MMS Prescriber Education: 17,063 courses, 5,905 individuals

Posted in Department of Public Health, Drug Abuse, opioids on August 5th, 2016 by MMS Communications – Be the first to comment

MMS has engaged in many efforts to address the opioid epidemic in the Commonwealth, from creating prescribing guidelines to public information campaigns for patients.  One of the major contributions of the Society – and one of the critical steps in alleviating the crisis as MMS President James S. Gessner, M.D. has noted — has been prescriber education.

MMS began offering free continuing medical education courses in opioids and pain management to all RXMonitoringprescribers beginning in May of last year, and demand for the courses has been high.

Over the 14-month period from May 26, 2015, when the free courses were first offered, through August 1, 2016, a total of 17,063 courses have been completed by 5,905 individuals. Currently, 18 courses are offered.

The courses appear to be having a positive impact, as multiple studies show that opioid prescribing has declined significantly in the state.

A study by athenahealth showed that the number of patients in Massachusetts who were prescribed opioids between the first and second quarter of 2016 dropped 14 percent, compared to an 8 percent decline for the rest of the nation.  Another study, released in June by the Cambridge-based Workers Compensation Research Institute, recorded decreases in the amount of opioids prescribed per worker’s compensations claims in the Commonwealth as well as many other states.

Finally, a Massachusetts Department of Public Health report, issued on August 3, noted that data from the state’s Prescription Drug Monitoring program showed that the total number of opioid Schedule II prescriptions and the number of individuals receiving Schedule II prescriptions were both at their lowest levels since the first quarter of 2015.  DPH said that the number of individuals who received one or more prescriptions for opioids dropped 16 percent from the first quarter of 2015 to the second quarter of 2016.

Despite the decline in prescription medications, deaths from opioid overdoses continue to rise, fueled by the synthetic opioid, fentanyl.  DPH reported that 66 percent of confirmed opioid-related overdoses deaths so far in 2016 involved fentanyl, an increase over  2015, when the rate was 57 percent.

Massachusetts Medical Society States Support of Governor Baker’s Proposal for Lyme Disease Treatment

Posted in Uncategorized on July 29th, 2016 by MMS Communications – Be the first to comment

MMS President James S. Gessner, M.D. today issued a statement of support for Governor Charlie Baker’s alternative proposal for the treatment of patients with Lyme disease.

“The Massachusetts Medical Society is firmly in support of the Governor’s initiative to provide insurance coverage for the treatment of patients with Lyme disease,” said Dr. Gessner.

“Public health officials have determined that Lyme disease is endemic throughout the Commonwealth,” Dr. Gessner added, “so much so that the state has the fourth highest incidence of Lyme disease in the nation.  It is imperative that we provide comprehensive care for those affected, and the Governor is attempting to do just that.”

The Governor’s bill, filed Thursday, would require private health insurers, nonprofit hospitals, and health maintenance organizations to cover the costs of medically appropriate and clinically proven treatments for Lyme disease equal to the coverage that the state’s Medicaid program provides.  That requirement would ensure needed treatment for patients with the condition.

Dr. Gessner added that he is gratified that the Governor acknowledges that his bill would provide coverage only for evidenced-based therapies that have proven to be clinically effective and that physicians of all specialties would be able to prescribe treatment when determined to be medically necessary.

August Physician Focus: Electronic Medical Records 

Posted in Physician Focus on July 29th, 2016 by MMS Communications – Be the first to comment

The introduction of electronic medical records has been one of the most rapid and widespread advances of technology in medicine affecting physicians of all specialties. More than 90 percent of Massachusetts physicians now use some form of EMR. While they offer great promise in improving patient care, EMRs have also presented physicians with great challenges, affecting clinical efficiency, workflow, interaction with patients, and reporting requirements.  Patients as well have expressed concerns about physician attention during the office visit and patient privacy and confidentiality.

From left, Dr. Dale Magee, Dr. Glenn Tucker, Dr. Joseph Heyman

From left, Dr. Dale Magee, Dr. Glenn Tucker, Dr. Joseph Heyman

The August edition of Physician Focus examines the pros and cons of electronic medical records with two members of the medical society’s Committee on Information Technology (CIT).

