COVID-19 and Rheumatology

COVID-19 and Rheumatology

Disclosures: Hummers, Mossell and Patty-Resk report no relevant financial disclosures.
September 10, 2021
11 min read
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Red Alert: Rheumatologists across US consumed by 'high-spread' red as COVID-19 surges

Disclosures: Hummers, Mossell and Patty-Resk report no relevant financial disclosures.
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There is not a single rheumatologist currently practicing in a U.S. county with low or even moderate COVID-19 spread, as defined by the CDC.

Or, at least, there are none that Healio Rheumatology can identify using the CDC COVID-19 tracker, Google, and a lot of time and patience. This may not be surprising to some, considering that, as of this writing on Sept. 9, more than 97% of counties in the U.S. are experiencing either substantial or high COVID-19 spread. Moreover, the remaining 2.89% of counties are among the most rural and least densely populated in the nation — where a years-long, ongoing workforce shortage has meant few, if any, nearby rheumatologists.

“We have taken a significant hit in morale, particularly since many of our colleagues believed that this wave was somewhat partially preventable, or at least it didn’t have to be as bad as it is,” Laura Hummers, MD, told Healio Rheumatology. Source: Adobe Stock

Let’s rewind: Three months ago, it appeared the COVID-19 pandemic was nearly over in the U.S. Case counts had plummeted throughout the spring, and by the start of summer they were at their lowest level since late March 2020. Vaccination rates, although slowed compared with the mad dash seen in late winter and early spring, were nonetheless steadily increasing. Practices were returning to face-to-face appointments and people, including physicians, were finally allowing themselves to feel optimistic.

Then the B.1.617.2 variant — widely known as “delta” — changed everything, and fast.

Fueled by a national relaxation of COVID-19 prevention measures and a regionally uneven uptake in vaccination, the delta surge exploded in early July. Later that month, the CDC began urging the fully vaccinated to again wear masks indoors if they lived in certain “substantial-” or “high-spread” counties. They also released an online tracker detailing how each county in the United States was faring.

By Aug. 12, 90% of U.S. counties were experiencing substantial or high transmission rates, and by Sept. 3, only a few dozen isolated islands of “low-” and “moderate-spread” areas remained.

To understand how rheumatology practices across the country are reacting to this ongoing delta surge, Healio Rheumatology spoke with providers in various counties with different rates of COVID-19 transmission.

Best Laid Plans

Or, rather, that was the original intention. As Healio Rheumatology began reaching out to rheumatologists and practices across the country, it became increasingly clear that such a story would mean racing against the increasing spread of the delta surge. This would prove difficult.

Rheumatologists practicing in a low- or moderate-spread county one day could, and often did, find themselves subsumed into the high- or substantial-spread categories the next week.

Further, many of the small practices operating in small towns were either too short-staffed or otherwise unable to return any of Healio Rheumatology’s numerous requests for interviews.

Eventually, all the rheumatologists secured for this story would find their counties classified by the CDC as “high spread.” And, ultimately, Healio Rheumatology ran out of low- and moderate-spread counties with practicing rheumatologists to seek out.

What follows, instead, is series of snapshots of what each practice was experiencing on the day of that interview. Together, they provide a glimpse into how the latest surge has impacted providers in large academic centers and small rural clinics alike, as well as their efforts to protect their patients, their fellow staff and themselves.

‘Substantial Spread’ Stabs at Morale in Baltimore

City of Baltimore, CDC snapshot on Aug. 12, 2021

  • Transmission level: Substantial
  • Residents aged 12 years and older with at least one vaccine dose: 65.2%.
  • Residents aged 12 years and older fully vaccinated: 57.9%.
  • 7-Day total cases: 473 (79.78 per 100,000); 58.19% increase in last week.
  • 7-day deaths: Less than 10.

There was a moment in time when it seemed like things were returning to normal at Johns Hopkins University, in Baltimore.

At the height of the pandemic, the facility’s rheumatology division was running exclusively on telehealth visits. Some of the front desk staff were sitting behind plexiglass shields as an alternative to wearing face shields or eye protection, and the waiting area was rearranged to avoid crowding. Care partners were regularly denied permission to accompany patients inside.

Laura Hummers

“We have loosened some of those — now patients and their care partners can sit together in our waiting room — but we still try to maintain social distance between unrelated patients and care partners,” Laura Hummers, MD, associate professor of medicine and clinical director of the division of rheumatology at Johns Hopkins University, told Healio Rheumatology.

“It is a bit of a challenge,” she added. “Some of our exam rooms are a little small, so we try to restrict the number of people in an exam room at one time. We are a teaching institution, so we have trainees who work with us, and over the past year, it did put a strain on our educational missions to train our trainees.”

As case counts decreased throughout the spring, so did the center’s reliance on telehealth. Now, about 90% of all visits at the rheumatology department are in-person. For many, it represented a welcome return, Hummers said.

