinand@zybex.com OTOLARYNGOLOGY HEAD & NECK SURGERY SOLO PRACTICE FOR SALE: Otolaryngology Head & Neck Surgery solo practice located in the Ximed building on the Scripps Memorial Hospital La Jolla campus is for sale. The office is approximately 3,000 SF with 1 or 2 Physician Offices.

It has 4 fully equipped exam rooms, an audio room, one procedure room, one conference room, one office manager room as well as in-house billing section, staff room and a bathroom. There is ample parking for staff and patients with close access to radiology and laboratory facilities. For further information please contact Christine Van Such at 858-3541895 or email: mahdavim3@gmail.com OFFICE SPACE / REAL ESTATE AVAILABLE KEARNY MESA OFFICE TO SUBLEASE/SHARE: 5643 Copley Dr., Suite 300, San Diego, CA 92111. Perfectly centrally situated within San Diego County. Equidistant to flagship hospitals of Sharp and Scripps healthcare systems.

Ample free parking. Newly constructed Class A+ medical office space/medical use building. 12 exam rooms per half day available for use at fair market value rates. Basic communal medical supplies available for use (including splint/ cast materials). Injectable medications and durable medical equipment (DME) and all staff to be supplied by individual physicians’ practices. 1 large exam room doubles as a minor procedure room. Ample waiting room area. In-office X-ray

NORTH COUNTY MEDICAL SPACE AVAILABLE: 2023 W. Vista Way, Suite C, Vista CA 92082. Newly renovated, large office space located in an upscale medical office with ample free parking. Furnishings, decor, and atmosphere are upscale and inviting. It is a great place to build your practice, network and clientele. Just a few blocks from Tri-City Medical Center and across from the urgent care. Includes: multiple exam rooms, access to a kitchenette/break room, two bathrooms, and spacious reception area all located on the property. Wi-Fi is not included. For inquiries, contact hosalkarofficeassist@gmail.com or call/text (858)740-1928.

PHYSICIAN OFFICE SPACE FOR LEASE: 1,500 Sq ft. 3 exam room. Large private office. Large reception area and patient prep room. New upgraded flooring. Private entrance.

Located in Rancho Bernardo in prime central location. Easy access to Interstate 15. Palomar /Pomerado within 10 min.

Security card access during off hours. $2,500/month.

Contact: (619) 585-0476. Ask for Peg. HILLCREST OFFICE TO SUBLEASE OR SHARE: Gorgeous office located across from Scripps Mercy hospital.

Office is approximately 2,000 sq. ft. with procedure/effusion room. Office is fully staffed and looking to add a new provider. We currently have Rheumatology/Pulmonary/Allergy specialists but can accommodate any specialty or Internal Medicine. Multiple days per week and full use of office is available. If interested please reach out to Melissa Coronado at Melissa@sdpulmonary.com or call (619) 819-7224.

SUBLEASE AVAILABLE: Sublease available in Del Mar off 5 freeway. Share rent. 2,100 sq ft office in professional building. Utilities included. Great opportunity in a very desirable area. 858-342-3104.

CHULA VISTA MEDICAL OFFICE: Ready with 8 patient rooms, 2,000sf, excellent parking ratios, Lease $4000/ mo. No need to spend a penny. Call Dr. Vin, 619-405-6307 vsnnk@yahoo.com OFFICE SPACE AVAILABLE IN BANKERS HILL: Approximately 500sq foot suite available to lease, includes

OFFICE AVAILABLE IN MISSION HILLS, UPTOWN SAN DIEGO: Close to Scripps Mercy and UCSD Hillcrest.

Comfortable Arts and Crafts style home in upscale Mission Hills neighborhood. Converted and in use as medical/surgical office. Good for 1-2 practitioners with large waiting and reception area. 3 examination rooms, 2 physician offices and a small kitchen area. 1700 sq. ft. Available for full occupancy in March 2022. Contact by Dr. Balourdas at greg@thehanddoctor.com.

OFFICE SPACE / REAL ESTATE WANTED

MEDICAL EQUIPMENT / FURNITURE FOR SALE

NON-PHYSICIAN POSITIONS AVAILABLE PROJECT SCIENTISTS: Project Scientists (non-tenured, Assistant, Associate or Full level): The University of California, San Diego, Office of Research Affairs https://research. ucsd.edu/, in support of the campus multidisciplinary Organized Research Units (ORUs) https://research.ucsd. edu/ORU/index.html is conducting an open search. Project Scientists are academic researchers who are expected to make significant and creative contributions to a research team, are not required to carry out independent research but will publish and carry out research or creative programs with supervision. Appointments and duration vary depending on the length of the research project and availability of funding. https://apol-recruit.ucsd.edu/JPF03262/apply OFFICE MANAGER: 1. Hiring, Training, Managing staff on procedures/policies. Monitors continuing compliance and office statistics. Oversee stocking/maintenance of supplies, retail. Equipment/facilities management. Daily bookkeeping, collections.2. Ensure smooth/efficient patient flow with increasing production/collections. 3. Create a friendly environment where patients’ expectations are exceeded, where staff can work together as a team. 4. Ensure staff working at maximum productivity/efficiency. Salary: $60-70K depending on experience/qualifications. Benefits: health care reimbursement, PTO, retirement, employee discount, bonuses, commission. Contact: info@manageyourage.com ASSISTANT PUBLIC HEALTH LAB DIRECTOR: The County of San Diego is currently accepting applications for Assistant Public Health Lab Director. The future incumbent for Assistant Public Health Lab Director will assist in managing public health laboratory personnel who perform laboratory activities for the purpose of identifying, controlling, and preventing disease in the community, as well as assist with the development and implementation of policy and procedures relating to the control and prevention of disease and other health threats. Please visit the County of San Diego website for more information and to apply online.

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