Guests are Glenn Tucker, M.D., Chair of CIT and Chief of Internal Medicine and Chief Medical Information Officer at Sturdy Memorial Hospital in Attleboro, and Joseph Heyman, M.D., Chief Medical Information Officer of Wellport Health Information Exchange in Newburyport, CIT member, former president of MMS and former chairman of the Board of the American Medical Association. Hosting this edition is Dale Magee, M.D., a past president of MMS.

The physicians discuss a number of issues, including the transition from paper to digital, the advantages and disadvantages of digital records, how EMRs can affect workflow in a physician’s office, the differences among systems, and how EMRs can benefit patients.

Physician Focus is distributed to public access television stations throughout Massachusetts, reaching residents in more than 275 cities and towns. It is also available online at www.physicianfocus.org, www.massmed.org/physicianfocus and on YouTube.

 

 

 

 

The President’s Podium: A Step Forward in the Opioid Battle

Posted in Department of Public Health, Drug Abuse, opioids, Public Health on July 22nd, 2016 by MMS Communications – 1 Comment

by James S. Gessner, M.D., President, Massachusetts Medical Society

Congress has helped Massachusetts and the nation take another step forward in the battle against prescription drug abuse. The Comprehensive Addiction and Recovery Act (CARA), a bipartisan effort incorporating several pieces of legislation targeted at opioid abuse, has been passed overwhelmingly by the House and Senate, and President Obama has signed it into law.

A compelling need to fund some of the law’s provisions still remains, but the symbolism and substance of its passage, like the enactment of Governor
Dr. James S. Gessner, MMS President '16-'17_editedCharlie Baker’s opioid bill in March, is hard to overstate.  According to the Centers for Disease Control, drug overdose deaths in the U.S. hit record numbers in 2014.  While heroin and fentanyl certainly claim their share of lives, prescription opioids continue to fuel the epidemic: at least half of all opioid overdose deaths involve a prescription opioid, and in 2014, more than 14,000 people died from overdoses involving prescription opioids. In Massachusetts alone, more than 1,500 opioid-related deaths occurred in 2015.

CARA includes several important provisions, including greater access to the life-saving therapies of naloxone and buprenorphine, help for infants and veterans, and the reauthorization of the National All Schedules Prescription Electronic Reporting Act, or NASPER, which provides for prescription monitoring programs that have proven to reduce opioid prescribing and overdose deaths.

One provision of CARA, however, can make a big difference: partial-fill prescriptions that will help patients balance the need to relieve pain with an adequate supply of medication by only filling part of a prescription.

The importance of a partial-fill prescription is that it can help to cut drug diversion – something that makes up a significant part of the opioid abuse crisis.  Estimates from the National Institute on Drug Abuse indicate that the majority of individuals – up to an astonishing 70 percent – who misuse or abuse pain medications get them from prescriptions written for someone else, such as family or friends.

Advocated by Massachusetts physicians, the partial-fill legislation was championed by Senator Elizabeth Warren and Congresswoman Kathrine Clark, who co-sponsored the Reducing Unused Medications Act of 2016 that became part of CARA. With few exceptions, U.S. Drug Enforcement Administration regulations had previously prevented partial-fill prescriptions.

While state law also now permits partial-fills, passed as part of the Governor’s opioid bill due to the efforts of Senator John Keenan of Quincy, the Federal law goes a step further by allowing the patient to fill the unused portion of the prescription, should patients need more relief.  State law currently does not.  This new provision in CARA will enable Massachusetts to change its law to become aligned with the new Federal law, as well as give other states the ability to pass partial-fill legislation.

In prescribing pain medicines, physicians are challenged with balancing the risk of addiction versus ensuring adequate pain relief for their patients. In efforts to reduce patients’ pain, however, too many prescriptions have been written, and prescription opioids have played a major role in driving this epidemic. Partial-fill prescriptions have the potential to shrink the amount of drugs susceptible to abuse and misuse or theft from unsecured locations such as family medicine cabinets – the place where Director of the White House Office of National Drug Policy Michael Botticelli has said the epidemic starts.

