SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y
DISEASE PERILS AND PROGRESS IN THE ENDLESS RACE
ZIKA AIDS GLOBAL INFECTIOUS DISEASE
A "POSTANTIBIOTIC WORLD"
PLUS: SFMS GALA PHOTOS
VOL.90 NO.2 March 2017
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IN THIS ISSUE
SAN FRANCISCO MEDICINE March 2017 Volume 90, Number 2
Infectious Disease FEATURE ARTICLES
10 Infectious Diseases: It’s All In The Number$ Kathleen Jordan, MD
President’s Message Man-Kit Leung, MD
11 Earth’s Zoonotic Virome: Towards Proactive Prevention Christine Hercik, PhD, Nathan Wolfe, DSc, MA, Edward Rubin, PhD, MD, FACMG 13 The Third Approach: Finding the Cure to End AIDS Paul Volberding, MD 15 Zika Virus Update Ryan Guinness, MD and Cora Hoover, MD, MPH
16 A "Post-Antibiotic World": California Leads The Way to Save Us; Will Washington Join In? David Wallinga, MD, MPA 18 Perils and Progress: A Global Update on Ebola, Zika, MERS and Tuberculosis John Maa, MD
Editorial Gordon Fung, MD, PhD, and Steve Heilig, MPH
29 Medical Community News 30 Upcoming Events
OF INTEREST 24 SFMS Annual Gala Photos 27 SFMS Annual Gala President's Remarks
20 Getting to Zero: San Francisco Consortium Working to Eliminate AIDS Diane Havlir, MD, and Susan Buchbinder, MD 22 Choosing Wisely: Infectious Disease Update Katie Raffel, MD, and Sarah Doernberg, MD, MAS
ADDICTION SUMMIT 5th Annual David E. Smith, MD Symposium
Friday, June 9, 2017 8:30am - 5:30pm UCSF Laurel Heights Auditorium 3333 California Street, San Francisco Join us for an action-oriented forum with leading multidisciplinary faculty covering: • • • • Editorial and Advertising Offices: San Francisco Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133 Phone: (415) 561-0850 Web: www.sfms.org
Opiates • Advances in addiction medicine Pain management and primary care Alcohol abuse • San Francisco problems and Tobacco responses, and more!
For more information, visit www.sfms.org or contact Steve Heilig at email@example.com Event co-sponsored by SFMS, SFDPH, CAFP, UCSF CME provided by CAFP
MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members
CURES Mandate Implementation Date Remains Unclear
CDPH Upgrades Immunization Registry to Allow for Real-time Updates
Under California law, all individuals practicing in California who possess both a state regulatory board license authorized to prescribe, dispense, furnish or order controlled substances and a Drug Enforcement Administration Controlled Substance Registration Certificate (DEA Certificate) must be registered to use the Controlled Substance Utilization Review and Evaluation System (CURES) https://oag.ca.gov/cures. Currently, physicians are encouraged—but not required—to check the database before prescribing controlled substances. Checking the CURES database will eventually be mandatory, under a law passed by the California Legislature in 2016. For more information on CURES, visit www.cmanet.org/cures.
The California Department of Public Health (CDPH) announced that it will roll out phase two of the California Immunization Registry (CAIR) this month, beginning with the Bay Area and Central Valley counties. A phase three update for Southern California is expected to begin in March. CAIR is a collaboration of immunization registries that ensures the secure, electronic exchange of immunization records to support the elimination of vaccine-preventable diseases. CDPH is working to develop an integrated, secure, readily-accessible statewide network of computerized immunization information systems to make each child’s full immunization history available to providers and other authorized users, such as schools, foster care and juvenile detention centers. The CAIR2 system will ensure that users have rapid access to complete and up-to-date immunization records, as well as expert vaccine forecasting. A major objective is to eliminate both missed opportunities to immunize and unnecessary duplicate immunizations. CAIR is a consortium of ten regional registries using four different softwares. Seven of the ten regional registries (Northern California, Greater Sacramento, Bay Area, Central Valley, Central Coast, LA-Orange and Inland Empire) are managed by CDPH. The CAIR2 project will combine these seven regions into a single, centralized registry to be known as CAIR2 that will use new software. CDPH says the CAIR2 update will allow real-time updates and faster access to the database in any web browser. This process should be completed by April 2017.
Additional resources: • Medical Board of California’s Guidelines for Prescribing Controlled Substances for Pain - http://bit.ly/2kB6lDP. • CMA On Call document #3212, California’s Prescription Drug Monitoring Program: The Controlled Substance Utilization Review and Evaluation System (CURES) - http://bit.ly/2l2gSZg.
CURES 1.0 Decommissioned
The Department of Justice and the Department of Consumer Affairs announced that CURES 1.0 will be decommissioned on Sunday, March 5, 2017. Thereafter, only CURES 2.0 will be available to users employing a secure internet browser such as Microsoft Internet Explorer, version 11.0 or higher, Mozilla Firefox, Google Chrome, or Apple Safari. Visit http://bit.ly/2lsFDi8 to view the full announcement of the CURES 1.0 Decommission.
Covered California Tax Credit Mix-ups Cause Headaches for Consumers
Physicians should be aware that approximately thirty-five thousand Californians insured through Covered California have, at least temporarily, lost federal premium subsidies or are facing higher-than-expected premium bills due to clerical errors by the state health exchange. Physicians who receive questions from their patients about either of these issues should direct them to contact Covered California directly at (800) 300-1506. Visit http://bit.ly/2lsG0Jv for more information. For physician practices, these two issues could result in changes to patient eligibility. Physicians are urged to be diligent in verifying patients’ eligibility and benefits each time they are seen to ensure they will be paid for services rendered (http://bit.ly/2kceEaz).
GAO Upholds Award of Tricare West Contract to Health Net Federal Services
The U.S. Government Accountability Office (GAO) has upheld the Department of Defense’s (DOD) decision to award Health Net Federal Services the contract to provide managed care services to Tricare beneficiaries in its Western Region, which includes California and twenty other states. As the California Medical Association (CMA) previously reported (http://bit.ly/2lsEAih), the DOD announced in July 2016 that it had awarded the contract to Health Net. The contract, worth up to $17.7 billion over nearly six years, had previously belonged to United Healthcare Military and Veterans Services since 2013. United protested the decision, but the GAO announced in mid-November 2016 (http:// bit.ly/2kB4m2f) that it would uphold the decision to award the west region to Health Net. A nine-month transition period is expected, with Health Net expected to start health care delivery for Tricare patients sometime in late 2017. Visit http://bit.ly/2lswnKU for more information.
SAN FRANCISCO MEDICINE MARCH 2017 WWW.SFMS.ORG
Medi-Cal’s Fiscal Intermediary to Change Name from Xerox Xerox State Healthcare, LLC, the current Medi-Cal fiscal intermediary for the California Department of Health Care Services’ (DHCS) fee-for-service system, has separated from the Xerox Corporation and has become a new, independent, publicly-traded company called Conduent State Healthcare, LLC. The shift to the new Conduent brand name began on January 3, 2017. The transition is not expected to impact business operations, including those involving providers and beneficiaries. Providers are encouraged to open and read all information sent from DHCS, Xerox or Conduent to stay informed about the transition. For more information, providers can subscribe to the Medi-Cal Subscription Service (MCSS) to receive notifications related to Medi-Cal Update bulletins, NewsFlash articles and System Status Alerts. Providers may sign up for MCSS by visiting www.medi-cal.ca.gov and completing the MCSS Subscriber Form.
FSMB Launches Free Online Education Program on Medical Regulation Issues Critical to New Physicians
The Federation of State Medical Boards (FSMB) has launched a new initiative designed to inform future physicians about medical licensing and regulation. A new series of online education modules will address important issues, including navigating the licensing process and dealing with physician health and impairment. Now live, the first module, “The Role of State Medical Boards” (http://www.fsmb.org/smb_module), focuses on providing medical students and residents with sufficient information about the functions of medical regulation so they will be prepared to interact effectively and professionally with state medical boards, fellow physicians and patients. Future modules (http://www.fsmb.org/policy/educationmeetings/educational-modules) will cover details on the medical licensing process, reasons physicians get in trouble, the medical disciplinary process and physician wellness issues.
Spotlight Your Practice and Expand Your Referral Base with an Updated Member Profile
With the SFMS print directory and online Physician Finder (http:// www.sfms.org/ForPatients/PhysicianFinder.aspx), physician members have the opportunity to promote their practices with customizable individual web profiles and connect with a larger patient and referral base. All updates must be received by March 31, 2017. Please contact Ariel Young at firstname.lastname@example.org or (415) 561-0850.
Take Full Advantage of Your Member Benefits
Don’t leave money on the table—take advantage of your group-buying discounts. Members can offset the price of their annual dues when using membership services and discounts. Members receive deep discounts on everything from magazines to office supplies to insurance products, including group medical, worker’s comp, homeowners, auto and more. For details, visit http://bit.ly/sfmsmembership.
CMA’s Practice Manager Tip of the Month
Trouble getting paid? CMA can help! CMA’s Center for Economic Services (CES) is staffed by a team of practice management experts with a combined experience of over 125 years in medical practice operations. Access to CMA experts is a free members-only benefit. Call (800) 786-4262 or email email@example.com.
March 2017 Volume 90, Number 2 Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production Editor Amanda Denz, MA Copy Editor Amy LeBlanc, MA EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Erica Goode, MD, MPH Stephen Askin, MD Shieva Khayam-Bashi, MD Toni Brayer, MD Arthur Lyons, MD Chunbo Cai, MD John Maa, MD Linda Hawes Clever, MD David Pating, MD
SFMS OFFICERS President Man-Kit Leung, MD President-Elect John Maa, MD Secretary Brian Grady, MD Treasurer Kimberly L. Newell, MD Immediate Past President Richard A. Podolin, MD SFMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Erin Henke Director of Administration Posi Lyon Membership Coordinator Ariel Young BOARD OF DIRECTORS Term: Jan 2017-Dec 2019 David T. Duong, MD Alexander B. Geng, MD Robert A. Harvey, MD Dawn D. Ogawa, MD Ray Oshtory, MD Justing P. Quock, MD Dennis Song, MD Joseph W. Woo, MD
Term: Jan 2016-Dec 2018 Charles E. Binkley, MD Benjamin L. Franc, MD Nida Degesys, MD Raymond Liu, MD David R. Pating, MD Monique D. Schaulis, MD Winnie Tong, MD
Term: Jan 2015-Dec 2017 Steven H. Fugaro, MD Todd A. May, MD Stephanie Oltmann, MD William T. Prey, MD Michael C. Schrader, MD Albert Y. Yu, MD (To be determined) CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD
MARCH 2017 SAN FRANCISCO MEDICINE
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PRESIDENT’S MESSAGE Man-Kit Leung, MD
Doctors Beyond Borders I don’t recall much of my early childhood, but I do remember it was always hot. My father was a foreign medical graduate and had difficulty matching into a residency program. He eventually found a residency opportunity in Bakersfield, California, and subsequently set up his first practice in Yuma, Arizona. After a few years, the heat was too overwhelming, and we ultimately moved to San Francisco, where my father has been a family medicine physician serving the immigrant Chinese community for more than thirty-five years. My father’s story is not unique. On a random Monday afternoon in the lunchroom at the office of the Chinese Community Healthcare Association, an independent physicians association located in San Francisco’s Chinatown, about half the doctors who came for lunch that day were either foreign born and/or foreign educated. Our community depends on the service of immigrant physicians. On January 27, 2017, President Donald Trump issued an executive order banning the citizens of seven Muslimmajority countries, including Iran, Iraq, Libya, Somalia, Sudan, Syria, and Yemen, from entering the U.S. for at least ninety days. At the time of issuance, this ban included individuals who are legal U.S. permanent residents (i.e., green-card holders). In addition, the executive order banned all Syrian refugees indefinitely. Interestingly, the executive order did not include any countries from which individuals actually killed Americans in the U.S. since September 11, 2001.1 Although the legality of the order is being challenged, the immigration ban could have far-reaching detrimental consequences on the American healthcare workforce. According to the 2014 census by the Federation of State Medical Boards, approximately one-quarter of all licensed doctors in the U.S. are foreign medical graduates, with more than one-third coming from countries with heavy Muslim populations including India, Pakistan, and the Philippines. Similarly, six of the ten international medical schools with the largest number of graduates who have an active licenses in the U.S. are located in the Philippines, Pakistan, Syria, or India.2 These numbers are mirrored in California, where about twenty-five percent of all active physicians were trained in a foreign medical school.3 Although there are U.S. nationals who attend medical schools abroad and return to practice in the U.S., most international medical graduates are foreign born. In fact, more than one-quarter of practicing physicians in the U.S. were not born in America. When the broader healthcare workforce is considered, about twenty-two percent of nursing, home health, and psychiatric aides, fifteen percent of registered nurses, as well as fifteen percent of other types of health care practitioners WWW.SFMS.ORG
(such as dentists, pharmacists and clinical technicians) in the U.S. are foreign-born. Overall, foreign-born professionals account for sixteen percent of all civilians employed in healthcare occupations.4 There are simply not enough native-born healthcare workers to meet demand—especially in geographic areas with the greatest need. Rural clinics and public safetynet systems in particular rely on immigrant medical professionals to deliver care to isolated and vulnerable populations. Our nation was founded by immigrants who centuries later continue to sustain it. The vast majority of immigrants, like my father, are honest, hard-working individuals in search of better opportunity. Although the executive order on travel ban is temporary, President Trump has proposed more permanent plans which involve “extreme vetting” to more tightly control immigration after the ban is lifted. With more than one-quarter of physicians and one-sixth of all healthcare professionals originating from other countries, the U.S. healthcare system— and our society as whole—depends on a functioning immigration program. Any reform to immigration policy must be carefully crafted, adeptly executed, and reflective of America’s core commitment to inclusiveness and religious tolerance. By the way, in the first week of February, the high temperature in Yuma, Arizona was 86°F. Man-Kit Leung, MD, is an otolaryngologist on staff at Chinese Hospital, California Pacific Medical Center, St. Francis Memorial Hospital, and St. Mary’s Medical Center. He welcomes correspondence at firstname.lastname@example.org.