“We have had this backlog of people who had been doing telemedicine over the course of the pandemic,” she said. “There is only so long you can really try to manage somebody without seeing them, so there is this pent-up demand for in-person visits. But there are certainly still patients who are requesting a telemedicine visit.”

That slight return to normalcy brought with it a sense of optimism that the pandemic would soon be over, according to Hummers. Unfortunately, it would not last.

“We had a very, very brief period where we were thinking, ‘Oh, should we really be 100% in-person again?’ And some of the restrictions that were placed on us, at least at the system-level, in terms of allowing patients to have care partners join them in the clinics, or allowing us to go unmasked in non-direct patient care locations within the clinic, had just started to ease,” Hummers said. “That was for a very short time. They have now been reimplemented.”

“We have taken a significant hit in morale, particularly since many of our colleagues believed that this wave was partially preventable, or at least it didn’t have to be as bad as it is,” she added. “We literally just started having our conferences, where masks were really optional, and we were doing some in-person meetings again, and we were seeing our colleagues again regularly. Everybody had this time where they were feeling really good, and this wave, in particular, has been a significant hit to the morale.”

In reaction to the delta surge, Johns Hopkins has again restricted its visitation policy at the institution level. Patients are now only allowed to have one caretaker or partner with them, whereas in June they could have two. Universal masking and face-shielding for any direct patient interaction has remained in place since the start of the pandemic.

In addition, Johns Hopkins University has initiated an institution-wide vaccine mandate for all staff. Those who are unable to receive the vaccine due to medical or religious considerations must submit to weekly COVID-19 testing.

“It’s not our requirement. It’s at the university and health system level,” Hummers said. “And it’s not specific to rheumatology.”

Detroit Area Moves Fast in Wrong Direction

Wayne County, Michigan, CDC snapshot on Aug. 5, 2021

  • Transmission level: Substantial
  • Residents aged 12 years and older with at least one vaccine dose: 54.8%.
  • Residents aged 12 years and older fully vaccinated: 51.1%.
  • 7-Day total cases: 974 (55.68 per 100,000); 51.01% increase in last week.
  • 7-day deaths: 11 (0.63 per 100,000); 8.33% decrease in last week.

On Aug. 3, when Healio Rheumatology first reached out to Cathy Patty-Resk, MSN, RN-BC, CPNP-BC, board member of the Rheumatology Nurses Society and pediatric nurse practitioner at Wayne Pediatrics, in Detroit, Wayne County, was still in the CDC’s “moderate transmission” column.

Two days later, when Healio Rheumatology spoke with Patty-Resk, the county had already been upgraded to “substantial spread.” By Aug. 9, Wayne County was firmly in the “high transmission” category, where it has remained ever since.

Cathy Patty-Resk

“What we are seeing with that is similar to what we have been hearing from around the country — that it’s mostly the unvaccinated population that we have in the hospital,” Patty-Resk said regarding the rapid change from “moderate” to “substantial” spread experienced in her county.

“I have heard some reports from a physician in another state who is on the front lines of COVID-19 and was talking about how there are some vaccinated persons who are admitted to the hospital,” she added. “I’m not sure about the actual data for that — with the delta variant I’m sure it’s always possible — but this is a reflection of the non-vaccinated persons in those hospital beds.”

When it comes to local vaccine uptake, there is a huge disparity between Detroit and the rest of Wayne County. Just 42.6% of residents aged 12 years and older in Detroit had received at least one dose, and only 34.8% were fully vaccinated, as of Aug. 24. For the remainder of the county, the rates were 67.9% and 61.9%, respectively.

“They are a lot lower for Detroit and that is something everyone in the community has been striving to increase,” Patty-Resk said. “There are a lot of different reasons why they are so low. It’s definitely not because of access. We have tremendous access; we have tremendous community outreach for the vaccine. At this time, it’s more vaccine hesitancy for this vaccine. I’m curious to see what happens — and we’re all anticipating — when [the Pfizer vaccine] goes for full FDA approval.”

The FDA would ultimately grant full approval to the Pfizer mRNA vaccine on Aug. 23.

“We are all hoping that perhaps that will change some of it so that we can get those numbers higher and the Detroit community much better protected,” she added. “I talk about the delta variant and how we are starting to see increased numbers. People are watching the news — they know. I just explain to people that the more variants we have, and the fewer vaccinated people, the more chances we have of variants developing that the vaccine won’t work against. That is everyone in the medical community’s biggest fear: That we will have a variant that the vaccine won’t even work for, and then we will really be in trouble.”

Wayne Pediatrics is a relatively new practice, affiliated with Wayne State University and launched during the pandemic in September 2020. It provides primary care, rheumatology, nephrology, immunology, infectious disease and endocrinology services to juvenile and adolescent patients.