The law permitting partial-fill prescriptions is another in a long list of substantive efforts taken to address the opioid epidemic.  Here in Massachusetts, we perhaps have had more actions taken much sooner than elsewhere to fight opioid abuse. Governor Baker’s Opioid Working Group that led to bipartisan landmark legislation, law enforcement programs such as Gloucester’s Angel Program and the Middlesex County Sheriff’s Office MATADOR program for inmates, prescribing guidelines and prescriber education offered by our state medical society, and public information campaigns are among endeavors contributing to prevention, education, treatment, recovery.  These efforts, underway for more than a year now, are now beginning to see some results in recovery and reduced prescribing rates.

Another major step will be taken in August, when the Department of Public Health launches its new prescription monitoring program, offering enhanced searching capability along with access to data from other states.

These actions provide encouragement and hope. Yet despite this momentum, the rate of opioid-related deaths in the Commonwealth continues to climb  – a stark reminder of the human cost of this epidemic.  And those rising numbers keep sending us an important message: that’s there’s no room for complacency, a need for even more vigilance, and a long, long way to go before we can claim real progress.

The President’s Podium appears periodically on the MMS blog, offering Dr. Gessner’s commentary on a range of issues in health and medicine. 

 


July Physician Focus: Men’s Health

Posted in Physician Focus, Primary Care on July 1st, 2016 by MMS Communications – Comments Off on July Physician Focus: Men’s Health

Studies and statistics confirm that when it comes to individual health, men fare far worse than women. Heart disease, substance abuse, injury and death from accidents all affect men far more than women.

Dr. Karlin (l) Dr. Schwartz (r) blog

“Men have really not taken good care of themselves,” says primary care physician Frederic Schwartz, M.D., co-chair of the Massachusetts Medical Society’s Men’s Health Committee. “There seems to be this ‘macho’ attitude where men feel that to access health care is not part of their creed. They delay care, they’re in denial, until it is too late.”

The differences between the sexes are large not only in visiting a physician, but also in listening to medical guidance, Dr. Schwartz says.  Women seem much more inclined in following through on the recommendations that physicians promote to maintain health.

Dr. Schwartz (photo, seated), an Assistant Professor of Medicine at the University of Massachusetts Medical School, offers his perspectives on men and health in the July episode of Physician Focus with program host Bruce Karlin, M.D., (standing) a primary care physician in Worcester.

The physicians discuss the reasons why men fall short on taking care of themselves and what they can and should do about improving their care.  Among other topics of conversation are prostate cancer, concern over the commonly prescribed Prostate Specific Antigen test; and how “low T” (low testosterone) and erectile dysfunction affect men’s health.

Physician Focus is distributed to public access television stations throughout Massachusetts, reaching residents in more than 275 cities and towns. It is also available online at www.physicianfocus.org, www.massmed.org/physicianfocus and on YouTube.

The President’s Podium: Encouraging Prescriber Education  

Posted in Drug Abuse, opioids, Public Health on June 24th, 2016 by MMS Communications – Comments Off on The President’s Podium: Encouraging Prescriber Education  

by James S.  Gessner, M.D., President, Massachusetts Medical Society

It is not an exaggeration to say that the Massachusetts Medical Society has been the leading health care organization in the Commonwealth responding to the opioid epidemic. For more than a year, we have been working with state and public health officials, legislators and other health care leaders and have developed multiple responses to address the crisis.  Gessner Crop

My predecessor, Dr. Dennis Dimitri, has been extraordinary in leading MMS over the past year and making the crisis the society’s number one priority. As Chairman of the Task Force on Opioid Therapy and Communication, I was privileged to be part of those efforts.

One of our major activities has centered on education, for both patients and physicians.  We have created a website and produced public service and video programs for patients, urging proper storage and disposal, consideration of alternative therapies, and discussions with their physicians on how best to treat pain.

One area we’re having significant impact is prescriber education.