References 1. http://www.npr.org/2017/01/31/512439121/trumpsexecutive-order-on-immigration-annotated 2. A. Young, H. J. Chaudhry, X. Pei et al, “A Census of Actively Licensed Physicians in the United States, 2014.” Journal of Medical Regulation, Vol. 101, No. 2: 8-23, 2015. 3. California Health Care Almanac, California Healthcare Foundation, 2010. 4. http://www.migrationpolicy.org/article/foreign-bornhealth-care-workers-united-states
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EDITORIAL Gordon Fung, MD, PhD, and Steve Heilig, MPH
Infectious Disease: A Subspecialty for Survival This is the way the world ends Not with a bang but a whimper. -T.S. Eliot Infectious Diseases is a medical subspecialty of internal medicine and pediatrics. Practitioners in the distant past were mainly associated with travel or tropical medicine, as that’s where many people returned from with "exotic" pathogens. Over the years the specialty found its place especially in the public health arena where major outbreaks of disease would affect large populations —such as the 1918 Russian Flu, the plague, HIV, and our current annual influenza seasons. But the advent of methods to diagnose infectious diseases (cultures, gram stains, microscopic analysis of urine and blood, diagnostic procedures such X-Rays, CT Scans, endoscopes, and ultrasounds, coupled with new treatments) helped to create a field focused on the population as a whole as well as specific populations who were susceptible to infections, such as immunocompromised hosts or anyone exposed to highly contagious agents. In some ways this involves a true Darwinian race between our species and the infectious agents that bedevil us. For a time many thought we might decisively win this war, with the development of antibiotics to treat common bacteria. But as we all know, there was much misuse and abuse of antibiotics, inevitably and quickly resulting in development of drug-resistant bacteria and even “super bugs” that can grow and destroy tissue despite our strongest antibiotics—such as multiply drug resistant tuberculosis. And even with some successes, there are dramatic newer epidemics that continue to threaten and even terrorize the whole world—SARS, MERS, Ebola, and now Zika. Confronting these requires expertise, resources and cooperation in both inpatient and outpatient as well as public health practice, from pediatrics to geriatrics. According to the Infectious Disease Society of America, the current top issues in infectious diseases are: (1) Antimicrobial resistance; (2) Ebola; (3) Emerging clinical issues (e.g., SARS, MERS); (4) Hepatitis C; (5) Immunization; (6) Influenza; (7) Lyme disease; and (8) Zika. Looking at this list, six of the top eight issues relate to viruses. The main issues are that viruses present in protean manifestations—from the very slow indolent growing type to the rapid aggressive total body inflammation and destruction that is characterized by Ebola. Our current approach is to continue surveillance efforts to detect new and existing viruses, diagnose the offending virus, investigate the life cycle and transmission of the agent and then try to find a treatment or means to support the patients affected. Except for Hepatitis C, there have been very few specific treatments for viruses. Hepatitis A through C and possibly E and F can, if left untreated, convert to liver cancer as Herpes can lead to cervical cancer. Prevention efforts have WWW.SFMS.ORG
led to development of vaccines for some of these agents—but this strategy has not been without its opponents. In this edition, our stellar authors tackle several of these major topics with examples from the San Francisco Bay area. Kathleen Jordan begins with the broad perspective of looking at the impact of infections on the populations. John Maa delves into a global perspective looking at the impact of Zika, MERS, and Tuberculosis. Katie Raffel and Sarah Doernberg discuss the Choosing Wisely campaign and a rational way to appropriately use antibiotics both to treat the patients and minimize the risk of overuse and misuse. David Wallinga warns about the specter of a postantibiotic world, hoping for the leadership of California's Governor and legislature to enact regulations to decrease the overuse of antibiotics in livestock. SFMS has been a leader in this field, calling on CMA and the state legislators as well as the AMA to address these concerns for the health of all Americans. Christine Hercik, Nathan Wolfe, and Edward Rubin write about the zoonotic virome and Ryan Guiness and Cora Hoover talk about the Zika virus. The story of HIV from initial diagnosis to discovering the agent involved and developing management strategies really began in San Francisco with leadership from Paul Volberding, who currently heads the HIV center at UCSF. He talks about the third (and hopefully final) approach to eliminate the disease via discovering a fully effective cure. Diane Havlir and Susan Buchbinder elaborate on how the once seemingly unobtainable aim of no new cases is being approached here in San Francisco. There are certainly many more topics one can discuss in this arena, including the ongoing crucial efforts to counter misinformation about the safety and efficacy of vaccines (see the SFMS video on YouTube wherein musical star Graham Nash was enlisted to help with education there). But we are pleased to present this roster of leaders summarizing some of the biggest threats and advances. And these efforts may be proven to be even more important than they are already seen as being. With the ever-expanding list of presentations of illnesses linked to infectious agents, one can’t help but wonder if virtually all diseases might be found one day to be at least partially a manifestation of an infectious process. Not so long ago, a viral agent was suspected, but then discounted, as the cause of chronic fatigue syndrome. Now, we are seeing similar reports concerning cancers and even autism. Whatever the research might bring us, we must preserve and expand our ability to outrun the bad bugs that could, unchecked, bring about the end of civilization and even humanity. We hope that we exaggerate here, but time will tell. MARCH 2017 SAN FRANCISCO MEDICINE
INFECTIOUS DISEASES It’s All In The Number$ Kathleen Jordan, MD More than any other field of medicine, infectious disease as a field of study embraces surveillance and epidemiology as a primary means to combat the very diseases they survey. We see, we diagnose, we
isolate, we prevent further disease. Sure, there are new fancy diagnostic tools, immunizations, sepsis protocols, antimicrobials, and supportive care, but the primary successes in the field of infectious diseases rely on surveillance tools triggering interventions to avoid further exposure. While we have new antibiotics and new antivirals, constant mutation and adaptation keep the microbes alive. Surveillance, combined with both early diagnosis and an appreciation of the epidemiology of disease that has led to greatest successes in the twenty-first century. Looking back at this century’s most notorious pandemics, it has been surveillance, timely recognition of disease, and minimizing exposure that succeeded in saving lives: recall SARS, “Bird flu”, MERS, anthrax, HIV, Ebola, and now Zika. We learn from the index cases and try to prevent the future cases by eliminating exposure either via isolation, education, or vector control. We kill mosquitos. We give away condoms. We issue travel warnings. We suit up. We inspect—and now irradiate—mail. We isolate the ill and the exposed. PEPFAR (The U.S. President’s Emergency Plan for AIDS Relief) is certainly a shining example of success in the world of infectious diseases and incorporates the basics of disease transmission avoidance with the goal of reaching an AIDS free generation. Launched with bipartisan efforts in 2003 for AIDS relief, it represents the largest commitment by any nation to combat a single disease and has attained success beyond what most of us anticipated at its inception. The plan outlines prevention and treatment efforts that enlist efforts from government agencies, faith based groups, private groups, foundations and individuals around the world leading to sustainable programs globally. While PEPFAR embraces access to treatment of HIV for all, only thirty percent of affected persons are estimated by the Centers for Disease Control and Prevention (CDC) to be on effective therapy, with only forty percent of those positive having access to care. Hence, the backbone of the plan also includes the basics of disease containment: increasing education, testing, and access to barriers for transmission prevention. This education, along with access to testing, has been effective in curbing transmission in countries the world over.
When these basics aren’t available, disease spreads: Ebola 2014. Surveillance with rapid diagnosis and isolation is
what contained twenty-four earlier outbreaks of Ebola that occurred between 1976 through 2014. Cases were identified with isolation and containment measures implemented swiftly and 10
effectively, minimizing mortality. The 2014 outbreak, however, occurred in West African nations with little healthcare infrastructure and limited ability to engage in health surveillance. This inability to recognize the rising number of mortalities in Western Africa led to a catastrophic spread of the virus before Medicins Sans Frontieres workers noted the abnormally high mortalities from what was being incorrectly attributed to Lassa Fever, cholera, and malaria. Blood samples were sent back to Lyon, France for testing. A crisis emerged. Over ten thousand people would die and the world would spend $32.6 billion dollars in one of the most comprehensive efforts taken on by the World Health Organization (WHO). More recently, surveillance of two diseases concomitantly rising in prevalence linked cause and effect: Zika virus and microcephaly. Zika virus, previously thought to be a mild infectious agent with little to no appreciated morbidity or mortality, became the new pandemic. Despite increased interest and research, there remains no effective treatment option and both religious and political obstacles abound when it comes to addressing this health crisis. But, again returning to the basics of understanding the epidemiology of the disease has led to our most effective interventions: disease transmission avoidance. We have limited travel of susceptible populations, engaged in mosquito control efforts, and engaged in education on avoidance and/or family planning. These efforts are not much different that management of tuberculosis and polio from decades past: know who and what harbors disease and avoid exposure.
So what are the surveillance numbers telling us now? Certainly with urbanization of rural areas and increased travel, the world seems always on the precipice of a pandemic. But current surveillance of disease is already finding a remarkable pattern in the spread of disease: the undeniable link of infectious disease mortality to poverty. Lower income people are more likely than higher income people to die from communicable diseases, both when comparing populations within the United States as well as comparing developed nations to developing nations. HIV/AIDS, diarrhea, pneumonia, tuberculosis, and malaria remain significant players in disease mortality in developing nations. Developing countries have far higher mortalities for infectious agents than their first world counterparts. While cardiovascular disease remains the leading single cause of death in all countries, it is only in developing countries that infectious diseases (HIV/AIDS, lung infections, tuberculosis, diarrheal disease, and malaria) combined claim more lives. Governments and NGOs alike continue to work with local governments to improve the health of the people by reducing
Continued on page 12 . . .
