MDedge Rheumatology

Opioid use does not decline after patients with inflammatory arthritis start TNF inhibitor therapy; in fact, average use appears to increase, results from a new study show.

“Starting a TNF inhibitor, you would think the pain would go down, and we were hoping the dose of opioids would go down with it,” said investigator Olafur Palsson, MD, from the University of Iceland in Reykjavik and Lund University in Sweden.

“But this research shows that the insertion of a TNF inhibitor has only a minor effect on that,” he told Medscape Medical News.

The findings are an “important reminder” to rheumatologists that they should broaden their consideration of other pain treatments and techniques for patients with inflammatory arthritis, Dr. Palsson said. “They should focus on trying other tactics to get patients’ pain and stiffness under control; there may be some underlying factors.”

The investigators compared opioid prescription rates in 940 patients with rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and undifferentiated arthritis with a control group of 4,700 matched subjects. Dr. Palsson presented the findings at the virtual European League Against Rheumatism (EULAR) 2020 Congress.

The team assessed nationwide databases that capture all patients taking biologics for rheumatic diseases and more than 90% of all drug prescriptions. They found that patients with inflammatory arthritis in Iceland were more likely to have received at least one opioid prescription than control subjects (75% vs. 43%).

During the study period, average yearly opioid dose rose much more in the patient group than in the control group. And 2 years after the initiation of TNF inhibitors, the number of patients taking opioids was unchanged from baseline, at about 40%.

Overall, the patient group was prescribed nearly six times more opioids than the control group. The investigators used a bootstrapping analysis to obtain a reliable confidence interval.

“In a way, the data are extremely skewed,” Dr. Palsson explained. “Most patients were taking very low doses of opioids and a few were taking extremely high doses. It’s hard to do a statistical analysis.”

“With bootstrapping, you don’t detect small fluctuations in data,” he said, acknowledging this study limitation. Also, “prescription data don’t necessarily reflect consumption” of a drug. People prescribed high doses may not necessarily be consuming high doses.”

Additionally, the risk for addiction is low when opioids are used as intended, said John Isaacs, MBBS, PhD, from Newcastle University in Newcastle Upon Tyne, United Kingdom, who is chair of the EULAR scientific program committee.

To alleviate chronic pain, opioids “should, in any case, only be part of a comprehensive therapy program in which doctors, psychologists, and physiotherapists work together,” Dr. Isaacs said in a EULAR news release.

Dr. Palsson has disclosed no relevant financial relationships. Dr. Isaacs is a consultant or has received honoraria or grants from Pfizer, AbbVie, Amgen, Merck, Roche, and UCB.

This article first appeared on Medscape.com.



 

Opioid use does not decline after patients with inflammatory arthritis start TNF inhibitor therapy; in fact, average use appears to increase, results from a new study show.

“Starting a TNF inhibitor, you would think the pain would go down, and we were hoping the dose of opioids would go down with it,” said investigator Olafur Palsson, MD, from the University of Iceland in Reykjavik and Lund University in Sweden.

“But this research shows that the insertion of a TNF inhibitor has only a minor effect on that,” he told Medscape Medical News.

The findings are an “important reminder” to rheumatologists that they should broaden their consideration of other pain treatments and techniques for patients with inflammatory arthritis, Dr. Palsson said. “They should focus on trying other tactics to get patients’ pain and stiffness under control; there may be some underlying factors.”

The investigators compared opioid prescription rates in 940 patients with rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and undifferentiated arthritis with a control group of 4,700 matched subjects. Dr. Palsson presented the findings at the virtual European League Against Rheumatism (EULAR) 2020 Congress.

The team assessed nationwide databases that capture all patients taking biologics for rheumatic diseases and more than 90% of all drug prescriptions. They found that patients with inflammatory arthritis in Iceland were more likely to have received at least one opioid prescription than control subjects (75% vs. 43%).

During the study period, average yearly opioid dose rose much more in the patient group than in the control group. And 2 years after the initiation of TNF inhibitors, the number of patients taking opioids was unchanged from baseline, at about 40%.

Overall, the patient group was prescribed nearly six times more opioids than the control group. The investigators used a bootstrapping analysis to obtain a reliable confidence interval.

“In a way, the data are extremely skewed,” Dr. Palsson explained. “Most patients were taking very low doses of opioids and a few were taking extremely high doses. It’s hard to do a statistical analysis.”

“With bootstrapping, you don’t detect small fluctuations in data,” he said, acknowledging this study limitation. Also, “prescription data don’t necessarily reflect consumption” of a drug. People prescribed high doses may not necessarily be consuming high doses.”

Additionally, the risk for addiction is low when opioids are used as intended, said John Isaacs, MBBS, PhD, from Newcastle University in Newcastle Upon Tyne, United Kingdom, who is chair of the EULAR scientific program committee.

To alleviate chronic pain, opioids “should, in any case, only be part of a comprehensive therapy program in which doctors, psychologists, and physiotherapists work together,” Dr. Isaacs said in a EULAR news release.

Dr. Palsson has disclosed no relevant financial relationships. Dr. Isaacs is a consultant or has received honoraria or grants from Pfizer, AbbVie, Amgen, Merck, Roche, and UCB.

This article first appeared on Medscape.com.



 

Opioid use does not decline after patients with inflammatory arthritis start TNF inhibitor therapy; in fact, average use appears to increase, results from a new study show.

“Starting a TNF inhibitor, you would think the pain would go down, and we were hoping the dose of opioids would go down with it,” said investigator Olafur Palsson, MD, from the University of Iceland in Reykjavik and Lund University in Sweden.

“But this research shows that the insertion of a TNF inhibitor has only a minor effect on that,” he told Medscape Medical News.

The findings are an “important reminder” to rheumatologists that they should broaden their consideration of other pain treatments and techniques for patients with inflammatory arthritis, Dr. Palsson said. “They should focus on trying other tactics to get patients’ pain and stiffness under control; there may be some underlying factors.”

The investigators compared opioid prescription rates in 940 patients with rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and undifferentiated arthritis with a control group of 4,700 matched subjects. Dr. Palsson presented the findings at the virtual European League Against Rheumatism (EULAR) 2020 Congress.

The team assessed nationwide databases that capture all patients taking biologics for rheumatic diseases and more than 90% of all drug prescriptions. They found that patients with inflammatory arthritis in Iceland were more likely to have received at least one opioid prescription than control subjects (75% vs. 43%).

During the study period, average yearly opioid dose rose much more in the patient group than in the control group. And 2 years after the initiation of TNF inhibitors, the number of patients taking opioids was unchanged from baseline, at about 40%.

Overall, the patient group was prescribed nearly six times more opioids than the control group. The investigators used a bootstrapping analysis to obtain a reliable confidence interval.

“In a way, the data are extremely skewed,” Dr. Palsson explained. “Most patients were taking very low doses of opioids and a few were taking extremely high doses. It’s hard to do a statistical analysis.”

“With bootstrapping, you don’t detect small fluctuations in data,” he said, acknowledging this study limitation. Also, “prescription data don’t necessarily reflect consumption” of a drug. People prescribed high doses may not necessarily be consuming high doses.”

Additionally, the risk for addiction is low when opioids are used as intended, said John Isaacs, MBBS, PhD, from Newcastle University in Newcastle Upon Tyne, United Kingdom, who is chair of the EULAR scientific program committee.

To alleviate chronic pain, opioids “should, in any case, only be part of a comprehensive therapy program in which doctors, psychologists, and physiotherapists work together,” Dr. Isaacs said in a EULAR news release.

Dr. Palsson has disclosed no relevant financial relationships. Dr. Isaacs is a consultant or has received honoraria or grants from Pfizer, AbbVie, Amgen, Merck, Roche, and UCB.

This article first appeared on Medscape.com.



 

The risk for venous thromboembolism is almost 50% lower in patients with RA taking TNF inhibitors than in those taking conventional synthetic disease-modifying antirheumatic drugs (DMARDs), according to data from the German RABBIT registry.

“Some rheumatologists have thought TNF inhibitors could increase the risk for venous thromboembolism events, but we don’t think this is true, based on our findings,” said investigator Anja Strangfeld, MD, PhD, from the German Rheumatism Research Center in Berlin.

The risk is more than one-third lower in RA patients treated with other newer biologics, such as abatacept, rituximab, sarilumab, and tocilizumab.

However, risk for a serious venous thromboembolism is twice as high in patients with C-reactive protein (CRP) levels above 5 mg/L and is nearly three times as high in patients 65 years and older.

For the study, Dr. Strangfeld and her colleagues followed about 11,000 patients for more than 10 years. The findings were presented at the European League Against Rheumatism (EULAR) 2020 Congress.

“Patients with RA have a greater risk for venous thromboembolism compared with the general population, but we didn’t know the risk conveyed by different DMARD treatments,” Dr. Strangfeld told Medscape Medical News. “It is also evident that higher age and lower capacity for physical function increase the risk, which was not so surprising.”

Chronic inflammation in RA patients elevates the risk for deep vein and pulmonary thrombosis by two to three times, said John Isaacs, MBBS, PhD, from Newcastle University in Newcastle Upon Tyne, United Kingdom, who is chair of the EULAR scientific program committee.

Among the supporting studies Dr. Isaacs discussed during an online press conference was a Swedish trial of more than 46,000 RA patients, which had been presented earlier by Viktor Molander, a PhD candidate from the Karolinska Institute in Stockholm (abstract OP0034).

Mr. Molander’s team showed that one in 100 patients with high disease activity will develop venous thromboembolism within a year, which is twice the number of events seen among patients in remission.

Combined with the RABBIT data, both studies “show if you can control their disease in the right way, you’re not only helping rheumatoid arthritis patients feel better, but you could be prolonging their lives,” Dr. Isaacs said.

The prospective RABBIT study followed RA patients who began receiving a new DMARD after treatment failed with at least one conventional synthetic DMARD, such as methotrexate or leflunomide. At baseline, those taking TNF inhibitors or other biologics had higher CRP levels on average, as well as a higher rate of existing cardiovascular disease. They also received glucocorticoids, such as prednisone, more often.

The observational nature of the RABBIT study is a weakness, Dr. Strangfeld said, and it could not prove cause and effect. But the methodology had several strengths, including input on patient factors from participating rheumatologists at least every 6 months.

“We enrolled patients at the start of treatment and observed them, regardless of any treatment changes, for up to 10 years,” she added. “That’s a really long observation period.”

The RABBIT data can help shape treatment decisions, said Loreto Carmona, MD, PhD, from the Musculoskeletal Health Institute in Madrid, who is chair of the EULAR abstract selection committee.

For a woman with RA who smokes and takes oral contraceptives, for example, “if she has high levels of inflammation, I think it’s okay to use TNF inhibitors, where maybe in the past we wouldn’t have thought that,” she said.

“The TNF inhibitors are actually reducing the inflammation and, therefore, reducing the risk,” Dr. Carmona told Medscape Medical News. “It could be an effect of using the drugs on people with higher levels of inflammation. It’s an indirect protective effect.”

The study was funded by a joint unconditional grant from AbbVie, Amgen, BMS, Fresenius-Kabi, Hexal, Lilly, MSD, Mylan, Pfizer, Roche, Samsung Bioepis, Sanofi-Aventis, and UCB. Dr. Strangfeld is on the speakers bureau of AbbVie, BMS, Pfizer, Roche and Sanofi-Aventis. Dr. Isaacs is a consultant or has received honoraria or grants from Pfizer, AbbVie, Amgen, Merck, Roche, and UCB. Dr. Carmona has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.