This effort began with the issuance of our Opioid Therapy and Physician Communication Guidelines in May of 2015.  Developed with the most relevance for physicians and health professionals in primary care — those who prescribe the majority of pain medications – these guidelines were subsequently adopted by the Massachusetts Board of Registration in Medicine and incorporated into its comprehensive advisory to physicians on prescribing issues and practices.

In that same month, we started offering our continuing medical education courses on opioids and pain management free to all prescribers. We recognized early that prescriber education would be a critical step in addressing the opioid epidemic and that our society could make a significant contribution by sharing our resources.

The response to these courses has been encouraging indeed.

In a span of 13 months, from May 2015 through June 20 of this year, a total of 15, 175 of the Society’s continuing medical education courses in pain management and safe opioid prescribing have been completed by 5,265 individuals. Of those, 86 percent are physicians, and 66 percent practice in Massachusetts.

We currently offer 18 opioid and pain management online courses, with a range of content. Among the topics are managing pain without overusing opioids, managing risk when prescribing narcotics, safe prescribing for chronic pain, screening and evaluation of substance abuse disorder, and alternative therapies to opioids.  These courses are reviewed and updated regularly, to provide health professionals with the latest information on opioids and pain management.

Our prescriber education efforts, however, have gone even further, to include working with state public health officials and the deans of the state’s four medical schools in creating core competencies on opioids and pain management for medical school students and reaching out to academic medical centers in developing similar educational offerings for residency training programs.

Prescriber education remains one of the critical steps to alleviating the opioid crisis – a fact recognized by Governor Charlie Baker, who also realizes the key role physicians must play in resolving this crisis: “I think we have to be incredibly vigilant and aggressive about working with our colleagues in the health care world on this if we expect to have any long-term success at all,” he told The Boston Globe.

Physicians have a unique role in health care, and we are clearly demonstrating that with our response to the opioid epidemic. MMS will continue its efforts to educate physicians, to improve prescribing practices and reduce the amount of drugs that can be abused or misused.

The President’s Podium appears periodically on the MMS blog, offering Dr. Gessner’s commentary on a range of issues in health and medicine.

 

 

 

Men’s Health: Breaking the Resistance

Posted in Uncategorized on June 17th, 2016 by MMS Communications – Comments Off on Men’s Health: Breaking the Resistance

Resistance by men to medical care and treatments remains a vexing challenge as evidenced by the presentations of five clinicians at the Massachusetts Medical Society’s 14th Annual Symposium on Current Issues in Men’s Health on Thursday, June 16th.

The annual symposium is sponsored by the MMS Committee on Men’s Health, currently co-chaired by Frederic S. Schwartz, M.D. and Michael B. Bader, M.D., and seeks to promote awareness of men’s health issues and improve the overall health of men through education and information for physicians and other healthcare providers, researchers, and the public.  Some 60 health care professionals attended this year’s event, held during National Men’s Health Week.

Dr. Frederic Schwartz, Co-Chair, MMS Men's Health Committee

Dr. Frederic Schwartz, Co-Chair, MMS Men’s Health Committee

The opening presentations, on the treatment of Hepatitis C and alcohol dependence, were followed by a discussion on erectile dysfunction and its relationship to cardiovascular disease, and a presentation that reported how a cohort of male patients responded to questions about access to health care. The symposium concluded with a presentation about the health and identity issues transgender patients face when seeking medical care.

In his introductory remarks, MMS President James S. Gessner, M.D. underscored the urgency that surrounds these topics.

“Statistically, we face numerous challenges with regard to male patients,” Dr. Gessner said, “because men continue to be more likely than women to make unhealthy lifestyle choices. One in every five men will suffer a heart attack before they reach the age of 65. We must adopt a dual role as practitioners and catalysts, to treat men and to motivate them to live healthier lives.”

George Abraham, M.D., in his presentation titled Citius, Altius, Fortius: The New Standards of Hepatitis C, declared that “the saddest statistic we face is that while we have conquered HIV, the prevalence of cirrhosis is quite high, and men are increasingly the victims.” He said that liver transplants have increased and liver cancer is common among male patients. The good news, however, is that we are now headed to help cure this problem more rapidly than ever, thanks to medical and pharmaceutical advancements. Yet male patients must make a commitment to recovery and that practitioners must urge them to embark on this path, he said, or reinfection is possible.