SAN FRANCISCO MEDICINE MARCH 2017 WWW.SFMS.ORG
EARTH’S ZOONOTIC VIROME Towards Proactive Prevention Christine Hercik, PhD, Nathan Wolfe, DSc, MA, Edward Rubin, PhD, MD, FACMG In the past decade, emerging zoonotic pathogens, such as Ebola virus, severe acute respiratory syndrome (SARS) coronavirus, Middle East respiratory syndrome (MERS) coronavirus, and novel influenza viruses, have sparked deadly outbreaks of human disease. These events are the result of viral spillover—or the trans-
mission from an animal reservoir to a human host. The frequency of viral spillover events has increased over the last century due to growing interactions between humans and wildlife. This increase in human-wildlife contact is driven by a number of anthropogenic factors including increases in human population, climate change, agricultural intensification, and the growth of extractive industries. Repeated outbreaks of emerging zoonotic pathogens suggest that the world is ill-prepared to both prevent viral spillover and mitigate its impact at a time when the likelihood of these events is predicted to increase. How can the scientific community improve the world’s resiliency to future pandemic threats? Estimates indicate that only approximately one percent of all microbial agents have been identified to date, with an estimated 1.3 million viruses still unidentified in taxonomic groups known to be reservoirs of high consequence pathogens.1,2 Recent studies suggest that “virodiversity” is associated with natural host diversity, which indicates that targeting pathogen discovery efforts in geographic areas of high mammalian and avian species diversity may increase the chances of discovering new pathogens.3,4 To combat the ongoing threat of viral spillover, the potential size and scope of the total zoonotic pool must be more thoroughly defined and characterized. A collaborative, international effort is required to support current and ongoing research efforts to identify when, where, and how viruses spillover into human populations. To this end, the United States Agency for International Development’s (USAID) Emerging Pandemic Threats Program launched the PREDICT project, a global surveillance project with the objective of detecting known and novel viruses in wildlife reservoirs (http:// data.predict.global). Since its inception in 2009, this project has created a robust emerging infectious disease surveillance network in over thirty countries. To date, more than eight hundred new viral agents were detected in the three hundred thousand samples collected from more than sixty-six thousand animals. Sequence data reveals that a subset of these viruses are closely related to viruses with a demonstrated ability to spillover to humans, heightening concerns that among the novel viruses discovered in wildlife are those that may also be capable of causing severe human disease. The sheer number of novel viruses detected by this program and others raises a larger question: Is it possible to catalogue our planet’s entire virome, specifically all mammalian and avian viruses that might pose a threat to human health? Preliminary metaWWW.SFMS.ORG
analyses of PREDICT data suggest viral diversity within each animal species or taxa group is finite and can be estimated, and therefore a targeted global sampling effort across wildlife could offer the means to discover nearly all viruses with zoonotic potential. To do this, a global initiative of massive scale, the Global Virome Project (GVP) (www.globalviromeproject.org), is proposed to extend the surveillance structures and approaches pioneered in the PREDICT project. The purpose of this ten-year initiative is to identify and map ninetynine percent of our planet’s high consequence viral threats, and to further characterize those viruses existing in wildlife that maintain the potential to spillover into human populations. The GVP would effectively leverage new technologies and scientific advancements, including high-throughput sequencing for generation of complete viral genomes, lending insights into viral diversity and the phylodynamics of detected pathogens. Identifying viral candidates with the potential to spark future pandemics, and subsequently characterizing their geographic distribution and host range, would provide the scientific community with access to a wealth of genomic and ecological data that could be used to more effectively combat the consequences of spillover of deadly viruses into human populations. As observed with the impact of the Human Genome Project on studies of human biology, the GVP has the potential to be truly transformative by converting the field of virology into a data rich science. Aggregated data will effectively seed the construction of an unprecedented viral database, which can provide comprehensive reference panels for the development of candidate diagnostic assays, vaccines, antivirals, and other medical countermeasures. Furthermore, establishment of a global surveillance architecture capable of characterizing our planet’s virome to this extent will require significant investment in local disease detection capabilities in high-risk, low-resource settings across “hot zone” regions.5 By the end of the next decade, the most vulnerable countries could be equipped with laboratories and field surveillance systems capable of early detection and characterization of novel viruses. This enhanced capacity will also support and enhance ground efforts to control known, endemic zoonotic diseases that currently burden much of the developing world. Up to this point, the international community has relied on a purely reactive approach to disease emergence events. However, recent events serve as an important reminder that a single microscopic agent, both highly virulent and rapidly transmissible in the human population, could emerge at any time. A proactive paradigm shift, driven by a global alliance, is necessary to accelerate our understanding of the viral unknown and to fuel a systematic re-design of global pandemic preparedness, grounded in pre-emptive countermeasures and global risk mitigation.
Continued on page 12 . . .
MARCH 2017 SAN FRANCISCO MEDICINE
Earth's Zoonic Virome Continued from page 11 . . .
Infectious Diseases Continued from page 10 . . .
Christine Hercik, PhD, is currently an infectious disease epidemiologist at Metabiota Inc. She received her PhD in Global Infectious Disease from Georgetown University, as well as a post-graduate degree certificate from the London School of Hygiene and Tropical Medicine (LSHTM). As a field epidemiologist, Dr. Hercik has worked with the U.S. Centers for Disease Control and Prevention’s Global Disease Detection Division to monitor for emerging infectious diseases of public health importance. Nathan Wolfe, DSc, MA, is the Founding Chief Executive Officer and Chairman of Metabiota Inc., and Chairman of the non-profit organization Global Viral. Dr. Wolfe received his doctorate in Immunology & Infectious Diseases from Harvard in 1998. He has received numerous awards including a Fulbright fellowship and the NIH Director’s Pioneer Award and was named a National Geographic Emerging Explorer in 2009 and a World Economic Forum Young Global Leader in 2010. He has authored over eighty scientific publications, along with his critically acclaimed book, The Viral Storm. Edward Rubin, PhD, MD, FACMG, is an internationally recognized geneticist and information scientist, and is currently the Chief Science Officer at Metabiota Inc. where he leads the USAID Pandemic Threat Program PREDICT Project. His past research has included pioneering studies on the use of massive scale DNA sequencing to decipher the interactions between humans and other biological and nonbiological systems. As the former Director of the U.S. Department of Energy’s Joint Genome Institute, Dr. Rubin led a team that sequenced thirteen percent of the human genome, as part of the International Human Genome Project.
poverty, enhancing access to care, improving agriculture, strengthening financial services to the poor, and raising overall health awareness. Multiple agencies and governments espouse universal access to health care and poverty reduction as the most important tools to saving lives. Some have gone so far as to say poverty is a disease, while others espouse poverty is merely a predictor of poor outcome for chronic diseases. What epidemiology tells us is that those living in poverty share a bigger burden of infectious disease morbidity and mortality. Mitigating the risk factor of poverty may be the most important health measure and development in infectious disease in the coming decades. Nothing would trump it.
References 1. S. J. Anthony et al. “A strategy to estimate unknown viral diversity in mammals.” MBio 4, e00598-00513 (2013). 2. PREDICT Consortium. “Reducing Pandemic Risk, Promoting Global Health.” (PREDICT Consortium, 2014). 3. Rondinini C., et al. “Global habitat suitability models of terrestrial mammals.” Philos. Trans. R. Soc. Lond. B Biol. Sci. 366:2633–2641 (2011). 4. Anthony S.J., et al. “A strategy to estimate unknown viral diversity in mammals.” mBio 4(5):e00598-13. doi:10.1128/mBio.00598-13 (2013). 5. Jones K.E. et al. “Global trends in emerging infectious diseases.” Nature 451(7181):990-3. doi: 10.1038/nature06536 (2008).
Kathleen Jordan, MD, is vice president and chief medical officer at Saint Francis Memorial Hospital.
Deadly, Drug-Resistant ‘Superbugs’ Pose Huge Threat, WHO Says From the New York Times February 27, 2017 By DONALD G. McNEIL Jr. The World Health Organization warned in February that a dozen antibiotic-resistant “superbugs” pose an enormous threat to human health, and urged hospital infection-control experts and pharmaceutical researchers to focus on fighting the most dangerous pathogens first. The rate at which new strains of drug-resistant bacteria have emerged in recent years, prompted by overuse of antibiotics in humans and livestock, terrifies public health experts. Many consider the new strains just as dangerous as emerging viruses like Zika or Ebola. “We are fast running out of treatment options,” said Dr. MariePaule Kieny, the W.H.O. assistant director general who released the list. “If we leave it to market forces alone, the new antibiotics we most urgently need are not going to be developed in time.” “We’re at a tipping point. We can take action and turn the tide — or lose the drugs we have.” Full story at: https://www.nytimes.com
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THE THIRD APPROACH Finding The Cure To End AIDS Paul Volberding, MD San Francisco physicians have seen firsthand the thousands of lives lost during the acquired immune deficiency syndrome (AIDS) epidemic. The numbers
undergoing active treatment continue to increase as fewer human immunodeficiency virus (HIV) infected individuals succumb to their illness. Globally, only fifty percent of the estimated thirty-eight million HIV-infected persons are now being treated. The World Health Organization (WHO) guidelines recommend lifelong antiretroviral treatment for all infected individuals. This directive will allow many lives to be extended but will clearly add many billions of dollars to the annual cost. Given the new U.S. administration, policy direction and funding priorities are rapidly shifting and raise questions that our government will continue its investment in care for HIV positive individuals. Moreover, while HIV treatment has improved immensely over the past twenty years, concern about the potential for long-term toxicity still remains, especially in low-income countries where older drugs by our standards are still in widespread use. Treating the many HIV-infected persons, whether in San Francisco or globally, is also complicated by the stigma they continue to experience. The goal to end the AIDS epidemic globally is healthdriven and compassionate, but demands a continued substantial financial commitment. Because of the many challenges of global, lifelong HIV treatment, a strategy to bring the epidemic to a close is an urgent priority. There are three primary avenues to ending the epidemic, each under active research investment: 1) developing a truly effective HIV vaccine, 2) applying public health interventions, and 3) finding a cure. Despite years of effort and the investment of enormous resources, HIV vaccine research progress has been limited. Currently, there is no product in testing that holds substantial promise and, in addition, given the realities of clinical testing, particularly the low transmission rate in most populations, any vaccine candidate will take many years to prove its effectiveness. We have made well-known dramatic advances in antiretroviral therapy that render HIV infection a chronic disease with a nearly normal life expectancy. HIV treatment is typically comprised of a single daily dose of one pill containing three to four drugs. Side effects are typically minimal and treatment is almost always successful in suppressing viral growth. The expected goal of HIV treatment is that quantitative tests of viral load in the blood cannot detect the virus. Viral suppression is not only beneficial to treatment recipients, but can also block transmission of the virus so effectively that sexual behavior no longer requires the use of condoms to prevent HIV transmission. Another less intensive HIV drug regimen is the single daily pill containing only two drugs, which is also a potent preventive treatment WWW.SFMS.ORG
for uninfected persons engaging in non-barrier protected sex, pre-exposure prophylaxis (PrEP). These advances are at the heart of the second method employed to end the AIDS epidemic: public health. The local Getting to Zero campaign in San Francisco has an aim of: zero new infections, zero HIV-related deaths, and zero instances of HIVassociated stigma and discrimination. The road to achieving this goal would involve testing all at-risk persons, suppressing viremia of all HIV positive individuals, and advocating PrEP for those who are at behavioral risk of becoming infected. Unlike vaccine approaches (or cure treatment), the public health approach employs current technology which require these drugs, testing campaigns, and HIV suppression maintenance to reach all infected or at risk of infection. While this approach is showing substantial progress in some cities (like San Francisco), implementing it in many regions will clearly be a major challenge, and still requires lifelong treatment and all associated costs. The third avenue to explore is finding a cure. One might ask, “If we can so easily treat HIV with one daily, convenient, and nontoxic pill, why pursue a cure?” I have often asked my patients this question but have yet to find one who would not rather be cured. Regardless of the success of current antiretroviral therapy, daily treatment is a constant reminder of the infection. Along with the likelihood for long-term toxicity, the social stigma still persists, in addition to the treatment costs for the millions of current/future cases. The medical infrastructure needed to deliver treatment in resource-limited settings is a serious constraint. International HIV treatment programs like PEPFAR and the Global Fund are primarily supported by the U.S. at a time when political changes in attitude to international aid could well derail these essential programs. We can easily see why an HIV cure is desired. In terms of cure research, we can ask what are the prospects and directions being explored? HIV infection rapidly establishes a pool of CD4 T-cells silently harboring the viral genome incorporated in host DNA. These cells are “latently” infected. This means the viral genome is inactive, resulting in cells that are invisibly infected. Therefore, the host immune system is unable to detect these cells and for that reason, does not kill them. Latently infected cells form what is called the “latent reservoir” of HIV and presents the central challenge to finding a cure. Not only are these cells invisible to the immune system, but also antiretroviral drugs have no affect on them. We have a very limited understanding of this latent reservoir and continue to ask, “How large is it, where is it located, what techniques are available to measure it?” This knowledge is essential as we consider treatment aimed at reducing or eliminating this pool of silent HIV
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The Third Approach Continued from the previous page . . . infection. We can detect occasional cells in the circulating blood that appear latently infected, but we suspect the vast majority of the latent reservoir is located in tissue not easily sampled. A treatment that completely eliminates all latently infected cells from the body, known as viral eradication, is the Holy Grail of cure research. We have seen a single case, Timothy Ray Brown, who appears cured after aggressive treatment for his leukemia, which included bone marrow transplantation with donor cells that were naturally resistant to HIV infection. Viral eradication, with this single extreme case, has not yet been possible. Many argue that treatment that does not eradicate all latent infection, but instead keeps it silent, an approach termed viral remission, may be more achievable. While we continue to search for full HIV elimination, this could perhaps allow a “functional cure,” a state in which an infected person would naturally suppress viremia to such a low level that transmission and disease progression risk are so reduced that treatment is not required. San Francisco is a main hub in the global effort of cure research, particularly one main research approach. Here, the avenues of “shock and kill” or “reduce and control” are closely related primary directions of our cure goal. This approach uses drugs to activate or “shock” the latent HIV genome in the reservoir, “waking” the virus enough to kill the infected cells directly or, more likely, to stimulate the cells to start producing HIV antigens on the cell surface. Production of these antigens might allow immunologic or drug treatments to target and kill these cells. This, combined with ongoing antiretroviral therapy to protect neighboring uninfected cells, might reduce the reservoir size. If this reduction was extreme, the host immune system might further “control” or contain the reservoir. This could occur if immune recognition and cell killing was augmented by stimulation through an HIV therapeutic vaccine, an HIV monoclonal antibody, or immune checkpoint inhibitors. These last drugs are exciting new agents in cancer therapy and cause reversal of the immune exhaustion, which may underlie the persistence of a “reservoir” of malignant cells after primary cancer therapy, comparable to the latent HIV reservoir. Several “shocking” drugs are being tested locally. Specifically, stimulators of a pathway of the innate immune system called “toll-like receptors” or TLR agonists. While to date the activity of each of these possible agents appears insufficiently potent, differing combinations and administration routes are being explored. The goal is to increase activity while limiting possible side effects. Agents being considered for the “killing” or “controlling” aspect of this cure research include one or more experimental HIV vaccines, monoclonal antibodies with a broad capacity of HIV neutralization, or immune checkpoint inhibitors already approved in immune-oncology. Other approaches in HIV cure research, although less so in San Francisco, include cell and gene therapies. In these avenues, agents capable of selectively locating and editing or removing the HIV latent gene from the reservoir cell are under study. Another approach being explored is the genetic manipulation of immune cells outside the body. This might provide the ability to recognize and kill reservoir cells when the manipulated cells are 14
reinfused in the HIV-infected patient. These approaches, while scientifically exciting, are currently incapable of being scalable, appearing far too expensive for application in resource-limited settings, where so many are in desperate need of a cure. The structure of the HIV cure effort in San Francisco is growing in size and complexity, and reflects a model of multidisciplinary collaboration. Central figures include University of California, San Francisco (UCSF) scientists and those of its close affiliates, the Gladstone Institute, and the Blood Systems Research Institute (BSRI). In addition, pharmaceutical companies such as Gilead Sciences are heavily involved. San Francisco support for the HIV cure effort comes from the National Institutes of Health (NIH) (Dr. Steven Deeks at UCSF and the Zuckerberg San Francisco General (ZSFG) is the Principal Investigator of a large NIH grant called the DARE Collaboratory) and increasingly through a unique collaboration with amfAR, a large private HIV research foundation. Two years ago, amfAR announced intentions to fund a single HIV Cure Research Institute with a five-year, twenty million dollar award. San Francisco cure scientists responded immediately to this challenge, and I was selected as the Principal Investigator to help lead the competition. Our group consists of leading scientists including Dr. Steven Deeks and Peter Hunt (UCSF/ ZSFG), Dr. Warner Greene (Gladstone Institute), Dr. Satish Pillai (Blood Systems Research Institute). We also invited chief amfAR scientist, Dr. Rowena Johnson to join our Board of Directors in a unique partnership between our scientists and our funding agency. In addition, we have core facilities supporting the Institute, led by Dr. Teri Liegler, Dr. Jeff Milush and Dr. Sulggi Lee at UCSF/ZSFG, and Dr. Afam Oyoke at the Oregon Primate Center. Our Institute is based within the UCSF AIDS Research Institute (ARI) where the Managing Director is Jessica Safier. We are excited to be a leader in HIV cure research and optimistic about our opportunity to impact the lives of millions faced with the challenges of living with HIV and AIDS. We are proud to be an integral part of the pioneering San Francisco medical community and look forward to keeping you apprised of our progress.