“On a daily basis, we are not really seeing any COVID-19 patients in our practice right now,” Patty-Resk said. “We are doing the screening at the door, so anyone with fever isn’t coming in. I haven’t had anyone in a long time come in with a cough or any symptoms who were able to get past the front door. The last time that happened was probably back in the spring.”

According to Patty-Resk, 100% of all patient visits at Wayne Pediatrics are in-person. Masking and social distancing requirements have been in place since the beginning, as have temperature screenings at the center’s entrance. Vaccines have not been required among staff; however, anyone with symptoms would be required to quarantine for 10 days and receive a COVID-19 test.

“We go in the rooms and even the kids are good about having their masks on and leaving them on,” she said. “There is only one part of the examination where I ask them to pull their mask down, so I can look in their nose and mouth, and then of course they always put it right back up. We haven’t had any problems there.”

‘High Spread’ Rolls over Rural Georgia

Tift County, Georgia, CDC snapshot on Aug. 6, 2021

  • Transmission level: High
  • Residents aged 12 years and older with at least one vaccine dose: 20.8%.
  • Residents aged 12 years and older fully vaccinated: 16.9%.
  • 7-Day total cases: 262 (644.62 per 100,000); 40.86% increase in last week.
  • 7-day deaths: Less than 10.

Although the CDC’s vaccination figures for Tift County, located about 100 miles south of Macon, are alarmingly low, they come — by the CDC’s own admission — with a large caveat. According to the CDC, just 55% of Georgia’s fully vaccinated population presented with a valid county of residence, compared with 98.6% for the city of Baltimore and 93.8% for Wayne County, Michigan.

“States with lower percentages for valid county of residence should be interpreted with caution,” the CDC COVID-19 tracker warns.

James E. Mossell III, DO, FACR, a rheumatologist at Tift Regional Medical Center, in Tifton, Georgia, said he has received data from a local hospital that paints a more promising picture — a total of 21,932 people, or about 54% of the county’s population, fully vaccinated as of Aug. 2.

James E. Mossell III

“There has always been a group of people who were not going to be vaccinated, and they still won’t,” Mossell told Healio Rheumatology. “Now we are seeing some mutation in the COVID-19, and logically we are seeing some of those numbers tick up, with some of it due to a lack of vaccination across the population. Again, only 50% of our population is vaccinated at this point.”

“Education is critical to getting people vaccinated,” he added. “There is a lot of false information that we hear on a one-on-one basis, every time we see someone. Or patients will call in and ask if they are OK to have the vaccine, and then we will look at their meds and let them know.”

Part of the not-for-profit Tift Regional Health System, Tift Regional Medical Center is a 181-bed referral hospital with three rheumatology care providers, including Mossell. The trio typically see approximately 55 to 60 patients each day, with many traveling from surrounding counties due to the scarcity of other rheumatologists serving the rural area.

“At this point, we are still open. We do have a few telehealth visits on a daily basis, but an overwhelming majority are live,” Mossell said. “Maybe only 5% are telehealth at this point.”

“[In December and January 2020], the majority of the patients we were seeing were virtual, so it was the exact opposite of what we have now,” he added. “It certainly had changed significantly in a positive way for us, but as of the last week or two, obviously the numbers have been ticking up, so we have made some changes.”

Among those changes, the hospital began barring pharmaceutical representatives from entering the facility in late July. In addition, patients are now limited to one accompanying family member in the office. Masking, temperature readings and social distance policies have remained in place throughout the pandemic. Vaccination is not required among staff.

Like much of the southern United States, Tift County has been classified has “high-spread” since the release of the CDC’s COVID tracker. As infections numbers rapidly increased, Mossell said an alarming number of his patients began canceling appointments due to testing positive for COVID-19.

“Lately, I have had calls from several patients who reported being positive for COVID, which is disturbing, because before, that had all kind of died down,” he said. “Just in the last several weeks, I have had several patients calling in to reschedule their appointment because they tested positive and they are in the hospital, or it’s a relative calling to say that they are in the hospital. I have seen an uptick in infections in my patient population, which, I’m assuming, is mostly unvaccinated people.”

“We need to encourage vaccination among our patients and their family members,” he added. “Push hard for all of these folks to be vaccinated, and then continue to wear a mask in the office and keep social distancing. There is a tendency at this point for people to not want to do that because they are tired of it, but persistence at this point is what I would recommend.”

For more information:

Laura Hummers, MD, can be reached at 5501 Hopkins Bayview Circle, Baltimore, MD 21224; email: wblount1@jhmi.edu.

James E. Mossell III, DO, FACR, can be reached at 901 18th St., Tifton, GA 31794, email: dr.james.mossell@tiftregional.com.

Cathy Patty-Resk, MSN, RN-BC, CPNP-BC, can be reached at 400 Mack Ave., Suite 1 East, Detroit, MI 48201; email: cathy.resk@gmail.com.