Drawing on two American authors – Ernest Hemingway and F. Scott Fitzgerald — as examples of men who battled and later succumbed to alcoholism, Kenneth Hetzler, M.D., in his presentation, Alcohol Dependence and Best Practices for Treatment, explored alcoholism symptoms and treatments. Noting that both Hemingway and Fitzgerald paid a high price for their alcohol dependencies — depression, cirrhosis and, in Hemingway’s case, suicide — he urged physicians to engage in frank dialogues with their patients about their drinking habits so patients can grasp the risks of alcohol dependency and turn to resources for sobriety.

Martin Miner, M.D., cited another American author, Mark Twain, in his presentation, Erectile Dysfunction and Cardiovascular Function: What We Know.  Twain’s remark, “You can’t break a bad habit by throwing it out the window. You’ve got to walk it slowly down the stairs,” illustrated what Dr. Miner said is an effective approach to discussing and treating erectile dysfunction, a subject men find difficult to broach. Male patients must take small steps to change their lives, Dr. Miner said, which often include lifestyle changes. Noting that the relationship between erectile dysfunction and cardiovascular health is being clinically explored, Dr. Miner said that working with men to change slowly and understand the implications of their health challenges over time remains a key imperative.

James E. Leone, Ph.D., in his presentation Advancing Health Behaviors in Men: Understanding Men’s Perceptions Regarding Accessing Health Care, urged physicians to work with male patients to “unpack the behaviors” that lead to their resistance of healthcare. These include fear, control, time/convenience, trust, and other issues that emerged from his research as examples of resistance by men to seeking healthcare. “We need to create a more robust dialogue with men,” Dr. Leone said, “to bring men back to being active participants” in their own well-being.

Dr. Kevin Ard, the recipient of this year’s Men’s Health Award from the MMS, followed with a presentation entitled Transgender Identity and Health Issues, noting that LGBT patients have traditionally felt marginalized by the medical profession.  He encouraged practitioners to “make their clinical settings more welcoming,” and to use preferred names and pronouns, to ask patients about their identity and sexual orientation, and to remain open to them by avoiding assumptions about their health issues.

—Robert Israel

Editor’s Note: The slide presentations of  Dr. Abraham, Dr. Hetzler, Dr. Minor, Dr. Leone, and Dr. Ard are available here. 

 

 

 

 

 

 

 

 

 

 

The President’s Podium: Physicians and Gun Violence

Posted in Public Health on June 16th, 2016 by MMS Communications – 1 Comment

by James S. Gessner, M.D., President, Massachusetts Medical Society

Yet another mass shooting has stunned the nation, this time in Orlando, Gessner CropFlorida leaving 49 people dead and another 50 injured.  The home of Walt Disney World and the destination of thousands of tourists each year is now the site of the largest mass shooting in the history of America, joining such names as Columbine, Virginia Tech, and Sandy Hook, along with more than a hundred other places.

Such events are becoming all too common.  According to Everytown for Gun Safety, 133 mass shootings in 39 states occurred in the U.S. between January 2009 and July 2015 – almost two per month.  Yet as horrible and shocking as they are, mass shootings – defined by the FBI as any incident in which at least four people were murdered with a gun – account for a small share of firearm homicides.

The Centers for Disease Control estimates that more than 33,000 deaths from firearms – about 91 a day on average – occur each year.

The statistics make it abundantly clear: gun violence is a public health issue. And the physician’s voice – ever so critical on matters of public health – must become stronger.

The MMS stance on this issue has been firm and long-standing. Our medical society’s policy on firearms and gun violence is expansive and dates back to 1995. It is guided by “the principles of reducing the number of deaths, disabilities, and injuries attributable to guns; making gun ownership safer; promoting education relative to guns, ammunition, and violence prevention for physicians and other health professionals as well as for the public; and encouraging research to understand the risk factors related to gun violence and deaths.”