Paul Volberding is a UCSFtrained oncologist who has helped lead the San Francisco medical community’s response to HIV/ AIDS from the earliest outbreak in 1981. He is a professor of medicine at UCSF where he is the director of the AIDS Research Institute, co-director of the UCSF-Gladstone Center for AIDS Research, and the principle investigator of the amfAR HIV Cure Research Institute. He is married to another UCSF physician, Molly Cooke, a general internist, also active in HIV care.
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ZIKA VIRUS UPDATE Ryan Guinness, MD, and Cora Hoover, MD, MPH Zika virus is a mosquito-borne flavivirus that was first identified in Africa in the 1940s; Zika has become an emerging infection of global public health importance over the last two years. Transmission primar-
ily occurs via the bite of the Aedes mosquito; however, sexual transmission and intrauterine transmission are also epidemiologically significant. Since its recognition, the virus likely circulated at a low level in Africa and Southeast Asia, eventually spreading to the Pacific Islands. The first large outbreaks of disease occurred on the island of Yap in 2007 and in French Polynesia in 2013-2014. Subsequently, the virus has spread rapidly throughout Latin America since early 2015, with active Zika transmission now occurring in more than sixty countries worldwide. As of February 1, 2017, 4,973 cases of Zika infection have been diagnosed in the United States; 486 cases have been diagnosed in California as of February 3, 2017. The majority of Zika infections in the United States have occurred in travelers returning from Zikaaffected countries and territories. A small proportion of infections are attributed to sexual transmission by a returning traveler to a sex partner, and a small proportion of infections are attributed to local mosquito-borne spread in Florida and Texas. While further transmission of Zika virus in the United States is possible, the likelihood of extensive outbreaks remains low. Most of those infected with Zika virus will be asymptomatic; when symptoms occur, they include fever, rash, conjunctivitis, and joint pain. Therapy is generally supportive and includes a combination of rest, fluids, and analgesics. Zika infection has been associated with Guillain-Barré syndrome, with a case-control study of the 2013 French Polynesia Zika epidemic revealing an incidence of 2.4 cases per ten thousand infected individuals. No specific antiviral treatment or vaccine is currently available for Zika. Zika infection during pregnancy is associated with a spectrum of congenital malformations, including microcephaly, intracranial calcifications, ocular malformations, and contractures. Infection during pregnancy can also cause spontaneous abortion and stillbirth. Based on preliminary data from the U.S. Zika Pregnancy Registry, six percent of completed pregnancies had a fetus or newborn with evidence of a Zika virus-related birth defect. Microcephaly and brain abnormalities were the most common outcomes noted. Given the association of birth defects with maternal Zika infection, the Centers for Disease Control and Prevention (CDC) has issued travel advisories for pregnant women and guidance to prevent sexual transmission. Pregnant women are advised not to travel to regions where Zika virus is circulating. If travel is unavoidable, pregnant women should take strict precautions to avoid mosquito bites. Because Zika virus may persist in semen for weeks to months following infection, men with possible Zika virus exposure who are considering attempting conception should wait at least six months WWW.SFMS.ORG
after symptom onset or last possible Zika exposure (if asymptomatic). Men with possible Zika virus exposure who have pregnant partners are advised to use condoms consistently or abstain from sex during the entire pregnancy. Women with possible Zika exposure are recommended to wait at least eight weeks after symptom onset or last possible Zika exposure (if asymptomatic) before attempting conception. Healthcare providers should offer Zika testing according to established guidelines. Currently, testing is recommended for any patient with Zika symptoms who has symptom onset within two weeks of potential Zika exposure. Zika exposure includes travel to a Zika-affected area or sexual contact with a person who traveled. Zika testing should also be offered to asymptomatic pregnant women with potential Zika exposure within the last twelve weeks. Diagnostic testing is now available from major commercial laboratories and may include polymerase chain reaction (PCR) (urine and serum) and/or indirect immunoglobulin M (IgM) serology, depending on the timing of testing and clinical scenario. If commercial testing is not available, Zika testing can also be done at the California Department of Public Health Laboratory, and should be coordinated with San Francisco Department of Public Health Communicable Disease Control Unit. The CDC has created an online decision tool to help healthcare providers apply the updated recommendations for Zika testing: https://www.cdc.gov/zika/hc-providers/index.html. Dr. Ryan Guinness is a second-year resident in the combined Internal & Preventive Medicine Residency Program at Kaiser San Francisco and University of California, San Francisco. Dr. Cora Hoover is Director, Communicable Disease Control and Prevention, Population Health Division, San Francisco Department of Public Health.
1. Cao-Lormeau, V., et al. “Guillain-Barré Syndrome outbreak associated with Zika virus infection in French Polynesia: a case-control study.” The Lancet, published online February 26, 2016 http://www.thelancet.com/ pdfs/journals/lancet/PIIS0140-6736(16)00562-6.pdf 2. Honein, M., et al. “Birth defects among fetuses and infants of US women with evidence of possible Zika virus infection during pregnancy.” Journal of the American Medical Association, published online January 3, 2017 http://jamanetwork.com/journals/jama/fullarticle/2593702 3. Petersen, L., et al. “Zika Virus.” New England Journal of Medicine, published online April 21, 2016 http://www.nejm.org.ucsf.idm.oclc.org/ doi/full/10.1056/NEJMra1602113 4. CDC’s Zika resources for healthcare providers: https://www.cdc. gov/zika/hc-providers/index.html 5. California Department of Public Health Zika resources: http://www. cdph.ca.gov/HealthInfo/discond/Pages/Zika.aspx 6. San Francisco Department of Public Health’s Zika resources for healthcare providers, including testing guidance: http://www.sfcdcp.org/ zika_providers MARCH 2017 SAN FRANCISCO MEDICINE
A "POST-ANTIBIOTIC WORLD" California Leads The Way to Save Us; Will Washington Join In? David Wallinga, MD, MPA The antibiotic resistance crisis is escalating. It’s cer-
tainly “one of the most serious threats to public health globally and threatens our ability to treat infectious diseases.”1 In September 2016, all United Nations (UN) member states signed onto a declaration to work together across sectors, including in human medicine, animal health, and agriculture to address the root causes of antibiotic resistance. Meanwhile, in the nation’s Capitol, a measure of antipathy towards public health is self-evident.2 Continued federal leadership to fully address the drivers of antibiotic resistance in the U.S. is therefore in question. By contrast, Governor Jerry Brown in 2015 signed into law SB 27, legislation that puts California out in front of other states in trying to curb unnecessary antibiotic use in food-producing animals, where the great bulk of antibiotics of human importance are used.3 What follows is an update on these state and federal developments.
The Worsening Crisis in Antibiotic Resistance
Some of the most alarming science in the last sixteen months includes studies that highlight the spread of genes conferring resistance to carbapenems and colistin. Resistance to these medicines of last resort—depended on for treating otherwise resistant gram negative infections in hospitals—has now been found on plasmids in bacteria isolated from patients and hog farms in the U.S.4,5 Resistance genes on plasmids, and different bacteria carrying them, are known to travel easily between human and animal settings. Underscoring this point is the fact that neither carbapenems nor colistin have ever been approved for use on hog farms in the U.S. Indeed, modern hog farms, where thousands of animals are tightly-housed and exposed routinely to antibiotics, could be wonderful incubators for amplifying colistin and carbapenem resistance, to the point where it is more likely to make its way back to the human population. Last month the Centers for Disease Control and Prevention (CDC) reported on a seventy-year-old woman who earlier had died in a Reno, Nevada, hospital from a carbapenem-resistant Enterobacteriaceae (CRE) infection.6 The specific Klebsiellae bacteria isolated, likely acquired on an extended trip to India, was pan-resistant to twenty-six different antibiotics—including to all fourteen of the different medicines given to her by doctors. Much of this particular bacterium’s resistance was carried on a very mobile plasmid, but apparently not its resistance to colistin (i.e. the plasmid lacked the mcr-1 gene).7 When (and not if, I wager) resistance to both colistin and carbapenems comes to lie on the same transmissable plasmid, and that plasmid circulates more broadly on our farms and in our practice settings, truly pan-resistant infections will become much more commonplace. In short, we sit on the threshold of the ‘post-antibiotic’ era that Margaret Chan, the Director-General of the World 16
Health Organization, first warned about five years ago.8 Antibiotic use and overuse in both humans and animals are important drivers of resistance. Around seventy percent of all U.S. antibiotics considered important to human medicine are sold for use in food animals, not people.9 When it comes to improving antibiotic stewardship, however, federal policymakers have been much more focused on addressing antibiotic overuse in human settings, while similar stewardship efforts in food animal production fall short.