 

The risk for venous thromboembolism is almost 50% lower in patients with RA taking TNF inhibitors than in those taking conventional synthetic disease-modifying antirheumatic drugs (DMARDs), according to data from the German RABBIT registry.

“Some rheumatologists have thought TNF inhibitors could increase the risk for venous thromboembolism events, but we don’t think this is true, based on our findings,” said investigator Anja Strangfeld, MD, PhD, from the German Rheumatism Research Center in Berlin.

The risk is more than one-third lower in RA patients treated with other newer biologics, such as abatacept, rituximab, sarilumab, and tocilizumab.

However, risk for a serious venous thromboembolism is twice as high in patients with C-reactive protein (CRP) levels above 5 mg/L and is nearly three times as high in patients 65 years and older.

For the study, Dr. Strangfeld and her colleagues followed about 11,000 patients for more than 10 years. The findings were presented at the European League Against Rheumatism (EULAR) 2020 Congress.

“Patients with RA have a greater risk for venous thromboembolism compared with the general population, but we didn’t know the risk conveyed by different DMARD treatments,” Dr. Strangfeld told Medscape Medical News. “It is also evident that higher age and lower capacity for physical function increase the risk, which was not so surprising.”

Chronic inflammation in RA patients elevates the risk for deep vein and pulmonary thrombosis by two to three times, said John Isaacs, MBBS, PhD, from Newcastle University in Newcastle Upon Tyne, United Kingdom, who is chair of the EULAR scientific program committee.

Among the supporting studies Dr. Isaacs discussed during an online press conference was a Swedish trial of more than 46,000 RA patients, which had been presented earlier by Viktor Molander, a PhD candidate from the Karolinska Institute in Stockholm (abstract OP0034).

Mr. Molander’s team showed that one in 100 patients with high disease activity will develop venous thromboembolism within a year, which is twice the number of events seen among patients in remission.

Combined with the RABBIT data, both studies “show if you can control their disease in the right way, you’re not only helping rheumatoid arthritis patients feel better, but you could be prolonging their lives,” Dr. Isaacs said.

The prospective RABBIT study followed RA patients who began receiving a new DMARD after treatment failed with at least one conventional synthetic DMARD, such as methotrexate or leflunomide. At baseline, those taking TNF inhibitors or other biologics had higher CRP levels on average, as well as a higher rate of existing cardiovascular disease. They also received glucocorticoids, such as prednisone, more often.

The observational nature of the RABBIT study is a weakness, Dr. Strangfeld said, and it could not prove cause and effect. But the methodology had several strengths, including input on patient factors from participating rheumatologists at least every 6 months.

“We enrolled patients at the start of treatment and observed them, regardless of any treatment changes, for up to 10 years,” she added. “That’s a really long observation period.”

The RABBIT data can help shape treatment decisions, said Loreto Carmona, MD, PhD, from the Musculoskeletal Health Institute in Madrid, who is chair of the EULAR abstract selection committee.

For a woman with RA who smokes and takes oral contraceptives, for example, “if she has high levels of inflammation, I think it’s okay to use TNF inhibitors, where maybe in the past we wouldn’t have thought that,” she said.

“The TNF inhibitors are actually reducing the inflammation and, therefore, reducing the risk,” Dr. Carmona told Medscape Medical News. “It could be an effect of using the drugs on people with higher levels of inflammation. It’s an indirect protective effect.”

The study was funded by a joint unconditional grant from AbbVie, Amgen, BMS, Fresenius-Kabi, Hexal, Lilly, MSD, Mylan, Pfizer, Roche, Samsung Bioepis, Sanofi-Aventis, and UCB. Dr. Strangfeld is on the speakers bureau of AbbVie, BMS, Pfizer, Roche and Sanofi-Aventis. Dr. Isaacs is a consultant or has received honoraria or grants from Pfizer, AbbVie, Amgen, Merck, Roche, and UCB. Dr. Carmona has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.




 

The risk for venous thromboembolism is almost 50% lower in patients with RA taking TNF inhibitors than in those taking conventional synthetic disease-modifying antirheumatic drugs (DMARDs), according to data from the German RABBIT registry.

“Some rheumatologists have thought TNF inhibitors could increase the risk for venous thromboembolism events, but we don’t think this is true, based on our findings,” said investigator Anja Strangfeld, MD, PhD, from the German Rheumatism Research Center in Berlin.

The risk is more than one-third lower in RA patients treated with other newer biologics, such as abatacept, rituximab, sarilumab, and tocilizumab.

However, risk for a serious venous thromboembolism is twice as high in patients with C-reactive protein (CRP) levels above 5 mg/L and is nearly three times as high in patients 65 years and older.

For the study, Dr. Strangfeld and her colleagues followed about 11,000 patients for more than 10 years. The findings were presented at the European League Against Rheumatism (EULAR) 2020 Congress.

“Patients with RA have a greater risk for venous thromboembolism compared with the general population, but we didn’t know the risk conveyed by different DMARD treatments,” Dr. Strangfeld told Medscape Medical News. “It is also evident that higher age and lower capacity for physical function increase the risk, which was not so surprising.”

Chronic inflammation in RA patients elevates the risk for deep vein and pulmonary thrombosis by two to three times, said John Isaacs, MBBS, PhD, from Newcastle University in Newcastle Upon Tyne, United Kingdom, who is chair of the EULAR scientific program committee.

Among the supporting studies Dr. Isaacs discussed during an online press conference was a Swedish trial of more than 46,000 RA patients, which had been presented earlier by Viktor Molander, a PhD candidate from the Karolinska Institute in Stockholm (abstract OP0034).

Mr. Molander’s team showed that one in 100 patients with high disease activity will develop venous thromboembolism within a year, which is twice the number of events seen among patients in remission.

Combined with the RABBIT data, both studies “show if you can control their disease in the right way, you’re not only helping rheumatoid arthritis patients feel better, but you could be prolonging their lives,” Dr. Isaacs said.

The prospective RABBIT study followed RA patients who began receiving a new DMARD after treatment failed with at least one conventional synthetic DMARD, such as methotrexate or leflunomide. At baseline, those taking TNF inhibitors or other biologics had higher CRP levels on average, as well as a higher rate of existing cardiovascular disease. They also received glucocorticoids, such as prednisone, more often.

The observational nature of the RABBIT study is a weakness, Dr. Strangfeld said, and it could not prove cause and effect. But the methodology had several strengths, including input on patient factors from participating rheumatologists at least every 6 months.

“We enrolled patients at the start of treatment and observed them, regardless of any treatment changes, for up to 10 years,” she added. “That’s a really long observation period.”

The RABBIT data can help shape treatment decisions, said Loreto Carmona, MD, PhD, from the Musculoskeletal Health Institute in Madrid, who is chair of the EULAR abstract selection committee.

For a woman with RA who smokes and takes oral contraceptives, for example, “if she has high levels of inflammation, I think it’s okay to use TNF inhibitors, where maybe in the past we wouldn’t have thought that,” she said.

“The TNF inhibitors are actually reducing the inflammation and, therefore, reducing the risk,” Dr. Carmona told Medscape Medical News. “It could be an effect of using the drugs on people with higher levels of inflammation. It’s an indirect protective effect.”

The study was funded by a joint unconditional grant from AbbVie, Amgen, BMS, Fresenius-Kabi, Hexal, Lilly, MSD, Mylan, Pfizer, Roche, Samsung Bioepis, Sanofi-Aventis, and UCB. Dr. Strangfeld is on the speakers bureau of AbbVie, BMS, Pfizer, Roche and Sanofi-Aventis. Dr. Isaacs is a consultant or has received honoraria or grants from Pfizer, AbbVie, Amgen, Merck, Roche, and UCB. Dr. Carmona has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.




 

The American College of Rheumatology will hold its annual meeting as a completely online event during Nov. 5-9, 2020, rather than in Washington, Nov. 6-11, as originally planned “due to public health/safety concerns related to the COVID-19 pandemic,” according to an announcement from the organization.

“We’ve given our annual meeting a new name, ACR Convergence 2020, and a fresh look, and we have reimagined #ACR20 without losing the elements you care about most: stellar rheumatology education, cutting-edge advances in science, and outstanding networking opportunities,” according to the announcement.

A frequently asked questions page for the meeting says that “ACR Convergence will include oral and poster discussion presentations, track-based clinical and basic science symposia, opportunities to engage with speakers and participants, as well as an exhibition and several special events.”

The ACR said that the meeting will be held on a new online platform, with more details to come in August, when registration will open. The final program for the virtual meeting will be available on the ACR website in July.

[email protected]

The American College of Rheumatology will hold its annual meeting as a completely online event during Nov. 5-9, 2020, rather than in Washington, Nov. 6-11, as originally planned “due to public health/safety concerns related to the COVID-19 pandemic,” according to an announcement from the organization.

“We’ve given our annual meeting a new name, ACR Convergence 2020, and a fresh look, and we have reimagined #ACR20 without losing the elements you care about most: stellar rheumatology education, cutting-edge advances in science, and outstanding networking opportunities,” according to the announcement.

A frequently asked questions page for the meeting says that “ACR Convergence will include oral and poster discussion presentations, track-based clinical and basic science symposia, opportunities to engage with speakers and participants, as well as an exhibition and several special events.”

The ACR said that the meeting will be held on a new online platform, with more details to come in August, when registration will open. The final program for the virtual meeting will be available on the ACR website in July.

[email protected]

The American College of Rheumatology will hold its annual meeting as a completely online event during Nov. 5-9, 2020, rather than in Washington, Nov. 6-11, as originally planned “due to public health/safety concerns related to the COVID-19 pandemic,” according to an announcement from the organization.

“We’ve given our annual meeting a new name, ACR Convergence 2020, and a fresh look, and we have reimagined #ACR20 without losing the elements you care about most: stellar rheumatology education, cutting-edge advances in science, and outstanding networking opportunities,” according to the announcement.

A frequently asked questions page for the meeting says that “ACR Convergence will include oral and poster discussion presentations, track-based clinical and basic science symposia, opportunities to engage with speakers and participants, as well as an exhibition and several special events.”

The ACR said that the meeting will be held on a new online platform, with more details to come in August, when registration will open. The final program for the virtual meeting will be available on the ACR website in July.

[email protected]

Nisha Mehta, MD, said her phone has been ringing with calls from tearful and shaken physicians who are distressed and unsettled about their work and home situation and don’t know what to do.

What’s more, many frontline physicians are living apart from family to protect them from infection. “So many physicians have called me crying. ... They can’t even come home and get a hug,” Dr. Mehta said. “What I’m hearing from a lot of people who are in New York and New Jersey is not just that they go to work all day and it’s this exhausting process throughout the entire day, not only physically but also emotionally.”

Physician burnout has held a steady spotlight since long before the COVID-19 crisis began, Dr. Mehta said. “The reason for that is multifold, but in part, it’s hard for physicians to find an appropriate way to be able to process a lot of the emotions related to their work,” she said. “A lot of that brews below the surface, but COVID-19 has really brought many of these issues above that surface.”

Frustrated that governments weren’t doing enough to support health care workers during the pandemic, Dr. Mehta, a radiologist in Charlotte, N.C., decided there needed to be change. On April 4, Dr. Mehta and two physician colleagues submitted to Congress the COVID-19 Pandemic Physician Protection Act, which ensures, among other provisions, mental health coverage for health care workers. An accompanying petition on change.org had received nearly 300,000 signatures as of May 29.
 