Our actions have matched our policy.  Our Committee on Violence Intervention and Prevention, also established in 1995, has provided a number of resources to help reduce violence in many forms, and gun violence has been prominent among the topics.

From testimony on proposed legislation on Beacon Hill, to education for patients, to resources for physicians on talking with patients, to our most recent Public Health Leadership Forum on Firearm Violence in April, to then-MMS President Dr. Richard Aghababian’s call to action following the school shootings in Newtown in 2012,  gun safety and gun violence have been key issues for our Society.

It is heartening to see more physician groups lend their strong support to the effort.  The American Medical Association, with longstanding policies on reducing violence from firearms, stated its position at this year’s annual meeting, adopting a policy calling gun violence in the U.S. “a public health crisis” that requires a comprehensive public health response and solution.  Perhaps most important, the AMA also resolved to lobby Congress to overturn legislation that for 20 years has banned the Centers for Disease Control and Prevention from conducting research on gun violence.

A second resolution by the AMA on firearm availability encourages legislation that would enforce a waiting period and background check for all firearm purchases and urges additional legislation to ban the manufacture, sale, or import of lethal and non-lethal guns of non-metallic materials that can not be identified by weapons detection devices.

In April of 2015, seven physician organizations, along with the American Public Health Association and American Bar Association, issued a call to action, declaring that “deaths and injuries related to firearms constitute a major public health problem in the United States.”

I am proud to say that more efforts at our medical society are underway. Our Leadership Forum will provide materials for six continuing medical education courses on gun violence to launch at the end of June.  Among the topics will be the role of the clinician, community-based prevention, and evaluating the risk for gun violence in patients.  Additionally, we are participating with Massachusetts Attorney General Healey in developing materials to enhance the provider-patient relationship regarding firearms.

The shock of Orlando may fade over time, but physician efforts to reduce gun violence should not.  Attorney General Healey, speaking at our Leadership Forum, highlighted the importance of physician participation in curbing gun violence, saying it will require a “partnership” with physicians.  Indeed it will.

The President’s Podium appears periodically on the MMS blog, offering Dr. Gessner’s commentary on a range of issues in health and medicine.

 

 

June Physician Focus: Infectious Disease: Fear vs. Evidence

Posted in Ebola, Flu, H1N1, Physician Focus, Public Health on June 10th, 2016 by MMS Communications – Comments Off on June Physician Focus: Infectious Disease: Fear vs. Evidence

The outbreak of an infectious disease is one of medicine’s most difficult challenges.  At the same time that public health agencies must contain the infection, they must also try to quell the public’s fears – a difficult task in today’s world of instant communication, multiple media channels, and constant media attention.  The experiences of Severe Acute Respiratory Syndrome in 2003, H1N1 Bird Flu in 2009, Ebola in 2014, Middle East Respiratory Syndrome in 2014, and now the Zika virus in 2016, are the most recent examples of threats targeting the public health.

June Physician Focus features Dr. Steven Hatch (r), with host Dr. Bruce Karlin

June Physician Focus features Dr. Steven Hatch (r), with host Dr. Bruce Karlin

The June edition of Physician Focus provides some perspective on the topic of media and public reaction to outbreaks of infectious disease through the experiences of Steven C. Hatch, M.D., an infectious disease specialist at UMass Memorial Medical Center and an Assistant Professor in the Division of Infectious Disease at UMass Medical School in Worcester. Hosting this edition is Bruce Karlin, M.D., a primary care physician in Worcester.

In 2014, Dr. Hatch spent five weeks in Liberia with the International Medical Corps treating patients stricken with Ebola and subsequently returned to that country several times to treat patients. Among the topics of conversation are what public health agencies must consider in reacting to infectious disease outbreaks, comments on how the media covered the Ebola outbreak in the U.S., and Dr. Hatch’s perspective on the latest outbreak of Zika.

Physician Focus is distributed to public access television stations throughout Massachusetts, reaching residents in more than 275 cities and towns. It is also available online at www.massmed.org/physicianfocus, www.physicianfocus.org/disease2016, and on YouTube.