A Lackluster Federal Response
The Obama Administration launched a National Action Plan to Combat Antibiotic Resistant Bacteria (the National Action Plan) two years ago.10 The National Action Plan has numeric goals for reducing inappropriate antibiotic use in hospitals and outpatient settings by twenty percent and fifty percent, respectively. No numeric goals were set for reducing the unnecessary use of antibiotics in livestock or poultry, however. The new Administration’s plans for a proactive, coordinated federal effort to protect the public’s health from antibiotic resistance are, as yet, unclear. Even before 2017, however, the National Action Plan had largely deferred to the Food and Drug Administration (FDA) in terms of any action to be taken to monitor and reduce antibiotic use and resistance on livestock farms. However, the FDA does not even comprehensively track antibiotic use on farms. For that, the FDA defers in turn to the U.S. Department of Agriculture, which has no plans or funds to do so. To its credit, the FDA did recently end the legal use of medically important antibiotics as animal feed or water additives to promote faster growth.11 Remaining such uses of antibiotics in animal feed or water also will now require veterinary oversight, for the first time. However, these FDA measures are likely to have much less impact than advertised on overall antibiotic usage in food animal production. FDA officials and the pharmaceutical industry itself agree in their estimate that growth promotion accounted for no more than ten to fifteen percent of overall antibiotic use in food animals.12,13 And yet FDA data make it clear that ninety-five percent of the medically important antibiotics sold for use in livestock and poultry are products administered via animal feed or water. By definition, the latter routes of administration are intended for groups of animals, if not for growth promotion than typically for disease prevention. In fact, a recent analysis by National Resources Defense Council (NRDC) shows that every medically important class of antibiotics used in poultry or livestock were, at least until January 2017, FDA-approved for both growth promotion and disease prevention, including at dosages and for periods of time that overlapped. What that signifies is that even after the FDA’s
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growth promotion ban, the same human drugs can continue to be used in the same way and at the same doses, so long as the veterinarian claims it is for disease prevention instead of growth promotion.14 The Netherlands is a major livestock producer that cut its overall sales and use of veterinary antibiotics by almost sixty percent over just a few years, from 2009 to 2015. When a limited ban on growth promotion alone was first attempted in 2006, however, it failed.15 Drug use for ‘therapy’, almost exclusively delivered to herds or flocks via feed or water, just increased such that total antibiotic use remained static. According to Dik Mevius of the Netherlands’ Central Institute for Animal Disease Control, this experience highlights how critical it is to clearly define necessary or treatment uses from non-treatment uses.16 Only after the Netherlands added strict measures to limit routine antibiotic use for disease prevention did it achieve its current level of success.
California is a fortunate contrast to lackluster leadership at the federal level. Barely eighteen months ago, Governor Jerry Brown signed into law the nation’s most aggressive regulations to ensure the stewardship of antibiotics that have been routinely given en masse to healthy poultry and livestock. SB 27 ended overthe-counter sales of all antibiotics, and required that future uses take place under veterinary oversight. SB 27 also closed the FDA loophole by only allowing antibiotics to be used to treat or control disease, and only under very limited circumstances—and never routinely or in a regular pattern—for disease prophylaxis. Finally, with SB 27 California became the first state to require that data on actual antibiotic use on farms be collected. No such data collection occurs nationally, even though having antibiotic use data at the farm level is imperative for taking effective action to ensure medically important antibiotics are being well-stewarded, and only used when necessary. Since SB 27 became law, the California Department of Food and Agriculture (CDFA) has been working with stakeholders to figure out how to implement it, including putting in place mechanisms for collecting and publicly reporting data on antibiotic use. By law, the different pieces of the law must be up and running by January 1, 2018; a report to the legislature on the progress of the law is due one year later. The medical community, including CMA, is fully invested in responding to the crisis in antibiotic resistance. Over a decade ago, in fact, CMA showed important leadership within organized medicine by calling for stronger policy on this issue over a decade ago, and then persuading the AMA to do likewise. Right now, SB 27 is unique among state or federal legislation in addressing what has been enormous, routine, and unnecessary use of antibiotics for preventing disease in healthy food-producing animals. At a time when many public health laws are under threat nationally, it is important that SFMS/CMA members consider acting on behalf of their patients to support SB 27, as one step to ensuring that antibiotics remain as effective as possible for sick people, or sick animals, who will need them in the future. Specifically, physicians could: • Call the Governor’s office, voice your continued support for SB 27, and urge that its implementation remain fully funded in future budgets. WWW.SFMS.ORG
• Ask CMA as an organization to closely monitor initial reports as SB 27 becomes effective next year. If the law appears successful at reducing the use of medically important antibiotics in California, then tout its success, including making the California Congressional delegation aware of the need for similar requirements at the national level. Dr. Wallinga is Senior Health Officer at the Natural Resources Defense Council in San Francisco. He can be reached directly at email@example.com.
References 1. Paulson JA, Zaoutis TE; Council on Environmental Health; Committee on Infectious Diseases. “Nontherapeutic Use of Antimicrobial Agents in Animal Agriculture: Implications for Pediatrics.” Pediatrics. 2015 Dec; 136(6):e1670-7. 2. “Trump’s F.D.A. Pick Could Undo Decades of Drug Safeguards.” New York Times, February 5, 2017. 3. SB-27 Livestock: use of antimicrobial drugs, Cal. Food & Ag Code § 14400 et seq. Also available in bill form at: http://leginfo.legislature.ca.gov/ faces/billNavClient.xhtml?bill_id=201520160SB27. 4. See https://www.cdc.gov/drugresistance/tracking-mcr1.html. 5. Dall C. “Researchers find worrisome CRE on US swine farm.” CIDRAP News. December 6, 2017. Accessed at http://www.cidrap.umn.edu/newsperspective/2016/12/researchers-find-worrisome-cre-us-swine-farm. 6. Chen L, Todd R, Kiehlbauch J, Walters M, Kallen A. “Notes from the Field: Pan-Resistant New Delhi Metallo-Beta-Lactamase-Producing Klebsiella pneumoniae — Washoe County, Nevada, 2016.” MMWR Morb Mortal Wkly Rep 2017;66:33. 7. Center for Infectious Disease Research and Policy. “Pan-resistant CRE reported in Nevada.” January 13, 2017. http://www.cidrap.umn.edu/newsperspective/2017/01/pan-resistant-cre-reported-nevada. 8. Chan M. “Antimicrobial resistance in the European Union and the world.” Keynote address at the conference on combating antimicrobial resistance: time for action. Copenhagen, Denmark. 14 March 2012 9. The Pew Charitable Trusts. “Record-High Antibiotic Sales for Meat and Poultry Production” (July 17, 2013). http://www.pewtrusts.org/en/ multimedia/datavisualizations/2013/recordhigh-antibiotic-sales-for-meatand-poultry-production. 10. World Health Organization: Library of National Action Plans. The National Action Plan for Combating Antibiotic Resistant Bacteria. March 2015. Accessed January 30, 2017 at http://www.who.int/antimicrobial-resistance/national-action-plans/library/en/. 11. FDA Website. FDA Announces Implementation of GFI #213, Outlines Continuing Efforts to Address Antimicrobial Resistance. January 3, 2017. Accessed at http://www.fda.gov/AnimalVeterinary/NewsEvents/CVMUpdates/ucm535154.htm. 12. Hoffman, Beth. “New FDA “Rules” Not Likely to Reduce Antibiotic Use on Farm.” Forbes, http://www.forbes.com/sites/bethhoffman/2013/12/13/ new-fda-rules-willnot-reduce-antibiotic-use-on-farm/#e24411962dd9 (Dec. 13, 2013). 13. The Natural Resources Defense Council, Center for Science in the Public Interest, Earthjustice, Food Animal Concerns Trust, Public Citizen, U.S. Public Interest Research Group, and California Public Interest Research Group. “Citizens Petition to the Food and Drug Administration.” Submitted September 13, 2016. Accessed at https://www.nrdc.org/media/2016/160913. 14. NRDC Fact Sheet. “FDA’s Efforts Fail to End Misuse of Livestock Antibiotics.” 15. Cogliani C, Goossens H, Greko C. “Restricting Antimicrobial Use in Food Animals: Lessons from Europe.” 2011; 11(11):276-279. Accessed at http://emerald.tufts.edu/med/apua/research/pew_12_846139138.pdf 16. Ibid. MARCH 2017 SAN FRANCISCO MEDICINE
PERILS AND PROGRESS A Global Update on Ebola, Zika, MERS, and Tuberculosis John Maa, MD
The World Innovation Summit in Health (WISH) convened for the third time in Qatar in November of 2016, bringing together over fourteen hundred delegates from one hundred nations to explore innovative solutions to transform healthcare around the world. Hosted by Lord Ara Darzi (a general surgeon and di-
rector of Global Health Innovation at the Imperial College of London) and the Qatar Foundation, the meeting convenes scientists, clinicians, researchers, political leaders, health and finance ministers, and policymakers from around the globe. The overarching intent of WISH is to examine key pressing health policy challenges worldwide, and to share best practices, products, services, and innovations to improve safety, quality, and access to healthcare. A WISH panel in 2013 focused on antimicrobial resistance, and highlighted the need to conserve the limited numbers of antimicrobial drugs available, raise awareness of drug resistance to both patients and practitioners, and promote sanitation and infection prevention. A follow-up plenary panel in 2016 focused on the global burden of infectious disease and emerging public health threats, and is the focus of this article. The panelists included: 1) Dame Sally Davies—the Chief Medical Officer of the National Health Service in England, 2) Seth Berkley—the CEO of Gavi (a global vaccine alliance), 3) Dr. Nguyen Thi Kim-Tien—the Minister of Health in Vietnam, 4) Sir George Alleyne—Director Emeritus of the Pan American Health Organization, and 5) Professor John Arne Rottingen—the Executive Director of Infection Control and Environmental Health at the Norwegian Institute of Public Health. Opening comments by Dame Davies characterized the current state of global preparedness to worldwide infectious threats. She framed the pressing challenges in 2016 through an analysis of the recent response to three outbreaks. The first was Ebola, a lethal and unanticipated vector that caught the global community unaware, leading to significant criticism of the initial response by public health agencies. To contain the spread, England provided Sierra Leone with four hundred million pounds of support for infrastructure and non-governmental organization/government partnerships. Successful lessons came through changes in burial practices after understanding the local cultural values in honoring the deceased. The urgent need for rapid diagnostic testing was identified, along with the limitation that an Ebola vaccine is not yet available. An ongoing challenge is in the management of Ebola survivors with persistent virus who can harbor long-term manifestations of the disease. The second emerging threat is the Zika virus, which was first discovered in 1947 in Africa. The first case in Brazil was reported in May of 2015, and by 2016 the virus had spread to seventy-five 18
nations worldwide through a mosquito vector. The primary lesson learned in the efforts to control Zika is that it is difficult to contain a mosquito borne outbreak that can also be sexually transmitted. Additionally, while the disease was initially thought to be mild (and is in most people), more recent reports have described an increased incidence of Guillain Barre disease and ascending paralysis after Zika infection, in addition to microcephaly in newborns. Again a major limitation in the global response is the lack of a vaccine against Zika. The third threat is from Middle East Respiratory Syndrome (MERS). An outbreak in May of 2015 in South Korea came after a single individual travelled through four Middle Eastern countries and subsequently infected 186 people through four “super spreaders”, resulting in thirty-six deaths. The special challenge here was the unfamiliarity by local public health officials of this new disease. Efforts to isolate and quarantine individuals were delayed, and the coronavirus quickly spread through overcrowded emergency rooms with inadequate ventilation and by family and friends visiting those patients carrying MERS. The repeat lessons from the MERS, severe acute respiratory syndrome (SARS), H1N1 flu virus, and anthrax outbreaks have been the critical need for rapid diagnostics, vaccines, and improved sanitation. Dame Davies noted that since 1980, thirty-five infectious disease outbreaks have emerged, about one every eight months. Some of the outbreaks result from the re-emergence of established diseases like cholera, yellow fever, dengue, and malaria, while other threats are from new infectious agents or the result of bioterrorism (such as anthrax). Often the new emerging diseases originate from animal, insects, and other species, and likely reflect the consequences of clearing jungles, climate change, and encroaching on animal habitats. The acceleration in the global threat has resulted from increased airline travel and international commerce, a breakdown of local public health measures, the rising threat of viruses, and antimicrobial resistance. The moderator also noted that in 2015, deaths worldwide numbered 1.8 million from TB, five hundred thousand from malaria, and 1.1 million from HIV, though newer diseases like Ebola, MERS, and Zika capture more media attention. Dame Davies identified the resurgence of multidrug resistant (MDR) tuberculosis (TB) that is no longer susceptible to the traditional combination of isoniazid and rifampin as a particularly concerning emerging threat, especially in India and Asia. Even more concerning is the emergence of extensively resistant TB (XDR TB), which harbors additional resistance to a fluoroquinolone and at least one of three injectable second-line drugs (i.e., amikacin, kanamycin, or capreomycin). The cure rate of XDR TB can be as low as thirty percent, requiring a toxic regimen of antituberculosis
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medications associated with many side effects. The resurgence of MDR TB is of special relevance to SFMS readers, as a 2008 report noted that the rate of tuberculosis in Silicon Valley is three times the national average in America as a result of the high rate of immigration to Silicon Valley from India and Asia. The panelists identified the following core principles to achieve control of these infectious diseases that do not recognize borders: 1) the need for comprehensive preventive measures and a global strategy to advance a shared and proactive vision, 2) international collaboration with neighboring countries to contain an outbreak (which may include strict border control), 3) continuous sharing and learning, and 4) a strong political commitment which can include a national steering committee, the leadership of the Health and/or Prime Minister, and collaboration with the World Health Organization. A key question asked by the moderator was what each panelist regarded as the greatest infectious threat in the future. Dame Sally focused on the emergence of drug resistant infections (especially MDR tuberculosis), while two other members raised the concern of pandemic flu (the other diseases cited were SARS and drug resistant malaria). The panel concluded with reflections about steps to enhance preparedness for a global pandemic flu like H1N1, or the 1918 Spanish flu pandemic that infected five hundred million and resulted in over fifty million deaths worldwide. The panelists estimated that the current world readiness for a similar event is only around a three on a scale of one (low) to ten (high). One serious concern is that modern vaccine preparation is an egg-based manufacturing process, which is slow and time-consuming. A strategy to rapidly prepare multiple vaccines for individual viral strains will be essential. The panelists did note that the eradication of polio in America demonstrates the successes that can be achieved if the infrastructure to eradicate the disease is combined with political and financial support. A successful public health response in 2017 will require a coordinated response to enhance local capacity and efforts on the ground (including quarantine), harnessing and sharing data transparently rapidly via technology, the joint international production of vaccines centrally with cost-sharing, and a plan for rapid vaccine distribution to countries in need (possibly by drones). Ultimately, success in treating a multi-national infectious disease outbreak requires the establishment of a coalition and architecture that can coordinate across countries to mobilize public and private resources to effectively respond to the public health emergency. Working across disciplines to improve public health capacity and promote healthcare as a public good is an overarching ambition of WISH. The WISH summit will likely reconvene as a global health initiative in 2018, and serve as the platform to assemble clinical practice, academic, and industry perspectives to identify, discuss, and debate innovative solutions and recommendations to strengthen the global delivery of health care. John Maa MD, FACS is President-elect of the SFMS and a general surgeon at Marin General Hospital and Dignity Health. He has attended each of the three WISH Summits as a representative of the American College of Surgeons.