Don’t suffer in silence

A career in medicine comes with immense stress in the best of times, she notes, and managing a pandemic in an already strained system has taken those challenges to newer heights. “We need better support structures at baseline for physician mental health,” said Dr. Mehta.

“That’s something we’ve always been lacking because it’s been against the culture of medicine for so long to say, ‘I’m having a hard time.’ ”

If you’re hurting, the first thing to recognize is that you are not alone in facing these challenges. This is true with respect not only to medical care but also to all of the family, financial, and business concerns physicians are currently facing. “Having all of those things hanging over your head is a lot. We’ve got to find ways to help each other out,” Dr. Mehta said.
 

Where to find support

Fortunately, the medical community has created several pathways to help its own. Types of resources for health care workers on the COVID-19 frontlines run the gamut from crisis hotlines to smartphone apps to virtual counseling, often for free or at discounted rates.

The following list represents a cross-section of opportunities for caregivers to receive care for themselves.

Crisis hotlines

• Physician Support Line. This free and confidential hotline was launched on March 30 by Mona Masood, DO, a Philadelphia-area psychiatrist and moderator of a Facebook forum called the COVID-19 Physicians Group. The PSL is run by more than 600 volunteer psychiatrists who take calls from U.S. physicians 7 days a week from 8:00 a.m. to 1:00 a.m., with no appointment necessary. The toll-free number is 888-409-0141.
• For the Frontlines. This 24/7 help line provides free crisis counseling for frontline workers. They can text FRONTLINE to 741741 in the United States (support is also available for residents of Canada, Ireland, and the United Kingdom).

Resources from professional groups

• Action Collaborative on Clinician Well-Being and Resilience. Created by the National Academy of Medicine in 2017, the Action Collaborative comprises more than 60 organizations committed to reversing trends in clinician burnout. In response to the pandemic, the group has compiled a list of strategies and resources to support the health and well-being of clinicians who are providing healthcare during the COVID-19 outbreak.
• American Medical Association. The AMA has created a resource center dedicated to providing care for caregivers during the COVID-19 pandemic. The website includes specific guidance for managing mental health during the pandemic.
• American College of Physicians. The professional society of internal medicine physicians has created a comprehensive guide for physicians specific to COVID-19, with a section dedicated to clinician well-being that includes information about hotlines, counseling services, grief support, and more.
• American Hospital Association. The AHA’s website now includes regularly updated resources for healthcare clinicians and staff, as well as a special section dedicated to protecting and enabling healthcare workers in the midst of the pandemic.

Virtual psychological counseling

Not unlike the way telemedicine has allowed some physicians to keep seeing their patients, many modalities enable participation in therapy through video, chat, phone call, or any combination thereof. Look for a service that is convenient, flexible, and HIPAA compliant.

Traditional in-office mental health therapy has quickly moved to telemedicine. Many if not most insurers that cover counseling visits are paying for telepsychiatry or telecounseling. If you don’t know of an appropriate therapist, check the American Psychiatric Association or its state chapters; the American Psychological Association; or look for a licensed mental health counselor.

Because financial constraints are a potential barrier to therapy, Project Parachute, in cooperation with Eleos Health, has organized a cadre of therapists willing to provide pro bono online therapy for health care workers. The amount of free therapy provided to qualified frontline workers is up to the individual therapists. Discuss these parameters with your therapists up front.

Similar services are offered from companies such as Talkspace and BetterHelp on a subscription basis. These services are typically less expensive than in-person sessions. Ask about discounts for healthcare workers. Talkspace, for example, announced in March, “Effective immediately, healthcare workers across the country can get access to a free month of our...online therapy that includes unlimited text, video, and audio messaging with a licensed therapist.”
 

Online support groups and social media

For more on-demand peer support, look for groups such as the COR Sharing Circle for Healthcare Workers on Facebook. The site’s search engine can point users to plenty of other groups, many of which are closed (meaning posts are visible to members only).

Dr. Mehta hosts her own Facebook group called Physician Community. “I would like to think (and genuinely feel) that we’ve been doing a great job of supporting each other there with daily threads on challenges, treatments, pick-me-ups, vent posts, advocacy, and more,” she said.

For anyone in need, PeerRxMed is a free, peer-to-peer program for physicians and other health care workers that is designed to provide support, connection, encouragement, resources, and skill-building to optimize well-being.

For those craving spiritual comfort during this crisis, a number of churches have begun offering that experience virtually, too. First Unitarian Church of Worcester, Massachusetts, for example, offers weekly services via YouTube. Similar online programming is being offered from all sorts of organizations across denominations.
 

Apps

For DIY or on-the-spot coping support, apps can help physicians get through the day. Apps and websites that offer guided meditations and other relaxation tools include Headspace, Calm, and Insight Timer. Before downloading, look for special discounts and promotions for healthcare workers.

Additionally, COVID Coach is a free, secure app designed by the U.S. Department of Veterans Affairs that includes tools to help you cope with stress and stay well, safe, healthy, and connected. It also offers advice on navigating parenting, care giving, and working from home while social distancing, quarantined, or sheltering in place.

For practicing daily gratitude, Delightful Journal is a free app that offers journaling prompts, themes, reminders, and unlimited private space to record one’s thoughts.
 

Adopt a ritual

Although self-care for physicians is more crucial now than ever, it can look different for every individual. Along the same lines as keeping a journal, wellness experts often recommend beginning a “gratitude practice” to help provide solace and perspective.

Tweak and personalize these activities to suit your own needs, but be sure to use them even when you’re feeling well, said Mohana Karlekar, MD, medical director of palliative care and assistant professor at Vanderbilt University Medical Center, Nashville, Tenn.

One exercise she recommends is known as Three Good Things. “Every day, at the end of the day, think about three good things that have happened,” she explained. “You can always find the joys. And the joys don’t have to be enormous. There is joy – there is hope – in everything,” Dr. Karlekar said.

A version of this article originally appeared on Medscape.com.

Nisha Mehta, MD, said her phone has been ringing with calls from tearful and shaken physicians who are distressed and unsettled about their work and home situation and don’t know what to do.

What’s more, many frontline physicians are living apart from family to protect them from infection. “So many physicians have called me crying. ... They can’t even come home and get a hug,” Dr. Mehta said. “What I’m hearing from a lot of people who are in New York and New Jersey is not just that they go to work all day and it’s this exhausting process throughout the entire day, not only physically but also emotionally.”

Physician burnout has held a steady spotlight since long before the COVID-19 crisis began, Dr. Mehta said. “The reason for that is multifold, but in part, it’s hard for physicians to find an appropriate way to be able to process a lot of the emotions related to their work,” she said. “A lot of that brews below the surface, but COVID-19 has really brought many of these issues above that surface.”

Frustrated that governments weren’t doing enough to support health care workers during the pandemic, Dr. Mehta, a radiologist in Charlotte, N.C., decided there needed to be change. On April 4, Dr. Mehta and two physician colleagues submitted to Congress the COVID-19 Pandemic Physician Protection Act, which ensures, among other provisions, mental health coverage for health care workers. An accompanying petition on change.org had received nearly 300,000 signatures as of May 29.
 

Don’t suffer in silence

A career in medicine comes with immense stress in the best of times, she notes, and managing a pandemic in an already strained system has taken those challenges to newer heights. “We need better support structures at baseline for physician mental health,” said Dr. Mehta.

“That’s something we’ve always been lacking because it’s been against the culture of medicine for so long to say, ‘I’m having a hard time.’ ”

If you’re hurting, the first thing to recognize is that you are not alone in facing these challenges. This is true with respect not only to medical care but also to all of the family, financial, and business concerns physicians are currently facing. “Having all of those things hanging over your head is a lot. We’ve got to find ways to help each other out,” Dr. Mehta said.
 

Where to find support

Fortunately, the medical community has created several pathways to help its own. Types of resources for health care workers on the COVID-19 frontlines run the gamut from crisis hotlines to smartphone apps to virtual counseling, often for free or at discounted rates.

The following list represents a cross-section of opportunities for caregivers to receive care for themselves.

Crisis hotlines

• Physician Support Line. This free and confidential hotline was launched on March 30 by Mona Masood, DO, a Philadelphia-area psychiatrist and moderator of a Facebook forum called the COVID-19 Physicians Group. The PSL is run by more than 600 volunteer psychiatrists who take calls from U.S. physicians 7 days a week from 8:00 a.m. to 1:00 a.m., with no appointment necessary. The toll-free number is 888-409-0141.
• For the Frontlines. This 24/7 help line provides free crisis counseling for frontline workers. They can text FRONTLINE to 741741 in the United States (support is also available for residents of Canada, Ireland, and the United Kingdom).

Resources from professional groups

• Action Collaborative on Clinician Well-Being and Resilience. Created by the National Academy of Medicine in 2017, the Action Collaborative comprises more than 60 organizations committed to reversing trends in clinician burnout. In response to the pandemic, the group has compiled a list of strategies and resources to support the health and well-being of clinicians who are providing healthcare during the COVID-19 outbreak.
• American Medical Association. The AMA has created a resource center dedicated to providing care for caregivers during the COVID-19 pandemic. The website includes specific guidance for managing mental health during the pandemic.
• American College of Physicians. The professional society of internal medicine physicians has created a comprehensive guide for physicians specific to COVID-19, with a section dedicated to clinician well-being that includes information about hotlines, counseling services, grief support, and more.
• American Hospital Association. The AHA’s website now includes regularly updated resources for healthcare clinicians and staff, as well as a special section dedicated to protecting and enabling healthcare workers in the midst of the pandemic.

Virtual psychological counseling

Not unlike the way telemedicine has allowed some physicians to keep seeing their patients, many modalities enable participation in therapy through video, chat, phone call, or any combination thereof. Look for a service that is convenient, flexible, and HIPAA compliant.

Traditional in-office mental health therapy has quickly moved to telemedicine. Many if not most insurers that cover counseling visits are paying for telepsychiatry or telecounseling. If you don’t know of an appropriate therapist, check the American Psychiatric Association or its state chapters; the American Psychological Association; or look for a licensed mental health counselor.

Because financial constraints are a potential barrier to therapy, Project Parachute, in cooperation with Eleos Health, has organized a cadre of therapists willing to provide pro bono online therapy for health care workers. The amount of free therapy provided to qualified frontline workers is up to the individual therapists. Discuss these parameters with your therapists up front.

Similar services are offered from companies such as Talkspace and BetterHelp on a subscription basis. These services are typically less expensive than in-person sessions. Ask about discounts for healthcare workers. Talkspace, for example, announced in March, “Effective immediately, healthcare workers across the country can get access to a free month of our...online therapy that includes unlimited text, video, and audio messaging with a licensed therapist.”
 

Online support groups and social media

For more on-demand peer support, look for groups such as the COR Sharing Circle for Healthcare Workers on Facebook. The site’s search engine can point users to plenty of other groups, many of which are closed (meaning posts are visible to members only).

Dr. Mehta hosts her own Facebook group called Physician Community. “I would like to think (and genuinely feel) that we’ve been doing a great job of supporting each other there with daily threads on challenges, treatments, pick-me-ups, vent posts, advocacy, and more,” she said.

For anyone in need, PeerRxMed is a free, peer-to-peer program for physicians and other health care workers that is designed to provide support, connection, encouragement, resources, and skill-building to optimize well-being.