 

Q&A with Dr. Catherine Brown of the Massachusetts DPH: What Physicians and Patients Should Know About Zika

Posted in Department of Public Health, Public Health on June 8th, 2016 by MMS Communications – Comments Off on Q&A with Dr. Catherine Brown of the Massachusetts DPH: What Physicians and Patients Should Know About Zika

Editor’s Note: Last week, the Massachusetts Department of Public Health posted new clinical guidance for physicians about the Zika virus on its website, which also includes handouts in multiple languages about the virus and travel advice for patients.

MMS spoke with Catherine Brown, D.V.M., M.S., M.P.H., Deputy State Epidemiologist and State Public Health Veterinarian at the Massachusetts Department of Public Health, about the potential for contracting Zika in the Commonwealth and what physicians and patients need to know.

We’ve seen a lot in the news about the Zika virus.
Should we be concerned about Zika virus in Massachusetts?
It’s extremely unlikely that we’ll see mosquito-borne Zika virus in Massachusetts.  The conditions in Massachusetts are not conducive to mosquito transmission of the virus here. In order for the Zika virus to spread, there needs to be widespread established populations of mosquitos and a significant number of people actively infected with that widespread population of mosquitoes.

Dr. Catherine Brown, Massachusetts Department of Public Health

Dr. Catherine Brown, Massachusetts Department of Public Health

The primary vector of Zika virus, not just in this current outbreak, and in almost all outbreaks, has been the yellow fever mosquito Aedes aegypti. This mosquito is more likely to spread disease because it breeds successfully in urban environments, and bites, almost exclusively, people–it doesn’t feed on other mammals—and unlike other types of mosquito, it takes multiple blood meals. Most mosquitoes take a single blood meal, so are less likely to transmit disease. The Aedes aegypti mosquito has not been found in Massachusetts.

The secondary vector is the Asian tiger mosquito Aedes albopictus. This is a non-native introduced species that is well established in the southern tier of the U.S. It feeds on humans as well as other mammals. There is some evidence, from Massachusetts mosquito surveillance, that we have geographically isolated and sporadic findings of Aedes albopictus. However, as with Aedes aegypti, there would need to be widespread established populations as well as significant numbers of actively infected people in contact with that widespread population of mosquitoes in order to spread the virus.  The people in Massachusetts who have been infected with the virus are travelers returning from affected areas; they don’t carry the virus in their blood for very long.

So the risk for people in Massachusetts relates to those traveling to or from an affected region.  What regions in and out of the U.S. are affected?
As of [this interview], there have been no cases of locally acquired, mosquito-borne transmission anywhere in the United States.  The areas involved in the current epidemic of Zika virus are most of Central and South America and the Caribbean, as well as Cape Verde and Papua New Guinea. The U.S. Territory of Puerto Rico has been particularly hard hit. This is the largest outbreak of Zika virus ever documented, both in terms of number of people infected and the geographic range of the outbreak. Because infection with Zika virus likely confers long-term immunity, previous outbreaks have waned relatively quickly as the percentage of susceptible people in the population declines.

Travelers concerned about the status of the Zika virus should check the CDC website for the most updated information on currently affected areas.

What are the symptoms of Zika?
Eighty percent of people infected with Zika virus will never develop symptoms. For those that do become symptomatic, the most common complaints are fever, a rash, joint pain and non-purulent conjunctivitis. Headache and pain behind the eyes have also been reported. For the vast majority of people, the illness lasts between two to seven days and is self-limiting. No specific treatment exists. Hospitalizations associated with Zika virus infection are rare but have been associated with Guillain-Barré, meningoencephalitis, and other neurologic problems.

It is not known if there are particular groups of people that are more likely to develop disease, or who are more likely to develop severe disease, including Guillain-Barré.  No evidence exists that pregnant women, infants, or children are at greater risk for developing disease and information about risk in immune-compromised patients is limited.

What is the risk from Zika to humans?
The most significant concern from Zika virus infection is for pregnant women who can transmit the virus to a developing fetus.