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SFMS Vaccination Public Service S.F. Medicine Announcement Featuring 02-20-14 Musical Icon Graham Nash “Teach your children” is the title of rock legend Graham Nash’s most-loved song, and also of the new SFMS video wherein he urges parents to fully vaccinate their children. Mr. Nash, of “America’s Beatles” Crosby, Stills, Nash and Young, graciously offers his words and classic music for this forty-five-second public message, “I vaccinated my kids and they’re all brilliant!” he says. Please enjoy and share this important message. See the video here: http://goo.gl/ SKFd5D. MARCH 2017 SAN FRANCISCO MEDICINE
GETTING TO ZERO San Francisco Consortium Working to Eliminate AIDS Diane Havlir, MD, and Susan Buchbinder, MD Building on tremendous successes in human immunodeficiency virus (HIV) treatment and prevention, a coalition of academic, community, private sector, and civic leaders formed the Getting to Zero San Francisco (SF) Consortium in 2014. The group’s overarching aim is to
achieve the Joint United Nations Programme on HIV/AIDS (UNAIDS) goals of no new HIV infections, HIV-related deaths, or HIVrelated stigma. Getting to Zero SF operates under the principles of collective impact, a framework developed to enable multiple sectors to address complex social issues under a common agenda. Collective impact is not merely a matter of encouraging more collaboration or public-private partnerships. Rather, collective impact is a systemic approach that focuses on the relationships between organizations and progress toward shared objectives to achieve social impact.1 Since Getting to Zero SF’s inception, more than two hundred volunteers from public health, academia, advocacy, private sector, hospital leadership, community-based organizations, and the greater community have joined together to develop, implement, and coordinate efforts to achieve these common goals. San Francisco is poised to become the first municipal jurisdiction in the United States to meet the UNAIDS’ Getting to Zero goals. In 2015, members of the Consortium adopted a comprehensive blueprint to achieve short-term goals of reducing the number of new HIV diagnoses and HIV-related deaths by ninety percent by 2020 as outlined in the Getting to Zero SF strategic plan. This blueprint describes three key strategies to attain these goals: 1) expand access to pre-exposure prophylaxis (PrEP), 2) implement city-wide RAPID (same day) anti-retroviral therapy initiation upon HIV diagnosis, and 3) develop programs to link or re-engage people living with HIV to care. By increasing knowledge and access to highly effective prevention strategies, increasing services for people living with HIV who are not engaged in care, and providing support and services for substance use, housing instability, and mental health promotion, the Getting to Zero SF team plans to dramatically impact the numbers of new HIV diagnosis and HIV-related deaths. Furthermore, Getting to Zero SF supports efforts to mitigate and measure stigma as persons living with or vulnerable to HIV still face stigma from family, friends, and community that hampers access to prevention and care. The structure of Getting to Zero SF is multi-layered. A dedicated “backbone” staff member manages and coordinates a myriad of logistical and administrative details needed for the initiative to function smoothly. The Steering Committee, comprised of institutional representatives and community members, provides guidance and strategic direction to the initiative. However, it is the four Working Committees—PrEP, RAPID, Retention/Re-engagement, and Ending Stigma—that prioritize their own programmatic goals, develop annual work plans, and establish performance indicators to measure 20
the impact of interventions. The Steering and Working Committees rely solely on volunteer efforts. San Francisco is fortunate to have a robust HIV Surveillance Unit housed in the Department of Public Health that provides detailed annual reports on the state of the local HIV epidemic. Getting to Zero SF builds its strategic plans and tracks progress based on these data, and on new data sources developed and tracked in collaboration with the HIV Surveillance Unit. Through the PrEP initiative, Getting to Zero SF is creating a sustainable, city-wide model of PrEP delivery to reach all San Franciscans who may benefit from PrEP, particularly those populations with the highest rates of new HIV infections. PrEP scale-up requires a three-pronged effort: 1) improve user knowledge and access through education campaigns and navigation programs; 2) increase provider capacity by comprehensive and coordinated provider trainings and support; and 3) measuring PrEP uptake, persistence, and PrEP-related stigma. Getting to Zero supports the city-wide expansion of the RAPID Initiative, the Zuckerberg San Francisco General Hospital-based program, which seeks to provide Antiretroviral Therapy (ART) and comprehensive services on the same day as HIV diagnosis.2 Rapid initiation of ART improves the health of newly diagnosed patients and mitigates the risk that delays in ART start lead to individuals falling out of care and suffering HIV-related complications. RAPID also may confer a community-level public health benefit by rapidly reducing the potential for forward HIV transmission by as much as ninety-six percent.3 The San Francisco Department of Health and University of California San Francisco recently issued an updated RAPID protocol, a practical guide for expanding RAPID citywide through Getting to Zero SF.4 Ensuring uninterrupted participation in medical care is critical for persons diagnosed with HIV to achieve positive health outcomes, including viral suppression. The Getting to Zero Retention & Re-engagement initiative convenes HIV providers, service organizations, community advocates and government to identify gaps and coordinate strategic interventions to maintain and re-link, if necessary, persons living with HIV into care. Consortium partners are implementing standards of care and intensive case management to increase retention. In 2012, a comprehensive, city-wide program called the Linkage, Integration, Navigation, and Comprehensive Services (LINCS) Program, or LINCS, was launched to identify patients who fall out of care to re-link and re-engagement not only into medical care but wraparound services. The San Francisco Department of Public Health reports linkage to care within three months and one month of HIV diagnosis has increased among newly diagnosed people. Furthermore, viral suppression within one year of diagnosis has increased among newly diagnosed individuals; in 2014, seventy-five percent were virally supporessed within one year of diagnosis compared to sixty-seven percent in 2012. The data show
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faster linkage to care improves outcomes. Data from the San Francisco Department of Health’s 2015 Annual HIV Epidemiology Report show overall improvement in HIV prevention and treatment. The number of new HIV diagnoses declined seventeen percent from 309 in 2014 to 255 in 2015, and deaths among people with HIV have continued to decline since 2013. In part, these results can be attributed to the uptake of PrEP throughout the city, early HIV diagnosis and treatment, and strong efforts to navigate and (re) link HIV+ individuals to care. However, in spite of the gains, disparities remain among people of color, youth, and homeless individuals. African American and Latino gay and bisexual men (especially adolescents and youth), African American and Latino women, transgender women and injection drug users are not linked to, retained, and virally suppressed at the same rates as others. PrEP use is increasing exponentially, but rates remain low in African Americans, youth, and transgender women, groups at high risk for HIV infection. Getting to Zero SF is committed to bridging these gaps by implementing targeted programs to reach these most disproportionally impacted populations and by addressing HIV-related stigma in San Francisco as it hinders individuals from accessing the care and services they need by reinforcing existing social inequities. San Francisco has always been at the forefront of the battle against HIV. Getting to Zero SF has received worldwide recognition for its innovative approach to strategically addressing systemic barriers that hinder San Franciscans from accessing and retaining healthcare. Getting to Zero SF is sharing best practices with other jurisdictions—New York State, Massachusetts, Detroit, Long Beach, Washington DC, Paris, Amsterdam, Cape Town, and London, to name a few—that are developing or supporting similar efforts. Meaningful engagement is central to the success of Getting to Zero SF effort. All San Franciscans, and especially those who are most vulnerable and most affected by HIV, must have a voice in the effort. Quarterly consortium-wide meetings are convened to discuss overarching important topics (e.g., HIV and youth, HIV and aging), and for each committee to report and receive feedback on their progress. Meetings are well attended, and open to the public to encourage feedback on the work and direction of the initiative. The innovative programmatic initiatives that are being implemented would not be possible without a strong commitment of support and resources from our Mayor, Board of Supervisors, Director of Public Health and corporate partners including the M•A•C AIDS Fund (supporting a re-engagement initiative), Bristol-Myers Squibb, and Gilead Sciences. Members of the San Francisco medical community are invited to join and help us Get to Zero! If you would like to join or for more information visit www.gettingtozerosf.org. Diane Havlir, MD, and Susan Buchbinder, MD, are co-founders of Getting to Zero San Francisco. Dr. Havlir is Chief of the HIV/AIDS Division at Zuckerberg San Francisco General Hospital and Professor of Medicine at UCSF. Dr. Buchbinder is Director of Bridge HIV at the SFDPH and Clinical Professor of Medicine, Epidemiology and Biostatistics at UCSF. They would like to thank the Consortium members and sponsors, members of the Steering Committee, the City of San Francisco government officials, Shannon Weber and Courtney Liebi, all of whom have worked to make Getting to Zero possible. A Full list of references is available at www.sfms.org. WWW.SFMS.ORG
Figures - San Francisco Department of Public Health. HIV Epidemiology Annual Report, 2015. San Francisco, CA: San Francisco Department of Public Health; 2016. Available at: https://www.sfdph. org/dph/comupg/oprograms/HIVepiSec/HIVepiSecReports.asp
MARCH 2017 SAN FRANCISCO MEDICINE
CHOOSING WISELY Infectious Disease Update Katie Raffel, MD, and Sarah Doernberg, MD, MAS Antibiotics are one of the most commonly prescribed classes of medications and have revolutionized the way we care for patients with infectious disease. The complications of antibiotic misuse or
overuse, namely drug-related adverse events, Clostridium difficile infections, and antibiotic resistance, however, threaten the benefit of these life-saving medications.