For those craving spiritual comfort during this crisis, a number of churches have begun offering that experience virtually, too. First Unitarian Church of Worcester, Massachusetts, for example, offers weekly services via YouTube. Similar online programming is being offered from all sorts of organizations across denominations.
 

Apps

For DIY or on-the-spot coping support, apps can help physicians get through the day. Apps and websites that offer guided meditations and other relaxation tools include Headspace, Calm, and Insight Timer. Before downloading, look for special discounts and promotions for healthcare workers.

Additionally, COVID Coach is a free, secure app designed by the U.S. Department of Veterans Affairs that includes tools to help you cope with stress and stay well, safe, healthy, and connected. It also offers advice on navigating parenting, care giving, and working from home while social distancing, quarantined, or sheltering in place.

For practicing daily gratitude, Delightful Journal is a free app that offers journaling prompts, themes, reminders, and unlimited private space to record one’s thoughts.
 

Adopt a ritual

Although self-care for physicians is more crucial now than ever, it can look different for every individual. Along the same lines as keeping a journal, wellness experts often recommend beginning a “gratitude practice” to help provide solace and perspective.

Tweak and personalize these activities to suit your own needs, but be sure to use them even when you’re feeling well, said Mohana Karlekar, MD, medical director of palliative care and assistant professor at Vanderbilt University Medical Center, Nashville, Tenn.

One exercise she recommends is known as Three Good Things. “Every day, at the end of the day, think about three good things that have happened,” she explained. “You can always find the joys. And the joys don’t have to be enormous. There is joy – there is hope – in everything,” Dr. Karlekar said.

A version of this article originally appeared on Medscape.com.

Nisha Mehta, MD, said her phone has been ringing with calls from tearful and shaken physicians who are distressed and unsettled about their work and home situation and don’t know what to do.

What’s more, many frontline physicians are living apart from family to protect them from infection. “So many physicians have called me crying. ... They can’t even come home and get a hug,” Dr. Mehta said. “What I’m hearing from a lot of people who are in New York and New Jersey is not just that they go to work all day and it’s this exhausting process throughout the entire day, not only physically but also emotionally.”

Physician burnout has held a steady spotlight since long before the COVID-19 crisis began, Dr. Mehta said. “The reason for that is multifold, but in part, it’s hard for physicians to find an appropriate way to be able to process a lot of the emotions related to their work,” she said. “A lot of that brews below the surface, but COVID-19 has really brought many of these issues above that surface.”

Frustrated that governments weren’t doing enough to support health care workers during the pandemic, Dr. Mehta, a radiologist in Charlotte, N.C., decided there needed to be change. On April 4, Dr. Mehta and two physician colleagues submitted to Congress the COVID-19 Pandemic Physician Protection Act, which ensures, among other provisions, mental health coverage for health care workers. An accompanying petition on change.org had received nearly 300,000 signatures as of May 29.
 

Don’t suffer in silence

A career in medicine comes with immense stress in the best of times, she notes, and managing a pandemic in an already strained system has taken those challenges to newer heights. “We need better support structures at baseline for physician mental health,” said Dr. Mehta.

“That’s something we’ve always been lacking because it’s been against the culture of medicine for so long to say, ‘I’m having a hard time.’ ”

If you’re hurting, the first thing to recognize is that you are not alone in facing these challenges. This is true with respect not only to medical care but also to all of the family, financial, and business concerns physicians are currently facing. “Having all of those things hanging over your head is a lot. We’ve got to find ways to help each other out,” Dr. Mehta said.
 

Where to find support

Fortunately, the medical community has created several pathways to help its own. Types of resources for health care workers on the COVID-19 frontlines run the gamut from crisis hotlines to smartphone apps to virtual counseling, often for free or at discounted rates.

The following list represents a cross-section of opportunities for caregivers to receive care for themselves.

Crisis hotlines

• Physician Support Line. This free and confidential hotline was launched on March 30 by Mona Masood, DO, a Philadelphia-area psychiatrist and moderator of a Facebook forum called the COVID-19 Physicians Group. The PSL is run by more than 600 volunteer psychiatrists who take calls from U.S. physicians 7 days a week from 8:00 a.m. to 1:00 a.m., with no appointment necessary. The toll-free number is 888-409-0141.
• For the Frontlines. This 24/7 help line provides free crisis counseling for frontline workers. They can text FRONTLINE to 741741 in the United States (support is also available for residents of Canada, Ireland, and the United Kingdom).

Resources from professional groups

• Action Collaborative on Clinician Well-Being and Resilience. Created by the National Academy of Medicine in 2017, the Action Collaborative comprises more than 60 organizations committed to reversing trends in clinician burnout. In response to the pandemic, the group has compiled a list of strategies and resources to support the health and well-being of clinicians who are providing healthcare during the COVID-19 outbreak.
• American Medical Association. The AMA has created a resource center dedicated to providing care for caregivers during the COVID-19 pandemic. The website includes specific guidance for managing mental health during the pandemic.
• American College of Physicians. The professional society of internal medicine physicians has created a comprehensive guide for physicians specific to COVID-19, with a section dedicated to clinician well-being that includes information about hotlines, counseling services, grief support, and more.
• American Hospital Association. The AHA’s website now includes regularly updated resources for healthcare clinicians and staff, as well as a special section dedicated to protecting and enabling healthcare workers in the midst of the pandemic.

Virtual psychological counseling

Not unlike the way telemedicine has allowed some physicians to keep seeing their patients, many modalities enable participation in therapy through video, chat, phone call, or any combination thereof. Look for a service that is convenient, flexible, and HIPAA compliant.

Traditional in-office mental health therapy has quickly moved to telemedicine. Many if not most insurers that cover counseling visits are paying for telepsychiatry or telecounseling. If you don’t know of an appropriate therapist, check the American Psychiatric Association or its state chapters; the American Psychological Association; or look for a licensed mental health counselor.

Because financial constraints are a potential barrier to therapy, Project Parachute, in cooperation with Eleos Health, has organized a cadre of therapists willing to provide pro bono online therapy for health care workers. The amount of free therapy provided to qualified frontline workers is up to the individual therapists. Discuss these parameters with your therapists up front.

Similar services are offered from companies such as Talkspace and BetterHelp on a subscription basis. These services are typically less expensive than in-person sessions. Ask about discounts for healthcare workers. Talkspace, for example, announced in March, “Effective immediately, healthcare workers across the country can get access to a free month of our...online therapy that includes unlimited text, video, and audio messaging with a licensed therapist.”
 

Online support groups and social media

For more on-demand peer support, look for groups such as the COR Sharing Circle for Healthcare Workers on Facebook. The site’s search engine can point users to plenty of other groups, many of which are closed (meaning posts are visible to members only).

Dr. Mehta hosts her own Facebook group called Physician Community. “I would like to think (and genuinely feel) that we’ve been doing a great job of supporting each other there with daily threads on challenges, treatments, pick-me-ups, vent posts, advocacy, and more,” she said.

For anyone in need, PeerRxMed is a free, peer-to-peer program for physicians and other health care workers that is designed to provide support, connection, encouragement, resources, and skill-building to optimize well-being.

For those craving spiritual comfort during this crisis, a number of churches have begun offering that experience virtually, too. First Unitarian Church of Worcester, Massachusetts, for example, offers weekly services via YouTube. Similar online programming is being offered from all sorts of organizations across denominations.
 

Apps

For DIY or on-the-spot coping support, apps can help physicians get through the day. Apps and websites that offer guided meditations and other relaxation tools include Headspace, Calm, and Insight Timer. Before downloading, look for special discounts and promotions for healthcare workers.

Additionally, COVID Coach is a free, secure app designed by the U.S. Department of Veterans Affairs that includes tools to help you cope with stress and stay well, safe, healthy, and connected. It also offers advice on navigating parenting, care giving, and working from home while social distancing, quarantined, or sheltering in place.

For practicing daily gratitude, Delightful Journal is a free app that offers journaling prompts, themes, reminders, and unlimited private space to record one’s thoughts.
 

Adopt a ritual

Although self-care for physicians is more crucial now than ever, it can look different for every individual. Along the same lines as keeping a journal, wellness experts often recommend beginning a “gratitude practice” to help provide solace and perspective.

Tweak and personalize these activities to suit your own needs, but be sure to use them even when you’re feeling well, said Mohana Karlekar, MD, medical director of palliative care and assistant professor at Vanderbilt University Medical Center, Nashville, Tenn.

One exercise she recommends is known as Three Good Things. “Every day, at the end of the day, think about three good things that have happened,” she explained. “You can always find the joys. And the joys don’t have to be enormous. There is joy – there is hope – in everything,” Dr. Karlekar said.

A version of this article originally appeared on Medscape.com.

Even before Atlanta had an official shelter-in-place order, patients at the private plastic surgery practice of Nicholas Jones, MD, began canceling and rescheduled planned procedures.

After a few weeks, Dr. Jones, aged 40 years, stopped seeing patients entirely, but as a self-employed independent contractor, that means he’d lost most of his income. Dr. Jones still makes some money via a wound care job at a local nursing home, but he’s concerned that job may also be eliminated.

“I’m not hurting yet,” he said. “But I’m preparing for the worst possible scenario.”

In preparation, he and his fiancé have cut back on extraneous expenses like Uber Eats, magazine subscriptions, and streaming music services. Even though he has a 6-month emergency fund, Jones has reached out to utility companies, mortgage lenders, and student loan servicers to find out about any programs they offer to people who’ve suffered financially from the coronavirus crisis.

He’s also considered traveling to one of the COVID-19 epicenters – he has family in New Orleans and Chicago – to work in a hospital there. Jones has trauma experience and is double-boarded in general and plastic surgery.

“I could provide relief to those in need and also float through this troubled time with some financial relief,” he said.

Whereas much of the world’s attention has been on physicians who are on the front line and working around the clock in hospitals to help COVID-19 patients, thousands of other physicians are experiencing the opposite phenomenon – a slowdown or even stoppage of work (and income) altogether.

Many practices are temporarily closing to meet social distancing requirements, and some may end up closed for months, leaving doctors without a source of income. Even among those practices that remain open, the number of patients has declined as people avoid going to the office unless they absolutely have to.

At the same time, doctors in two-income households may have a spouse experiencing a job loss or income decline. Nearly 10 million Americans applied for unemployment benefits in the last 2 weeks of March, the largest number on record.

Still, while there’s uncertainty around how long the coronavirus crisis will last, experts agree that at some point America will return to a “new normal” and business operations will begin to reopen. For physicians experiencing a reduction in income who, like Jones, have an emergency fund with a few months’ worth of expenses, now’s the time to tap into it. (Or if you still have income, now’s the time to focus on growing that emergency fund to give yourself an even bigger safety net.)

If you’re among the more than half of Americans with less than 6 months of expenses saved for a rainy day, here’s how to stay afloat in the near term:
 

Cut back on expenses

Some household spending has naturally tapered off for many families because social distancing restrictions reduce spending on eating out, travel, and other leisure activities. But this is also an opportunity to look for other ways to reduce spending. Look through your credit card bills to see whether there are recurring payments you can cut, such as a payment to a gym that’s temporarily closed or a monthly subscription box that you don’t need.

Some gyms are not allowing membership termination right now, but it pays to ask. If a service you’re not using won’t facilitate the cancellation, call your credit card company to dispute and stop the charges, and report them to the Better Business Bureau.