Right now, there are still more questions than answers about Zika virus.  We do know that women infected with Zika virus during pregnancy are more likely to give birth to an infant with birth defects or some other poor birth outcome. Exactly how much risk is associated with infection is not known. There is some information that infection with Zika virus during the first trimester, as opposed to later trimesters, is more likely to cause microcephaly in the developing fetus, but poor birth outcomes and other types of birth defects have been reported associated with infection during all trimesters of gestation. Microcephaly has received much of the attention; fetal loss, intracranial calcifications, and hearing and vision defects have also been reported.  It is not known how often vertical transmission –a mother with the virus transmitting it to a fetus—occurs, or how often this results in problems with the developing fetus or the pregnancy.

How should physicians counsel their patients?
Physicians should counsel pregnant women or those who want to become pregnant in the next two months that they really should not travel to areas where there is a reported threat of Zika virus transmission. If they do travel to those areas, they should wait eight weeks after returning before attempting conception.

Sexual transmission from symptomatic males has been documented, so male patients who have been symptomatic for Zika should use condoms consistently and correctly for all sexual contact for six months as a precaution to avoid transmitting the virus to a woman who may be, or may wish to become, pregnant.

What if the male traveled to an affected region, but has not been symptomatic for Zika?
Males who have traveled to an affected region but did not develop characteristic Zika signs and symptoms should use condoms consistently and correctly for all sexual contact for eight weeks after their last possible exposure.

If a patient has traveled to an affected area, what does the physician need to know?
Anyone who was pregnant when they traveled, or who became pregnant within eight weeks of returning, should be tested for Zika virus infection whether or not they developed symptoms of Zika.  If the male partner of a pregnant woman traveled to an affected area, testing of the pregnant woman (and sometimes her male partner), is indicated if either one of them develops symptoms of Zika virus infection.

Patients who develop Guillain-Barré syndrome following a Zika-like infection should also be evaluated for testing.

Why shouldn’t everyone who has traveled be tested?
Testing is not as simple as marking a checkbox on a lab test order. There are two types of testing: antigen-based and antibody-based. Whether the patient is symptomatic or asymptomatic, and the timing of specimen collection, determine what type of testing needs to happen. Right now, the commercially available, antigen-based test is only good for three to four days after the onset of symptoms, so this test is completely inappropriate for patients who have no symptoms. The Massachusetts State Public Health Laboratory has the ability to run both the antigen- and antibody-based tests; preliminary positive results from the antibody test require confirmation which is currently being done by CDC. Clinicians should check the Mass. Department of Public Health clinical advisory (found under the section, “Information for Health Care Providers” on the MDPH’s Zika website) to ensure they’re ordering the appropriate test for the patient.

Physicians should also keep in mind that it’s possible that pregnant women returning from the affected regions to Massachusetts to deliver their babies here have received virtually no prenatal care, and probably haven’t been tested previously for Zika. The pediatrician may be the first health care provider to recognize that Zika is involved. Physicians should call the MDPH Epidemiology Line at 617-983-6800 to determine if testing is recommended.  When Zika virus testing is appropriate, the results can help to inform the provider’s clinical decision-making and help to provide answers to parents.

Is the Department of Public Health tracking these cases?
Yes. While no single state is going to have enough data to draw all conclusions that we need to draw in order to guide clinical and prevention practices, individual states are collecting de-identified data from OB/GYN providers on pregnant moms with lab verified exposure to Zika virus. Additionally, states are working with pediatricians to follow the infants for 12 months after birth as part of participation in the U.S. Zika Pregnancy Registry being operated by CDC. Most information on the pregnant women can be collected during routine phone calls with OB/GYN providers to discuss laboratory testing and to share results. The Massachusetts Center for Birth Defects Research and Prevention within MDPH is aiding this effort by providing information on both the mother and the initial neonatal assessment as part of their routine work identifying infants with birth defects.  MDPH will work with individual pediatricians to gather the requested data in as unobtrusive a manner as possible. We have been delighted by the positive relationships being developed with providers who understand the importance of collecting this information. By collecting information on the progress of pregnancies and serial assessments of infants’ health, we hope to rapidly and completely identify both the risks of infection during pregnancies and the spectrum of possible effects to infants that might include more subtle developmental problems.