1) Drug-related adverse events: Antibiotics cause an estimated one hundred fifty thousand emergency department visits each year, accounting for nineteen percent of drug-related adverse events.1 The majority of these presentations were for allergic reactions, and this data does not capture mild adverse events. 2) C. difficile infection: The use of broad-spectrum antibiotics is associated with potentially fatal C. difficile infections (CDI). In 2013, the Centers for Disease Control and Prevention (CDC) disseminated a report describing a tiered classification of the top eighteen drug-resistant threats in the United States.2 Only three infections were placed in the highest hazard tier â€œurgent,â€? one of which was C. difficile. Currently, the CDC estimates one half million patients are infected annually with CDI in the United States, costing up to 760 million healthcare dollars. Not only does C. diff have a cost and resource impact, it is also independently associated with increased inhospital mortality.2,3,4 3) Antibiotic resistance: The CDC estimates that two million illnesses and over twenty thousand deaths occur due to antibiotic-resistant organisms each year. In 2014, the White House released a document outlining strategy to reduce antibiotic resistance. The first of the five goals included slowing the development of resistant bacteria through antibiotic stewardship.5 We know that providers imperfectly prescribe antibiotics. A retrospective analysis of hospitalized patients discovered that antibiotic prescribing could be improved in thirtyseven percent of the most common prescription scenarios.6 In the outpatient setting, thirty percent of antibiotics prescribed are unnecessary.7
Choosing Wisely and Infectious Disease
The Choosing Wisely campaign is an initiative developed by the American Board of Internal Medicine to engage providers in reducing overuse of tests and treatments in order to improve patient health. The Infectious Disease Society of America (IDSA) has pro22
vided five Choosing Wisely recommendations, four of which center around antimicrobial stewardship: Do not treat asymptomatic bacteriuria with antibiotics; avoid prescribing antibiotics for upper respiratory infections (URI); do not use antibiotic therapy for stasis dermatitis of lower extremities; and avoid prophylactic antibiotics for treatment of mitral valve prolapse. While the IDSA is the only infectious disease society that has provided formal Choosing Wisely recommendations, given the burden of inappropriate antibiotic use, other societies from family medicine to urology have also provided recommendations on the theme of stewardship. A study evaluating overuse reduction in eleven countries discovered that fifty-one of 628 recommendations (eight percent) addressed topics of infectious disease.8 Avoiding antibiotics in asymptomatic bacteriuria and in upper respiratory infections were recommended by five and six societies respectively.8
IDSA Recommendations and Personal/Institutional Practice
Awareness of the IDSA Choosing Wisely recommendations is not enough to alter practice. Instead, practice change requires implementation of standardized and simplified care protocols, audit and feedback and EMR-based cognitive aids. Below we describe some successful interventions addressing the two most ubiquitous IDSA Choosing Wisely recommendations.
1) Do not treat asymptomatic bacteriuria with antibiotics: Bacteriuria is common in patients without clinical urinary tract infection (UTI), and it can be challenging to distinguish between asymptomatic bacteriuria and UTI, particularly among the elderly, those with chronic indwelling Foley catheters, or hospitalized patients unable to provide a history (e.g. those in the intensive care unit). The impact of diagnostic uncertainty in overuse may be mitigated by protocols to assist in UTI diagnosis. A time series study performed in the Intensive Care Unit of an academic hospital evaluated the effect of a reflex urine culture protocol on initiation of antimicrobial therapy for UTI.9 This protocol stipulated that urinalysis must first demonstrate pyuria (sensitivity nears one hundred percent in UTI, though the same cannot be said about specificity) before urine culture would be performed. Use of this protocol led to a reduction in the number of urine cultures performed and reduced initiation of antimicrobials for misdiagnosed UTI or asymptomatic bacteriuria. Further work is needed to determine how to improve overtreatment of asymptomatic bacteriuria with pyuria, though.
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2) Avoid prescribing antibiotics for upper respiratory infections (URI): The majority of URIs are due to viral etiology, and only 0.5-2% will progress to bacterial infection.10
Delayed Antibiotic Strategy: Providers that fear either complications of URI or reduction of patient satisfaction without antibiotics may find a delayed antibiotic strategy useful. A randomized control study compared four patient cohorts with URI exposed to different strategies for antibiotic administration: patients provided immediate antibiotic prescription; those provided delayed prescription either to be taken at patient discretion or to be collected at clinic; and no prescription.11 The rates of antibiotic use were ninetyone percent, thirty-three percent, twenty-three percent, and twelve percent and respectively. While immediate antibiotic treatment groups had 0.5-1.5 days of fewer symptoms, it was not found to be clinically significant, a finding corroborated in other studies.12,13 Further, patient satisfaction was largely equivalent and high among the four groups.
ples of high-value care and antimicrobial stewardship should be built into graduate medical education as core competencies for providers. Katie Raffel, MD, is the Chief Resident for Quality and Safety in Internal Medicine at University of California, San Francisco Health. She has an interest in implementation science and plans to remain at UCSF as a hospitalist and Quality Improvement medical educator. Sarah Doernberg, MD, MAS, is an infectious diseases doctor practicing at UCSF Health, where she is the Medical Director of Adult Antimicrobial Stewardship and a Transplant Infectious Diseases specialist. In addition to her clinical work, she has an active involvement in clinical research in antimicrobial resistance and antibiotic stewardship. A full list of references is available at www.sfms.org.
San Francisco Free Clinic 4900 California St
Audit and Feedback: Audit and feedback alone can improve
adherence to practice standards, particularly when there is lower baseline performance and high frequency of feedback.14 Peer comparison may increase the affect of audit and feedback due to the social component of such an intervention. A cluster randomized control trial found that inappropriate antibiotic use decreased among clinicians provided regular comparison of their practice to those of “top performing” peers, in this case those prescribing fewer courses of antibiotics for diagnoses where antibiotics are typically not necessary.15
Electronic Medical Record (EMR) Decision-Support Tools: The EMR holds promise for reducing overuse, although
its role should be thoughtfully planned given the time and effort required for modifications and the growing burden of alert fatigue. In the above study by Meeker et al., providers that were forced to enter justification for antibiotic use in URI had lower rates of antibiotic prescribing.15 This justification would be visible in the EMR in an “antibiotic justification note.”
Choosing Wisely in Medical Education: The Next Frontier
High-value care is becoming an increasingly important aspect of medical education, and the integration of “Choosing Wisely,” in particular, is necessary given the known impact of attending physician practice patterns on trainee’s future practice.16,17 A curricular focus on engaging trainees in the development of high-value care recommendations and implementation has promise.18 The inappropriate use of antibiotics is common and contributes to adverse events, C. difficile infection, and antibiotic resistance. To curtail overuse, the IDSA recommends against the use of antibiotics in asymptomatic bacteriuria, upper respiratory infection, venous stasis dermatitis, and mitral valve prolapse endocarditis prophylaxis. In order to respond to these recommendations, antibiotic practices of providers/institutions must be audited and new processes implemented to either assist in appropriate use or prevent inappropriate use. Further, princiWWW.SFMS.ORG
San Francisco, CA The San Francisco Free Clinic provides free health care to individuals without
insurance in the Bay Area. First founded by physicians in 1993, the clinic has s e r v e d a s a s a f e t y n e t f o r th o s e w h o could not qualify for the ACA and with nowhere else to go.
Services offered include: *Chronic disease management *Acute care medicine *Health care maintenance *Visual acuity screening and eyeglasses *Depression screening and treatment *Food insecurity treatment
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We are particularly grateful to the surrounding medical community for their continued support and services: Over 85 physicians donate specialty consults in their own offices 40 physicians donate supplies and medications 5 specialists volunteer onsite consults one halfday per month 2 local hospitals donate multiple modalities of imaging and studies
MARCH 2017 SAN FRANCISCO MEDICINE
San Francisco Medical Society January 27, 201 7
Asian Art Museum of San Francisco
Celebrating 149 Years of Physician Advocacy and Camaraderie More than 175 physicians and influential stakeholders in the medical community joined in the SFMS Annual Gala festivities on January 27, 2017. Held at the Asian Art Museum, the event marked SFMS’ 149th year as the only physician association that advocates for physicians across all specialties and their patients in San Francisco. Attendees were able to network with colleagues, meet SFMS leaders, and enjoy a private viewing of the museum’s second floor galleries. A special performance by the San Francisco Police Department’s Lion Dancers kicked off the evening’s program, which included the installation of Man-Kit Leung, MD as the 2017 SFMS President, acknowledgment of the contributions of Richard A. Podolin, MD, SFMS’s Immediate Past President, and a tribute to two SFMS members who have been members of the medical society for fifty years—Ed Chow, MD and Dick Shadoan, MD. SFMS would like to thank our members, sponsors, and special guests, Assemblymember David Chiu, Senator Scott Weiner, Former Senator Mark Leno, CMA President Ruth Haskins, MD, and CMA Speaker of the House Lee Snook, MD, for their support of the event and of SFMS. All photos courtesy of Ginger Tree Photography. All rights reserved.
2017 SFMS Officers—from left to right: President-Elect John Maa, Immediate Past President Richard Podolin, President Man-Kit Leung, San Francisco Medicine Editor Gordon Fung. Not pictured: Secretary Brian Grady and Treasurer Kimberly Newell.
Assemblymember David Chiu and Senator Scott Weiner present Immediate Past President Richard Podolin with proclamations in recognition of leading SFMS efforts to ensure access to care, viability of our local health care system, and safeguard the integrity of the practice of medicine. Left: Man-Kit Leung with wife, Cindy Phan, MD.
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Presenting Sponsor Mechanics Bank awards check to Carlina Hansen for the Womenâ€™s Community Clinic.
SFMS Past Presidents.
Man-Kit Leung presents Certificate of Appreciation to outgoing SFMS Board member, Rachel Shu.
From left: Senator Scott Weiner, CMA President Ruth Haskins, SFMS President-Elect John Maa, Former Senator Mark Leno.
MARCH 2017 SAN FRANCISCO MEDICINE
SFMS President Man-Kit Leung presents pin to fifty-year member Ed Chow.
Fifty-year members, Dick Shadoan (left) and Ed Chow (middle) with Man-Kit Leung (right).
Congratulations Fifty-Year Members! Edward A. Chow, MD | Edward A, Chow, MD is a native San Franciscan who received his MD degree from St. Louis University School of Medicine (1963), and completed his internal medicine residency at the Southern Pacific Memorial Hospital, San Francisco (1967). He served as lieutenant commander (LCDR) in the U.S. Navy Reserve (Medical Corps), including one year in I Corps (Republic of Vietnam) as Division Internist for the third Marine Division and Chief of Medicine for the 3rd Med BN Hospital, and was awarded a Bronze Star with Combat V. Returning to San Francisco, he began his private practice, and served as Editor, President, and a member of the CMA Council at the SFMS. He has subsequently served as a consultant to the SFMS board. In1989, he was appointed to the San Francisco Health Commission serving under five Mayors for twenty-seven years overseeing the rebuilding of Laguna Honda and Zuckerberg San Francisco General hospitals, as well as the development of medical neighborhood clinics and the San Francisco Health Network. In Chinatown, he formed the Chinese Community Health Care Association, and was its Executive Director for thirty-five years. With Chinese Hospital he helped to create the Chinese Community Health Plan (CCHP). He has been lovingly supported in these endeavors by his wife Loretta, and their children Cheryl, Marc, and daughter-in-law, Vickie Nam.
Richard Albert Shadoan, MD | Dr. Richard Albert Shadoan earned his medical degree from the University of Hamburg, after serving in the U.S. Army in Germany. Upon completing his internship and residency in psychiatry at Mt. Zion Hospital in San Francisco, he held positions there as Associate Director and then Medical Director of Inpatient Psychiatry. Dr. Shadoan was the Medical Director of the Family Service Agency in San Francisco from 1978-2002. He also held several academic appointments with the University of California, San Francisco Department of Psychiatry. He served as President of the Northern California Psychiatric Society; Treasurer, President-Elect and President of the California Psychiatric Association; and Member of the Board of Trustees of the American Psychiatric Association. Dr. Shadoan also chaired the SFMS Psychiatric Committee for many years. Among the awards he has received are the California Psychiatric Association and American Psychiatric Associationâ€™s Warren Williams Award, and the Northern California Psychiatric Societyâ€™s Meritorious Service Award. Dr. Shadoan retired in December 2015 at the age of eighty-five, after being in practice forty-nine years.
Left: UCSF medical students. Right: SFMS Executive Director/CEO Mary Lou Licwinko with Jim Reddy.
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SFMS President's Gala Remarks STANDING UP FOR MEDICAL—AND AMERICAN—VALUES Dr. Man-Kit Leung, an ear, nose, and throat specialist based at Saint Francis Hospital and in Chinatown, gave these remarks while taking office as 2017 President of the SFMS. When doctors gather it is rarely as Democrats, Republicans, or Independents, but as physicians. We share some essential values including beliefs that every life has worth, that everyone deserves to be as healthy as possible, and that the practice of medicine is advanced with scientific discovery. These are what drew most of us to this profession in the first place. But today we must acknowledge that major challenges face us all. The repeal of the Affordable Care Act may leave millions uninsured; block grants to Medicaid could reduce healthcare services to our poorest populations; and the defunding of Planned Parenthood could leave millions without access to family planning. Our biggest challenge, however, may be addressing the degradation of social mores in our nation. During the past election, derogatory statements against immigrants, Muslims, Mexicans, women, and the disabled were not only tolerated but endorsed by a large portion of America. I am an immigrant. My wife became a gynecologist to advance women’s health rights. We have a daughter who deserves equal control over her own body and a son who we once thought could have a developmental disability. Like many of you, I have Latino and Muslim friends, colleagues, and patients. Words and actions consistent with racism, discrimination, misogyny, religious intolerance, and xenophobia are, to me,
personally insulting and antithetical to our values. We must take a stand against the tolerance of intolerance, against the permission of prejudice, against the indulgence of inequality. When faced with a formidable challenge, I am reminded of the Chinese proverb “When people share the same heart, mountains can be moved.” When physicians unite, mindsets can be changed. Doctors have done it before, right here in San Francisco. In 1977 the first LGBT medical society was founded in San Francisco as Bay Area Physicians for Human Rights. Our San Francisco Medical Society shared many members and joined in their efforts, especially when the HIV epidemic struck so tragically here. Since then, Bay Area physicians have moved mountains on the public’s perception of the LGBT community. Organized medicine has fought bigotry before and we can do it successfully again. But that means we must stay active, vocal, and engaged. We must stay proud yet humbled to be doctors. Above all we must, in our daily interactions with patients and colleagues and with family, friends, and foes, continue to practice and promulgate the values of medicine, which are rooted in the core values of our country. These values include the beliefs that everyone, regardless of creed, gender, gender identity, sexual orientation, ethnicity, or immigration status, deserves an equal right to life, that everyone deserves equal liberty especially concerning his or her own body, and that everyone deserves an equal right to health which is a necessary prerequisite to pursue happiness. We all want to make America great; let us do that by working together to preserve, protect, and defend the values upon which it was founded.