You should also stop contributing to nonemergency savings accounts such as your retirement fund or your children’s college funds.

“A lot of people are hesitant to stop their automatic savings if they’ve been maxing out their 401(k) contribution or 529 accounts,” says Andrew Musbach, a certified financial planner and cofounder of MD Wealth Management in Chelsea, Mich. “But if you’re thinking long term, the reality is that missing a couple of months won’t make or break a plan. Cutting back on the amount you’re saving in the short term will increase your cash flow and is a good way to make ends meet.”
 

Take advantage of regulatory changes

Although many physicians won’t qualify for direct payments via the Coronavirus Aid Relief and Economic Security (CARES) Act (the $1,200 payments to individuals start phasing out once income hits $75,000 and disappear entirely for those making more than $99,000), there are other provisions in the stimulus bill that may help physicians. The bill, for example, boosts state unemployment payments by $600 per week for the next 4 months, meaning qualified workers could receive an average of nearly $1,000 per week, depending on their state, and there are new provisions providing unemployment payments to self-employed and contract workers.

The CARES Act also includes a break for federal student loan holders. Under that rule, you can skip your payments through September without incurring additional interest. Physicians in the loan forgiveness program will still get credit for payments skipped during this program.

Separately, the IRS has extended the tax deadline from April 15 to July 15, which means not only do you not have to file your taxes until then, you also don’t have to pay any taxes you owe until mid-July. The deadline for first quarter estimated tax payments has also moved to July 15. (If you’re expecting a refund, however, you should file ASAP, since the IRS will typically issue those within a few weeks of receiving your returns.)
 

Tap your home equity – if you’re planning to stay put

If you have good credit and still have some income, you might consider refinancing your home mortgage or opening a home equity line of credit. Interest rates have fallen recently amid economic turbulence, so if you haven’t refinanced recently you may be able to shave your monthly payment. If you need cash, a cash-out refinance, home equity line of credit, or a reverse mortgage (available if you’re over age 62) are among the lowest-cost ways to borrow.

“With interest rates so low, there can be a lot of benefit to refinancing and leveraging your house, especially if you’re planning to stay there,” says Jamie Hopkins, a director at the Carson Group. “The challenge is if you’re planning to move in the next few years. There’s a real risk that the housing market could go down in the next couple of years, and if you’re planning to sell, there’s a risk that you might not get back what you borrowed.”
 

Communicate early with your bank or landlord

If you don’t have the income to refinance, and you think you’re going to run into trouble making your housing payment, you should let your bank or landlord know as soon as possible. The CARES Act allows homeowners with federally backed mortgages to obtain a 180-day postponement of mortgage payments because of COVID-19 financial hardship, with the potential to extend for another 180 days. It also bans eviction by landlords with federal mortgages for 120 days.

Even if you don’t have a federally backed mortgage, you should still get in touch with your lender. Many mortgage servicers have their own forbearance programs for borrowers who can prove a temporary financial hardship. (Some banks are also waiving fees on early withdrawals on CDs and giving cardholders a reprieve on credit card payments.) Commercial landlords are also working with struggling tenants, so you may also be able to get some relief on your office lease as well.

“All of the lenders are setting up helplines for people affected,” says Amy Guerich, a partner with Stepp & Rothwell, a Kansas City–based financial planning firm. “The best thing you can do is contact them right away if you think that you’re going to have a problem vs. just letting the bills go.”
 

Consider retirement account withdrawals

Standard personal finance advice holds that you should exhaust all other options before pulling money out of your retirement account because of the high penalties for early withdrawals and because money removed from retirement accounts is no longer compounding over time.

Still, the CARES act has provisions making it less financially onerous to pull money from your retirement accounts. Under the new law, you can take a distribution of up to $100,000 from your IRA or 401(k) without having to pay the 10% early withdrawal penalty. You’ll owe ordinary income taxes on the withdrawal, but you have 3 years to pay them or to return the money to your retirement account.

“That’s a great relief provision, especially for higher-income physicians who might have a higher 401(k) balance,” said Jamie Hopkins.
 

Be smart about credit cards

Although using credit cards that you can’t pay off every month is typically an expensive way to access money, getting a new card with a low or zero percent introductory rate is a short-term strategy to consider when you’ve exhausted other options. If you have good credit, you may be able to qualify for a credit card with a 0% introductory interest rate on new transactions. Pay close attention to the fine print, including the cap on the balance you can carry without interest and whether you’ll be required to make minimum payments.

The average 0% credit card offer is for 11 months, but there are some cards that can extend the offer for up to a year-and-a-half. If you choose to use this strategy, you’ll need a plan to pay off the entire balance before the introductory period ends. If there’s a balance remaining once the rate resets, you may end up owing deferred interest on it.

The financial ramifications of the coronavirus can feel overwhelming, but it’s important not to panic. While it remains unclear how long the current crisis will last, making some smart money moves to preserve your cash in the meantime can help you stay afloat.

A version of this article originally appeared on Medscape.com.

Even before Atlanta had an official shelter-in-place order, patients at the private plastic surgery practice of Nicholas Jones, MD, began canceling and rescheduled planned procedures.

After a few weeks, Dr. Jones, aged 40 years, stopped seeing patients entirely, but as a self-employed independent contractor, that means he’d lost most of his income. Dr. Jones still makes some money via a wound care job at a local nursing home, but he’s concerned that job may also be eliminated.

“I’m not hurting yet,” he said. “But I’m preparing for the worst possible scenario.”

In preparation, he and his fiancé have cut back on extraneous expenses like Uber Eats, magazine subscriptions, and streaming music services. Even though he has a 6-month emergency fund, Jones has reached out to utility companies, mortgage lenders, and student loan servicers to find out about any programs they offer to people who’ve suffered financially from the coronavirus crisis.

He’s also considered traveling to one of the COVID-19 epicenters – he has family in New Orleans and Chicago – to work in a hospital there. Jones has trauma experience and is double-boarded in general and plastic surgery.

“I could provide relief to those in need and also float through this troubled time with some financial relief,” he said.

Whereas much of the world’s attention has been on physicians who are on the front line and working around the clock in hospitals to help COVID-19 patients, thousands of other physicians are experiencing the opposite phenomenon – a slowdown or even stoppage of work (and income) altogether.

Many practices are temporarily closing to meet social distancing requirements, and some may end up closed for months, leaving doctors without a source of income. Even among those practices that remain open, the number of patients has declined as people avoid going to the office unless they absolutely have to.

At the same time, doctors in two-income households may have a spouse experiencing a job loss or income decline. Nearly 10 million Americans applied for unemployment benefits in the last 2 weeks of March, the largest number on record.

Still, while there’s uncertainty around how long the coronavirus crisis will last, experts agree that at some point America will return to a “new normal” and business operations will begin to reopen. For physicians experiencing a reduction in income who, like Jones, have an emergency fund with a few months’ worth of expenses, now’s the time to tap into it. (Or if you still have income, now’s the time to focus on growing that emergency fund to give yourself an even bigger safety net.)

If you’re among the more than half of Americans with less than 6 months of expenses saved for a rainy day, here’s how to stay afloat in the near term:
 

Cut back on expenses

Some household spending has naturally tapered off for many families because social distancing restrictions reduce spending on eating out, travel, and other leisure activities. But this is also an opportunity to look for other ways to reduce spending. Look through your credit card bills to see whether there are recurring payments you can cut, such as a payment to a gym that’s temporarily closed or a monthly subscription box that you don’t need.

Some gyms are not allowing membership termination right now, but it pays to ask. If a service you’re not using won’t facilitate the cancellation, call your credit card company to dispute and stop the charges, and report them to the Better Business Bureau.

You should also stop contributing to nonemergency savings accounts such as your retirement fund or your children’s college funds.

“A lot of people are hesitant to stop their automatic savings if they’ve been maxing out their 401(k) contribution or 529 accounts,” says Andrew Musbach, a certified financial planner and cofounder of MD Wealth Management in Chelsea, Mich. “But if you’re thinking long term, the reality is that missing a couple of months won’t make or break a plan. Cutting back on the amount you’re saving in the short term will increase your cash flow and is a good way to make ends meet.”
 

Take advantage of regulatory changes

Although many physicians won’t qualify for direct payments via the Coronavirus Aid Relief and Economic Security (CARES) Act (the $1,200 payments to individuals start phasing out once income hits $75,000 and disappear entirely for those making more than $99,000), there are other provisions in the stimulus bill that may help physicians. The bill, for example, boosts state unemployment payments by $600 per week for the next 4 months, meaning qualified workers could receive an average of nearly $1,000 per week, depending on their state, and there are new provisions providing unemployment payments to self-employed and contract workers.

The CARES Act also includes a break for federal student loan holders. Under that rule, you can skip your payments through September without incurring additional interest. Physicians in the loan forgiveness program will still get credit for payments skipped during this program.

Separately, the IRS has extended the tax deadline from April 15 to July 15, which means not only do you not have to file your taxes until then, you also don’t have to pay any taxes you owe until mid-July. The deadline for first quarter estimated tax payments has also moved to July 15. (If you’re expecting a refund, however, you should file ASAP, since the IRS will typically issue those within a few weeks of receiving your returns.)
 

Tap your home equity – if you’re planning to stay put

If you have good credit and still have some income, you might consider refinancing your home mortgage or opening a home equity line of credit. Interest rates have fallen recently amid economic turbulence, so if you haven’t refinanced recently you may be able to shave your monthly payment. If you need cash, a cash-out refinance, home equity line of credit, or a reverse mortgage (available if you’re over age 62) are among the lowest-cost ways to borrow.

“With interest rates so low, there can be a lot of benefit to refinancing and leveraging your house, especially if you’re planning to stay there,” says Jamie Hopkins, a director at the Carson Group. “The challenge is if you’re planning to move in the next few years. There’s a real risk that the housing market could go down in the next couple of years, and if you’re planning to sell, there’s a risk that you might not get back what you borrowed.”
 

Communicate early with your bank or landlord

If you don’t have the income to refinance, and you think you’re going to run into trouble making your housing payment, you should let your bank or landlord know as soon as possible. The CARES Act allows homeowners with federally backed mortgages to obtain a 180-day postponement of mortgage payments because of COVID-19 financial hardship, with the potential to extend for another 180 days. It also bans eviction by landlords with federal mortgages for 120 days.

Even if you don’t have a federally backed mortgage, you should still get in touch with your lender. Many mortgage servicers have their own forbearance programs for borrowers who can prove a temporary financial hardship. (Some banks are also waiving fees on early withdrawals on CDs and giving cardholders a reprieve on credit card payments.) Commercial landlords are also working with struggling tenants, so you may also be able to get some relief on your office lease as well.

“All of the lenders are setting up helplines for people affected,” says Amy Guerich, a partner with Stepp & Rothwell, a Kansas City–based financial planning firm. “The best thing you can do is contact them right away if you think that you’re going to have a problem vs. just letting the bills go.”
 

Consider retirement account withdrawals

Standard personal finance advice holds that you should exhaust all other options before pulling money out of your retirement account because of the high penalties for early withdrawals and because money removed from retirement accounts is no longer compounding over time.

Still, the CARES act has provisions making it less financially onerous to pull money from your retirement accounts. Under the new law, you can take a distribution of up to $100,000 from your IRA or 401(k) without having to pay the 10% early withdrawal penalty. You’ll owe ordinary income taxes on the withdrawal, but you have 3 years to pay them or to return the money to your retirement account.

“That’s a great relief provision, especially for higher-income physicians who might have a higher 401(k) balance,” said Jamie Hopkins.
 

Be smart about credit cards

Although using credit cards that you can’t pay off every month is typically an expensive way to access money, getting a new card with a low or zero percent introductory rate is a short-term strategy to consider when you’ve exhausted other options. If you have good credit, you may be able to qualify for a credit card with a 0% introductory interest rate on new transactions. Pay close attention to the fine print, including the cap on the balance you can carry without interest and whether you’ll be required to make minimum payments.

The average 0% credit card offer is for 11 months, but there are some cards that can extend the offer for up to a year-and-a-half. If you choose to use this strategy, you’ll need a plan to pay off the entire balance before the introductory period ends. If there’s a balance remaining once the rate resets, you may end up owing deferred interest on it.

The financial ramifications of the coronavirus can feel overwhelming, but it’s important not to panic. While it remains unclear how long the current crisis will last, making some smart money moves to preserve your cash in the meantime can help you stay afloat.

A version of this article originally appeared on Medscape.com.

Even before Atlanta had an official shelter-in-place order, patients at the private plastic surgery practice of Nicholas Jones, MD, began canceling and rescheduled planned procedures.

After a few weeks, Dr. Jones, aged 40 years, stopped seeing patients entirely, but as a self-employed independent contractor, that means he’d lost most of his income. Dr. Jones still makes some money via a wound care job at a local nursing home, but he’s concerned that job may also be eliminated.

“I’m not hurting yet,” he said. “But I’m preparing for the worst possible scenario.”

In preparation, he and his fiancé have cut back on extraneous expenses like Uber Eats, magazine subscriptions, and streaming music services. Even though he has a 6-month emergency fund, Jones has reached out to utility companies, mortgage lenders, and student loan servicers to find out about any programs they offer to people who’ve suffered financially from the coronavirus crisis.

He’s also considered traveling to one of the COVID-19 epicenters – he has family in New Orleans and Chicago – to work in a hospital there. Jones has trauma experience and is double-boarded in general and plastic surgery.

“I could provide relief to those in need and also float through this troubled time with some financial relief,” he said.

Whereas much of the world’s attention has been on physicians who are on the front line and working around the clock in hospitals to help COVID-19 patients, thousands of other physicians are experiencing the opposite phenomenon – a slowdown or even stoppage of work (and income) altogether.

Many practices are temporarily closing to meet social distancing requirements, and some may end up closed for months, leaving doctors without a source of income. Even among those practices that remain open, the number of patients has declined as people avoid going to the office unless they absolutely have to.

At the same time, doctors in two-income households may have a spouse experiencing a job loss or income decline. Nearly 10 million Americans applied for unemployment benefits in the last 2 weeks of March, the largest number on record.

Still, while there’s uncertainty around how long the coronavirus crisis will last, experts agree that at some point America will return to a “new normal” and business operations will begin to reopen. For physicians experiencing a reduction in income who, like Jones, have an emergency fund with a few months’ worth of expenses, now’s the time to tap into it. (Or if you still have income, now’s the time to focus on growing that emergency fund to give yourself an even bigger safety net.)

If you’re among the more than half of Americans with less than 6 months of expenses saved for a rainy day, here’s how to stay afloat in the near term:
 

Cut back on expenses

Some household spending has naturally tapered off for many families because social distancing restrictions reduce spending on eating out, travel, and other leisure activities. But this is also an opportunity to look for other ways to reduce spending. Look through your credit card bills to see whether there are recurring payments you can cut, such as a payment to a gym that’s temporarily closed or a monthly subscription box that you don’t need.

Some gyms are not allowing membership termination right now, but it pays to ask. If a service you’re not using won’t facilitate the cancellation, call your credit card company to dispute and stop the charges, and report them to the Better Business Bureau.

You should also stop contributing to nonemergency savings accounts such as your retirement fund or your children’s college funds.

“A lot of people are hesitant to stop their automatic savings if they’ve been maxing out their 401(k) contribution or 529 accounts,” says Andrew Musbach, a certified financial planner and cofounder of MD Wealth Management in Chelsea, Mich. “But if you’re thinking long term, the reality is that missing a couple of months won’t make or break a plan. Cutting back on the amount you’re saving in the short term will increase your cash flow and is a good way to make ends meet.”
 

Take advantage of regulatory changes

Although many physicians won’t qualify for direct payments via the Coronavirus Aid Relief and Economic Security (CARES) Act (the $1,200 payments to individuals start phasing out once income hits $75,000 and disappear entirely for those making more than $99,000), there are other provisions in the stimulus bill that may help physicians. The bill, for example, boosts state unemployment payments by $600 per week for the next 4 months, meaning qualified workers could receive an average of nearly $1,000 per week, depending on their state, and there are new provisions providing unemployment payments to self-employed and contract workers.

The CARES Act also includes a break for federal student loan holders. Under that rule, you can skip your payments through September without incurring additional interest. Physicians in the loan forgiveness program will still get credit for payments skipped during this program.

Separately, the IRS has extended the tax deadline from April 15 to July 15, which means not only do you not have to file your taxes until then, you also don’t have to pay any taxes you owe until mid-July. The deadline for first quarter estimated tax payments has also moved to July 15. (If you’re expecting a refund, however, you should file ASAP, since the IRS will typically issue those within a few weeks of receiving your returns.)
 

Tap your home equity – if you’re planning to stay put

If you have good credit and still have some income, you might consider refinancing your home mortgage or opening a home equity line of credit. Interest rates have fallen recently amid economic turbulence, so if you haven’t refinanced recently you may be able to shave your monthly payment. If you need cash, a cash-out refinance, home equity line of credit, or a reverse mortgage (available if you’re over age 62) are among the lowest-cost ways to borrow.

“With interest rates so low, there can be a lot of benefit to refinancing and leveraging your house, especially if you’re planning to stay there,” says Jamie Hopkins, a director at the Carson Group. “The challenge is if you’re planning to move in the next few years. There’s a real risk that the housing market could go down in the next couple of years, and if you’re planning to sell, there’s a risk that you might not get back what you borrowed.”
 

Communicate early with your bank or landlord

If you don’t have the income to refinance, and you think you’re going to run into trouble making your housing payment, you should let your bank or landlord know as soon as possible. The CARES Act allows homeowners with federally backed mortgages to obtain a 180-day postponement of mortgage payments because of COVID-19 financial hardship, with the potential to extend for another 180 days. It also bans eviction by landlords with federal mortgages for 120 days.

Even if you don’t have a federally backed mortgage, you should still get in touch with your lender. Many mortgage servicers have their own forbearance programs for borrowers who can prove a temporary financial hardship. (Some banks are also waiving fees on early withdrawals on CDs and giving cardholders a reprieve on credit card payments.) Commercial landlords are also working with struggling tenants, so you may also be able to get some relief on your office lease as well.

“All of the lenders are setting up helplines for people affected,” says Amy Guerich, a partner with Stepp & Rothwell, a Kansas City–based financial planning firm. “The best thing you can do is contact them right away if you think that you’re going to have a problem vs. just letting the bills go.”
 

Consider retirement account withdrawals

Standard personal finance advice holds that you should exhaust all other options before pulling money out of your retirement account because of the high penalties for early withdrawals and because money removed from retirement accounts is no longer compounding over time.

Still, the CARES act has provisions making it less financially onerous to pull money from your retirement accounts. Under the new law, you can take a distribution of up to $100,000 from your IRA or 401(k) without having to pay the 10% early withdrawal penalty. You’ll owe ordinary income taxes on the withdrawal, but you have 3 years to pay them or to return the money to your retirement account.

“That’s a great relief provision, especially for higher-income physicians who might have a higher 401(k) balance,” said Jamie Hopkins.
 

Be smart about credit cards

Although using credit cards that you can’t pay off every month is typically an expensive way to access money, getting a new card with a low or zero percent introductory rate is a short-term strategy to consider when you’ve exhausted other options. If you have good credit, you may be able to qualify for a credit card with a 0% introductory interest rate on new transactions. Pay close attention to the fine print, including the cap on the balance you can carry without interest and whether you’ll be required to make minimum payments.

The average 0% credit card offer is for 11 months, but there are some cards that can extend the offer for up to a year-and-a-half. If you choose to use this strategy, you’ll need a plan to pay off the entire balance before the introductory period ends. If there’s a balance remaining once the rate resets, you may end up owing deferred interest on it.

The financial ramifications of the coronavirus can feel overwhelming, but it’s important not to panic. While it remains unclear how long the current crisis will last, making some smart money moves to preserve your cash in the meantime can help you stay afloat.

A version of this article originally appeared on Medscape.com.

Here are the stories our MDedge editors across specialties think you need to know about today:

Tips to keep your finances healthy during COVID-19

If you’re among the more than half of Americans with less than 6 months of expenses saved for a rainy day, here are some tips on how to stay afloat in the near term. Cut back on expenses: Look through your credit card bills to see whether there are recurring payments you can cut, such as a payment to a gym that’s temporarily closed or a monthly subscription box that you don’t need. Tap your home equity: If you have good credit and still have some income, you might consider refinancing your home mortgage or opening a home equity line of credit. Consider retirement account withdrawals: the CARES Act has provisions making it less financially onerous to pull money from your retirement accounts. Under the new law, you can take a distribution of up to $100,000 from your IRA or 401(k) without having to pay the 10% early withdrawal penalty. Read more.

Nursing homes overhaul infection control

The toll that COVID-19 has taken on nursing homes and their postacute and long-term care residents has a multilayered backstory involving underresourced organizational structures, inherent susceptibilities, minimally trained infection prevention staff, variable abilities to isolate and quarantine large numbers of patients and residents, and a lack of governmental support. “Nursing homes have been trying their best to combat this pandemic using the best infection control procedures they have, but blindfolded and with their hands tied behind their backs,” said Joseph G. Ouslander, MD, professor of geriatric medicine at Florida Atlantic University, Boca Raton. Experts in both long-term care and infectious disease said in interviews that, through the rest of the pandemic and beyond, nursing homes need the following: “Infection preventionists” to lead improvements in emergency preparedness and infection prevention and control, well-qualified and engaged medical directors, a survey/inspection process that focuses on education, and more resources and attention to structural reform. Read more.

WHO backtracks on asymptomatic SARS-CoV-2 transmission

Maria Van Kerkhove, PhD, WHO’s COVID-19 technical lead and an infectious disease epidemiologist, caused a stir on June 8 when she said that countries are reporting that many of their asymptomatic cases develop into cases of mild disease. For patients with truly asymptomatic disease, countries are “not finding secondary transmission onward. It’s very rare,” she said. But on June 9 – following a day of criticism – Dr. Van Kerkhove sought to clarify her comments on asymptomatic transmission during a live social media Q&A. She noted that while “the majority of transmission that we know about” is through individuals with symptoms, “there are a subset of people who don’t develop symptoms, and to truly understand how many people don’t have symptoms – we don’t actually have that answer yet.” Physicians and public health experts slammed the initial comments, saying that they created confusion. Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, weighed in on the controversial WHO comments, telling Good Morning America on June 10 that Dr. Van Kerkhove’s initial statement that asymptomatic SARS-CoV-2 transmission is a rare event is “not correct.” Read more.