Please join the San Francisco Medical Society as we gratefully acknowledge the support of these dedicated partners.
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SFMS would also like to thank Saint Francis Memorial Hospital for providing meeting space and parking for the 2017 SFMS board meetings, the SFPD Lion Dance Team for providing entertainment at the Gala, and Ginger Tree Photography for their photography services at the Gala. And special thanks goes to the 2017 Annual Gala Fundraising Chair, John Maa, MD.
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Marriott Marquis San Diego Marina l May 5-7, 2017 l San Diego, CA
Exceptional conference with tremendous speakers that ignite the passion of medicine. Well worth the time attending and look forward to the next one. Minh Q. Nguyen, DO, FACOEM Vice President of Medical – West Division U.S. HealthWorks – 2016 WHCLA attendee
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Continuing its tradition of excellence, the 20th Annual Western Health Care Leadership Academy will bring together top speakers, leaders and thinkers to share strategies and resources for accelerating the shift to a more high-performing and sustainable health care system. A diverse mix of general and breakout sessions will examine the most significant operational, financial and environmental challenges facing health care today, while presenting proven models and innovative approaches that will enable you to transform your organization’s care delivery and business practices.
MEDICAL COMMUNITY NEWS CPMC
Edward Eisler, MD
Kaiser Permanente Maria Ansari, MD
Sutter Health marked another milestone as it relaunched the Sutter Health brand. For generations, physicians have helped build our reputation as innovative pioneers, dedicated to designing and delivering a better kind of health care. Patients and their families will receive physical access to care when, where, and how they need it; intellectual clarity by communicating in a way they understand, explaining problems and solutions in everyday language; and emotional connections by listening carefully and responding compassionately. Radio and TV commercials and streaming digital ads on the internet started this past January. The Leapfrog Group, a national nonprofit organization dedicated to advancing quality and safety in health care, has once again recognized California Pacific Medical Center (CPMC) with top honors. This year, our California campus was honored in the top teaching hospital category, making CPMC one of only twenty-nine hospitals in the nation to receive this recognition! This is the seventh time in the past eleven years that at least one of our campuses has been named a Leapfrog Group Top Hospital. This recognition from Leapfrog is a tribute to the efforts we have made to improve the quality and safety of the care we deliver to our patients. Senior Scientist Dr. David Minor and colleagues at CPMC pioneered the new trial “A Feasibility Study of Sequential Hepatic Internal Radiation with Yttrium 90 and systemic Ipilimumab and Nivolumab in Patients with Uveal Melanoma Metastatic to Liver,” which will use initial therapy with the radioisotope Yttrium-90 to improve treatment with immunotherapy. “Recent experimental and clinical evidence suggests synergy between radiation therapy and immunotherapy,” says Dr. Minor. “Ipilimumab and nivolumab are is the most potent immunotherapy combination for cutaneous melanoma. A world expert on ocular melanoma, Dr. Takami Sato at the Thomas Jefferson University in Philadelphia, will also be participating in the trial.” WWW.SFMS.ORG
We are emerging from the most severe influenza season in the past decade as evidenced by data from Northern California Kaiser Permanente facilities, which the California Department of Health uses to measure severity of the impact of influenza in the state. Not surprisingly, Kaiser Permanente clinicians have seen marked increases over the expected number of influenza related clinic appointments, emergency room visits, hospitalizations, and Intensive Care Unit admissions this season. Adding to the influenza burden were the many outbreaks in long term care facilities, more than twice the number as last year. And all of this, despite an excellent match between this year’s influenza vaccination and the major circulating strain, AH3N2. Although not perfect, influenza vaccination is still the best defense we have and should continue to be offered to everyone over six months of age until the end of the flu season. And then, of course, there is Zika virus, a serious concern especially for pregnant women. Zika is the only flavivirus to be sexually transmitted and to cause serious birth defects. Screening for travel history and counseling about avoiding travel to Zika epidemic areas has become a routine part of our obstetrical care. Clinicians now have to keep abreast of the spread of Zika around the world including in the United States. Finally, we remain vigilant for the reappearance of childhood viral infections that few of us have seen during our careers. Mumps outbreaks on college campuses are becoming commonplace, even when students are fully vaccinated. The loss of herd immunity to measles caused by parents declining routine vaccinations for their children has allowed a resurgence of measles, the most contagious infection of all. It’s clear from the current landscape that we will continue to be challenged by viral infections, both new and old.
Community Health Care Forum with Congresswoman Nancy Pelosi SFMS leaders, as well as UCSF residents and medical students, were among those who recently met with Congresswoman Nancy Pelosi at a community health forum to discuss efforts to save the Affordable Care Act (ACA). Preserving the ACA is critical for the 20 million newly insured Americans, and the more than 150 million Americans who receive coverage through their employer. Leader Pelosi's central message was to remember that 27% of people younger than age 65 and covered through the ACA will be unable to buy insurance because of pre-existing conditions if the ACA is repealed. Photo: 2017 SFMS President Man-Kit Leung, MD meets with Congresswoman Nancy Pelosi. Photo by Steven Underhill. Announcing
THE SAN FRANCISCO ADDICTION SUMMIT The 5th Annual David E. Smith, MD, Symposium
The Surgeon General’s Report, Clinical Advances, and Policy Perspectives Friday, June 9, 2017; 8:30 a.m. to 5:30 p.m. UCSF Laurel Heights Auditorium, 3333 California Street, San Francisco Co-Sponsored by the SFMS, SFDPH, UCSF Philip R. Lee Institute for Health Policy Studies, California Academy of Family Physicians, and San Francisco Community Clinic Consortium. Join us for an action-oriented forum covering opiates, pain management, alcohol abuse, tobacco, advances in addiction medicine and primary care, San Francisco problems and responses, and more, with a leading multidisciplinary faculty. CME Provided by the California Academy of Family Physicians. For more information, visit www.sfms.org or email Steve Heilig at Heilig@sfms.org. MARCH 2017 SAN FRANCISCO MEDICINE
UPCOMING EVENTS Breast Cancer Screening on Trial: What Should Publicly Funded Programs Cover?
American Medical Women’s Association Annual Meeting
March 9, 2017, 6:30 p.m. to 8:30 p.m. | Jewish Community Center of San Francisco Join us for an interactive evening as we put mammogram screening guidelines “on trial” and explore the process of developing evidence-based coverage decisions. We’ll compare how decisions made by public funders may differ from those made by community members. As a member of the audience you will serve on a jury. You will have a chance to ask questions from the expert witnesses, deliberate, and reach a verdict. We will conclude with an open discussion. Seating is limited. RSVP is required here: http://bit. ly/2kXPsEe. Sponsored by the University of California, San Francisco (UCSF) Center for Healthcare Value as part of the “Healthy Discourse” series, the UCSF National Center of Excellence in Women’s Health, and the San Francisco Medical Society.
March 30 to April 2, 2017 | Embassy Suites SFO Waterfront Register for the American Medical Women’s Association Annual Meeting in San Francisco at https://www.amwa-doc.org/ amwa102/. Highlights include talks from luminary women physician leaders, networking, mentoring, free CV review, free professional coaching, and over twenty-four CME credits. First time attendee discount: AMWAGrant
Coalition for Compassionate Care of California Palliative Care Summit
March 13 to 14, 2017 | Hyatt Regency, Sacramento Learn how to integrate palliative care into primary care and specialty care at the Coalition for Compassionate Care of California 9th Annual Palliative Care Summit. Immerse yourself in two days full of talks, breakouts, office hours, and social events focused on the latest in research and innovations about integrating palliative care into all aspects of health care. http://ccccsummit.org/
Physician Wellness Retreat
March 17-19, 2017 | Esalen, CA Do you need to recharge? Join the Institute for Physician Wellness and fellow physicians for a wellness retreat at beautiful Esalen on the California coast. Learn about physician wellness at the personal, institutional and cultural levels. Explore the roles of self-compassion and vulnerability in medicine. Recharge with other physicians in the healing practices of yoga and meditation. Nourish your body with fresh farm-to-table meals. Enjoy a community of friendship and support. This is your chance to rest and relax as you retreat from the intensity of medicine, while earning CME. To learn more, visit http://bit.ly/2kuUswx.
CMA Legislative Advocacy Day Webinar Training
March 29, 2017, 7:00 p.m. to 8:00 p.m. CMA will host its forty-third annual Legislative Advocacy Day on Tuesday, April 18, at the Sheraton Grand in Sacramento. Attendees will also go to the Capitol to meet with legislators on health care issues. More than four hundred physicians, medical students and CMA Alliance members will be coming to Sacramento to act as champions for medicine and their patients by lobbying their legislative leaders. In preparation for Legislative Advocacy Day, CMA’s Center for Government Relations will host a special webinar. This webinar will review in detail CMA’s list of bills to be lobbied, effective advocacy tips, and other relevant program information. Available to CMA members only; this webinar is free. Register at http://bit.ly/2kuvnSm. 30
CMA Legislative Advocacy Day
April 18, 2017 | Sheraton Grand, Sacramento The California Medical Association will host its forty-third annual Legislative Advocacy Day on April 18th. Join SFMS at the State Capitol to learn about legislative issues affecting medicine, foster relationships with state legislators, and gain hands on experience in the practical aspects of physician advocacy. SFMS members will have the opportunity to meet with legislators. All meetings with legislators will be scheduled and coordinated by SFMS. Visit http://www.sfms.org/events/lobby-day.aspx for more information.
Physician Investment Discussion Group
April 25, 2017 | 6:00 p.m. to 7:30 p.m. Join us for a quarterly discussion group for SFMS member physicians and associates who are interested in learning more about investing. The informal group provides an opportunity to learn and grow as an investor—from basic to more advanced concepts. For more information or to RSVP, contact George Fouras, MD, at email@example.com or Roger Eng, MD, at firstname.lastname@example.org. Please note: This discussion group does not offer investment or financial planning advice, nor do we promote any financial products or services. SFMS is not liable for any risks associated with investment/financial decisions made as a result of participating in the discussion group.
Western Health Care Leadership Academy May 5 to 7, 2017| Marriott Marquis San Diego Marina Save the date for the 20th Annual Western Health Care Leadership Academy. The 2017 Leadership Academy will continue its mission of providing the information and skills needed to succeed in today’s rapidly changing health care marketplace. Visit http://bit.ly/2kXOkjG for more information.
The San Francisco Addiction Summit
June 9, 2017; 8:30 a.m. to 5:30 p.m. | UCSF Laurel Heights Auditorium, 3333 California Street, San Francisco Join us for an action-oriented forum covering opiates, pain management, alcohol abuse, tobacco, advances in addiction medicine and primary care, San Francisco problems and responses, and more, with a leading multidisciplinary faculty. CME Provided by the California Academy of Family Physicians. For more information, visit www.sfms. org or email Steve Heilig at Heilig@sfms.org.
SAN FRANCISCO MEDICINE MARCH 2017 WWW.SFMS.ORG
“When we found we could refinance our student loans with our First Republic personal banker, we jumped at the chance.” CHRISTINA PHAM, M.D.
J O H A N N E S K R AT Z , M . D .
UCSF Medical Center
UCSF Medical Center
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Do you know What, When and How to Report Child Abuse?
FREE ONLINE COURSE! Course developed by the Child Abuse Prevention Center
Approved for 1.25 AMA PRA Category 1 Credits™ Approved for 1.25 CE credits
ALL healthcare providers (MD, DO, RN, PhD, LCSW, MSW) are encouraged to take this valuable course!
Course available 24/7
Course can be offered in a group training using a single log-in. Contact Leslie Iacopi at (415) 882-5167 for more details. Register NOW at: http://www.imq.org/education/caprrc.aspx
San Francisco Medicine, Vol. 90, No. 2, March 2017