E-cigs linked to smoking relapse

The use of electronic nicotine delivery systems is associated with increased risk of cigarette smoking relapse among former smokers, results from a large longitudinal cohort study demonstrated. The findings come from a survey of adult former smokers who participated in the Population Assessment of Tobacco and Health (PATH) Study (2013-2018). Adjusted hazard ratio (AHR) analysis revealed that the use of electronic nicotine delivery systems was associated with significant risk of cigarette smoking relapse among recent former smokers (AHR 1.63) and among long-term former smokers (AHR 3.79). The use of other tobacco products was similarly associated with a significant risk for cigarette smoking relapse among recent former smokers (AHR 1.97) and among long-term former smokers (AHR 3.82). “For the many clinicians treating former smokers who have successfully quit all nicotine products, the implications are that use of [electronic nicotine delivery systems] should be discouraged, just as use of all other tobacco products is discouraged,” researchers led by Colm D. Everard, PhD, reported in a study published in JAMA Network Open. Read more.

Formula feeding leads to early weaning

Breastfed infants who receive formula in the hospital are more than twofold more likely to wean during the first year, compared with infants who are exclusively breastfed, according to research published online in Pediatrics. The finding is based on an analysis of data from over 8,000 infants in the Minnesota Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). “Our study strengthens the evidence that formula supplementation of breastfed infants negatively affects breastfeeding duration,” said Marcia Burton McCoy, MPH, of the Minnesota Department of Health’s WIC, and Pamela Heggie, MD, of the University of Minnesota in Minneapolis. Read more.
 

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

Here are the stories our MDedge editors across specialties think you need to know about today:

Tips to keep your finances healthy during COVID-19

If you’re among the more than half of Americans with less than 6 months of expenses saved for a rainy day, here are some tips on how to stay afloat in the near term. Cut back on expenses: Look through your credit card bills to see whether there are recurring payments you can cut, such as a payment to a gym that’s temporarily closed or a monthly subscription box that you don’t need. Tap your home equity: If you have good credit and still have some income, you might consider refinancing your home mortgage or opening a home equity line of credit. Consider retirement account withdrawals: the CARES Act has provisions making it less financially onerous to pull money from your retirement accounts. Under the new law, you can take a distribution of up to $100,000 from your IRA or 401(k) without having to pay the 10% early withdrawal penalty. Read more.

Nursing homes overhaul infection control

The toll that COVID-19 has taken on nursing homes and their postacute and long-term care residents has a multilayered backstory involving underresourced organizational structures, inherent susceptibilities, minimally trained infection prevention staff, variable abilities to isolate and quarantine large numbers of patients and residents, and a lack of governmental support. “Nursing homes have been trying their best to combat this pandemic using the best infection control procedures they have, but blindfolded and with their hands tied behind their backs,” said Joseph G. Ouslander, MD, professor of geriatric medicine at Florida Atlantic University, Boca Raton. Experts in both long-term care and infectious disease said in interviews that, through the rest of the pandemic and beyond, nursing homes need the following: “Infection preventionists” to lead improvements in emergency preparedness and infection prevention and control, well-qualified and engaged medical directors, a survey/inspection process that focuses on education, and more resources and attention to structural reform. Read more.

WHO backtracks on asymptomatic SARS-CoV-2 transmission

Maria Van Kerkhove, PhD, WHO’s COVID-19 technical lead and an infectious disease epidemiologist, caused a stir on June 8 when she said that countries are reporting that many of their asymptomatic cases develop into cases of mild disease. For patients with truly asymptomatic disease, countries are “not finding secondary transmission onward. It’s very rare,” she said. But on June 9 – following a day of criticism – Dr. Van Kerkhove sought to clarify her comments on asymptomatic transmission during a live social media Q&A. She noted that while “the majority of transmission that we know about” is through individuals with symptoms, “there are a subset of people who don’t develop symptoms, and to truly understand how many people don’t have symptoms – we don’t actually have that answer yet.” Physicians and public health experts slammed the initial comments, saying that they created confusion. Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, weighed in on the controversial WHO comments, telling Good Morning America on June 10 that Dr. Van Kerkhove’s initial statement that asymptomatic SARS-CoV-2 transmission is a rare event is “not correct.” Read more.

E-cigs linked to smoking relapse

The use of electronic nicotine delivery systems is associated with increased risk of cigarette smoking relapse among former smokers, results from a large longitudinal cohort study demonstrated. The findings come from a survey of adult former smokers who participated in the Population Assessment of Tobacco and Health (PATH) Study (2013-2018). Adjusted hazard ratio (AHR) analysis revealed that the use of electronic nicotine delivery systems was associated with significant risk of cigarette smoking relapse among recent former smokers (AHR 1.63) and among long-term former smokers (AHR 3.79). The use of other tobacco products was similarly associated with a significant risk for cigarette smoking relapse among recent former smokers (AHR 1.97) and among long-term former smokers (AHR 3.82). “For the many clinicians treating former smokers who have successfully quit all nicotine products, the implications are that use of [electronic nicotine delivery systems] should be discouraged, just as use of all other tobacco products is discouraged,” researchers led by Colm D. Everard, PhD, reported in a study published in JAMA Network Open. Read more.

Formula feeding leads to early weaning

Breastfed infants who receive formula in the hospital are more than twofold more likely to wean during the first year, compared with infants who are exclusively breastfed, according to research published online in Pediatrics. The finding is based on an analysis of data from over 8,000 infants in the Minnesota Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). “Our study strengthens the evidence that formula supplementation of breastfed infants negatively affects breastfeeding duration,” said Marcia Burton McCoy, MPH, of the Minnesota Department of Health’s WIC, and Pamela Heggie, MD, of the University of Minnesota in Minneapolis. Read more.
 

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

Here are the stories our MDedge editors across specialties think you need to know about today:

Tips to keep your finances healthy during COVID-19

If you’re among the more than half of Americans with less than 6 months of expenses saved for a rainy day, here are some tips on how to stay afloat in the near term. Cut back on expenses: Look through your credit card bills to see whether there are recurring payments you can cut, such as a payment to a gym that’s temporarily closed or a monthly subscription box that you don’t need. Tap your home equity: If you have good credit and still have some income, you might consider refinancing your home mortgage or opening a home equity line of credit. Consider retirement account withdrawals: the CARES Act has provisions making it less financially onerous to pull money from your retirement accounts. Under the new law, you can take a distribution of up to $100,000 from your IRA or 401(k) without having to pay the 10% early withdrawal penalty. Read more.

Nursing homes overhaul infection control

The toll that COVID-19 has taken on nursing homes and their postacute and long-term care residents has a multilayered backstory involving underresourced organizational structures, inherent susceptibilities, minimally trained infection prevention staff, variable abilities to isolate and quarantine large numbers of patients and residents, and a lack of governmental support. “Nursing homes have been trying their best to combat this pandemic using the best infection control procedures they have, but blindfolded and with their hands tied behind their backs,” said Joseph G. Ouslander, MD, professor of geriatric medicine at Florida Atlantic University, Boca Raton. Experts in both long-term care and infectious disease said in interviews that, through the rest of the pandemic and beyond, nursing homes need the following: “Infection preventionists” to lead improvements in emergency preparedness and infection prevention and control, well-qualified and engaged medical directors, a survey/inspection process that focuses on education, and more resources and attention to structural reform. Read more.

WHO backtracks on asymptomatic SARS-CoV-2 transmission

Maria Van Kerkhove, PhD, WHO’s COVID-19 technical lead and an infectious disease epidemiologist, caused a stir on June 8 when she said that countries are reporting that many of their asymptomatic cases develop into cases of mild disease. For patients with truly asymptomatic disease, countries are “not finding secondary transmission onward. It’s very rare,” she said. But on June 9 – following a day of criticism – Dr. Van Kerkhove sought to clarify her comments on asymptomatic transmission during a live social media Q&A. She noted that while “the majority of transmission that we know about” is through individuals with symptoms, “there are a subset of people who don’t develop symptoms, and to truly understand how many people don’t have symptoms – we don’t actually have that answer yet.” Physicians and public health experts slammed the initial comments, saying that they created confusion. Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, weighed in on the controversial WHO comments, telling Good Morning America on June 10 that Dr. Van Kerkhove’s initial statement that asymptomatic SARS-CoV-2 transmission is a rare event is “not correct.” Read more.

E-cigs linked to smoking relapse

The use of electronic nicotine delivery systems is associated with increased risk of cigarette smoking relapse among former smokers, results from a large longitudinal cohort study demonstrated. The findings come from a survey of adult former smokers who participated in the Population Assessment of Tobacco and Health (PATH) Study (2013-2018). Adjusted hazard ratio (AHR) analysis revealed that the use of electronic nicotine delivery systems was associated with significant risk of cigarette smoking relapse among recent former smokers (AHR 1.63) and among long-term former smokers (AHR 3.79). The use of other tobacco products was similarly associated with a significant risk for cigarette smoking relapse among recent former smokers (AHR 1.97) and among long-term former smokers (AHR 3.82). “For the many clinicians treating former smokers who have successfully quit all nicotine products, the implications are that use of [electronic nicotine delivery systems] should be discouraged, just as use of all other tobacco products is discouraged,” researchers led by Colm D. Everard, PhD, reported in a study published in JAMA Network Open. Read more.

Formula feeding leads to early weaning

Breastfed infants who receive formula in the hospital are more than twofold more likely to wean during the first year, compared with infants who are exclusively breastfed, according to research published online in Pediatrics. The finding is based on an analysis of data from over 8,000 infants in the Minnesota Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). “Our study strengthens the evidence that formula supplementation of breastfed infants negatively affects breastfeeding duration,” said Marcia Burton McCoy, MPH, of the Minnesota Department of Health’s WIC, and Pamela Heggie, MD, of the University of Minnesota in Minneapolis. Read more.
 

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

Food insecurity is not knowing how you will get your next meal. This pandemic has led to a lot of it, especially as a result of massive unemployment. Now imagine being in that situation with a food-allergic child. It would be frightening.

There is always a level of anxiety for parents of food-allergic children, but the Food and Drug Administration–mandated labeling of food allergens has helped to allay some of those concerns. Shopping can feel safer, even if it’s not foolproof.

Now, that fear for the safety of food-allergic children is going to be compounded by the FDA’s latest announcement, made at the behest of the food industry.

Disruptions in the food supply chain caused by the COVID-19 pandemic have created some problems for the food industry. The industry sought – and received – relief from the FDA; they are now allowing some ingredient substitutions without mandating a change in labeling. These changes were made without opportunity for public comment, according to the FDA, because of the exigency of the situation. Furthermore, the changes may stay in effect for an indeterminate period of time after the pandemic is deemed under control.

Labeling of gluten and the major eight allergens (peanuts, tree nuts, milk, eggs, soy, wheat, fish, and crustacean shellfish) cannot change under the new guidelines. The FDA also advised “consideration” of major food allergens recognized in other countries (sesame, celery, lupin, buckwheat, molluscan shellfish, and mustard). Of these, lupin is known to cross-react with peanut, and sesame seed allergy is increasingly prevalent. In fact, the FDA has considered adding it to the list of major allergens.

Meanwhile, according to this temporary FDA policy, substitutions should be limited to no more than 2% of the weight of the final product unless it is a variety of the same ingredient. The example provided is substitution of one type of mushroom for another, but even that could be an issue for the rare patient. And what if this is misinterpreted – as will surely happen somewhere – and one seed is substituted for another?

A friend of mine is a pediatrician and mother of a child who is allergic to sesame, peanuts, tree nuts, and garbanzo beans. Naturally, she had grave concerns about these changes. She also wondered what the liability would be for the food manufacturing company in the current situation despite the FDA notice, which seems like a valid point. It is worth noting that, at the very top of this FDA notice, are the words “contains nonbinding recommendations,” so manufacturers may want to think twice about how they approach this. A minority of companies have pledged to relabel foods if necessary. Meanwhile, without any alert in advance, it is now up to patients and their physicians to sort out the attendant risks.

The FDA should have advised or mandated that food manufacturers give notice to online and physical retailers of ingredient changes. A simple sign in front of a display or alert online would be a very reasonable solution and pose no burden to those involved. It should be self-evident that mistakes always happen, especially under duress, and that the loosening of these regulations will have unintended consequences. To the severe problem of food insecurity, we can add one more concern for the parents of allergic children: food-allergen insecurity.

A version of this article originally appeared on Medscape.com.

Food insecurity is not knowing how you will get your next meal. This pandemic has led to a lot of it, especially as a result of massive unemployment. Now imagine being in that situation with a food-allergic child. It would be frightening.

There is always a level of anxiety for parents of food-allergic children, but the Food and Drug Administration–mandated labeling of food allergens has helped to allay some of those concerns. Shopping can feel safer, even if it’s not foolproof.

Now, that fear for the safety of food-allergic children is going to be compounded by the FDA’s latest announcement, made at the behest of the food industry.

Disruptions in the food supply chain caused by the COVID-19 pandemic have created some problems for the food industry. The industry sought – and received – relief from the FDA; they are now allowing some ingredient substitutions without mandating a change in labeling. These changes were made without opportunity for public comment, according to the FDA, because of the exigency of the situation. Furthermore, the changes may stay in effect for an indeterminate period of time after the pandemic is deemed under control.

Labeling of gluten and the major eight allergens (peanuts, tree nuts, milk, eggs, soy, wheat, fish, and crustacean shellfish) cannot change under the new guidelines. The FDA also advised “consideration” of major food allergens recognized in other countries (sesame, celery, lupin, buckwheat, molluscan shellfish, and mustard). Of these, lupin is known to cross-react with peanut, and sesame seed allergy is increasingly prevalent. In fact, the FDA has considered adding it to the list of major allergens.

Meanwhile, according to this temporary FDA policy, substitutions should be limited to no more than 2% of the weight of the final product unless it is a variety of the same ingredient. The example provided is substitution of one type of mushroom for another, but even that could be an issue for the rare patient. And what if this is misinterpreted – as will surely happen somewhere – and one seed is substituted for another?

A friend of mine is a pediatrician and mother of a child who is allergic to sesame, peanuts, tree nuts, and garbanzo beans. Naturally, she had grave concerns about these changes. She also wondered what the liability would be for the food manufacturing company in the current situation despite the FDA notice, which seems like a valid point. It is worth noting that, at the very top of this FDA notice, are the words “contains nonbinding recommendations,” so manufacturers may want to think twice about how they approach this. A minority of companies have pledged to relabel foods if necessary. Meanwhile, without any alert in advance, it is now up to patients and their physicians to sort out the attendant risks.

The FDA should have advised or mandated that food manufacturers give notice to online and physical retailers of ingredient changes. A simple sign in front of a display or alert online would be a very reasonable solution and pose no burden to those involved. It should be self-evident that mistakes always happen, especially under duress, and that the loosening of these regulations will have unintended consequences. To the severe problem of food insecurity, we can add one more concern for the parents of allergic children: food-allergen insecurity.

A version of this article originally appeared on Medscape.com.

Food insecurity is not knowing how you will get your next meal. This pandemic has led to a lot of it, especially as a result of massive unemployment. Now imagine being in that situation with a food-allergic child. It would be frightening.

There is always a level of anxiety for parents of food-allergic children, but the Food and Drug Administration–mandated labeling of food allergens has helped to allay some of those concerns. Shopping can feel safer, even if it’s not foolproof.

Now, that fear for the safety of food-allergic children is going to be compounded by the FDA’s latest announcement, made at the behest of the food industry.

Disruptions in the food supply chain caused by the COVID-19 pandemic have created some problems for the food industry. The industry sought – and received – relief from the FDA; they are now allowing some ingredient substitutions without mandating a change in labeling. These changes were made without opportunity for public comment, according to the FDA, because of the exigency of the situation. Furthermore, the changes may stay in effect for an indeterminate period of time after the pandemic is deemed under control.

Labeling of gluten and the major eight allergens (peanuts, tree nuts, milk, eggs, soy, wheat, fish, and crustacean shellfish) cannot change under the new guidelines. The FDA also advised “consideration” of major food allergens recognized in other countries (sesame, celery, lupin, buckwheat, molluscan shellfish, and mustard). Of these, lupin is known to cross-react with peanut, and sesame seed allergy is increasingly prevalent. In fact, the FDA has considered adding it to the list of major allergens.

Meanwhile, according to this temporary FDA policy, substitutions should be limited to no more than 2% of the weight of the final product unless it is a variety of the same ingredient. The example provided is substitution of one type of mushroom for another, but even that could be an issue for the rare patient. And what if this is misinterpreted – as will surely happen somewhere – and one seed is substituted for another?

A friend of mine is a pediatrician and mother of a child who is allergic to sesame, peanuts, tree nuts, and garbanzo beans. Naturally, she had grave concerns about these changes. She also wondered what the liability would be for the food manufacturing company in the current situation despite the FDA notice, which seems like a valid point. It is worth noting that, at the very top of this FDA notice, are the words “contains nonbinding recommendations,” so manufacturers may want to think twice about how they approach this. A minority of companies have pledged to relabel foods if necessary. Meanwhile, without any alert in advance, it is now up to patients and their physicians to sort out the attendant risks.

The FDA should have advised or mandated that food manufacturers give notice to online and physical retailers of ingredient changes. A simple sign in front of a display or alert online would be a very reasonable solution and pose no burden to those involved. It should be self-evident that mistakes always happen, especially under duress, and that the loosening of these regulations will have unintended consequences. To the severe problem of food insecurity, we can add one more concern for the parents of allergic children: food-allergen insecurity.

A version of this article originally appeared on Medscape.com.

Patients with rheumatoid arthritis (RA) have an elevated risk of interstitial lung disease (ILD), but methotrexate does not accentuate that risk and may in fact be protective, new data show. These were among key findings of a pair of studies reported at the annual European Congress of Rheumatology, held online this year due to COVID-19.

Although a guideline-recommended cornerstone in the management of RA, methotrexate has been associated with both hypersensitivity pneumonitis and diffuse lung disease. However, its involvement in the development of ILD among patients with RA is unclear.

A Danish study of more than 30,000 RA patients reported at the congress found that their risk of ILD was about three to five times that of the general population. However, risk did not differ significantly whether they had filled a methotrexate prescription or not.

In addition, a multinational case-control study of more than 1,000 RA patients also reported at the congress found that, compared with never-users of methotrexate, ever-users actually had a 59% lower likelihood of developing ILD.

However, both studies were limited by their retrospective design, Elizabeth R. Volkmann, MD, codirector of the connective tissue disease–related interstitial lung disease program at the University of California, Los Angeles, cautioned in an interview. Hence, there was likely systematic bias and confounding.

“I would interpret the conclusions of both studies with caution,” she maintained. “To understand how a particular intervention, such as methotrexate use, affects the outcome of ILD development, a prospective design is needed, which adequately adjusts for known ILD risk factors, such as male sex and smoking.”

As to whether the new findings are practice changing and how they might affect patient counseling, “the answers to these questions are not straightforward and depend on other patient-related factors,” according to Dr. Volkmann.
 

Danish nationwide study

René Cordtz, MD, a clinical assistant at the Center for Rheumatology and Spine Diseases, Rigshospitalet‐Gentofte, Copenhagen, and colleagues conducted a nationwide population-based cohort study using registry data from 1997 to 2015 to assess lung disease among patients with RA by prescriptions filled.

Results based on 30,512 RA patients showed that, compared with peers filling no methotrexate prescriptions, patients filling at least one did not have a significantly elevated risk of ILD at either 1 year of follow-up (hazard ratio, 1.03) or 5 years of follow-up (HR, 1.00). (Findings were similar for sulfasalazine, with respective nonsignificant HRs of 0.88 and 1.14.)

In addition, patients with RA had a similarly sharply elevated 5-year risk of ILD relative to the general population regardless of whether they had filled neither methotrexate nor sulfasalazine prescriptions (standardized incidence ratio, 3.38) or had filled prescriptions for methotrexate only (SIR, 3.63), sulfasalazine only (SIR, 4.12), or both (SIR, 5.45).

“RA patients have an increased risk of ILD, compared to the general population, which was not surprising, but very importantly, that risk was not further exacerbated in those treated with methotrexate,” Dr. Cordtz concluded. “We do acknowledge that purchasing your medicine is different from taking your medicine, which is why we found it extra reassuring that when requiring at least two methotrexate prescriptions to be considered exposed, it did not change our results.”

Multinational study

Pierre-Antoine Juge, MD, a rheumatologist at Bichat-Claude Bernard Hospital, Paris, and colleagues performed a case-control study among 482 RA patients with ILD and 741 RA patients without ILD in three cohorts: a French discovery cohort, a multinational (Brazilian, Italian, Mexican, United Kingdom, and United States) replication cohort, and a combined cohort. Those with methotrexate hypersensitivity pneumonitis were excluded.

Results showed that relative to peers without ILD, patients with ILD had a lower prevalence of ever having used methotrexate and had received a lower cumulative methotrexate dose, findings that were consistent across all three cohorts.

Methotrexate ever-use was associated with a significantly lower adjusted likelihood of ILD in the discovery cohort (odds ratio, 0.46), the replication cohort (OR, 0.38), and the combined cohort (OR, 0.41). Furthermore, ever-users were less commonly represented among patients with ILD regardless of chest high-resolution CT pattern (usual interstitial pneumonia pattern vs. not).

Finally, methotrexate use appeared to delay the adjusted time to onset of ILD by 3.5 years in the discovery cohort (P = .001), by 3.2 years in the replication cohort (P < .0001), and by 3.5 years in the combined cohort (P < .0001).

“Outside of methotrexate hypersensitivity pneumonitis, methotrexate was not a risk factor for RA-associated ILD in our study. We observed an inverse relationship that was similar whatever the high-resolution CT pattern,” Dr. Juge commented. “But this possible protective effect should be confirmed through a dedicated prospective, randomized, controlled trial.”

“Methotrexate should not be considered as a causal factor for RA-associated ILD, and its [discontinuation] should be discussed through a multidisciplinary discussion,” he recommended. In addition, “this study does not investigate the impact of methotrexate use on RA-associated ILD prognosis.”

The Danish study did not receive any specific funding, and none of its authors reported having any financial disclosures. The multinational study did not receive any specific funding. Dr. Juge disclosed that he had no relevant conflicts of interest, but many of his coauthors reported financial relationships with industry. Dr. Volkmann disclosed consulting for Boehringer Ingelheim and Forbius, and receiving grant support from Forbius and Corbus.

SOURCES: Cordtz R et al. Ann Rheum Dis. 2020;79[suppl 1]:147-8, Abstract OP0232; Juge P-A et al. Ann Rheum Dis. 2020;79[suppl 1]:25, Abstract OP0236.

Patients with rheumatoid arthritis (RA) have an elevated risk of interstitial lung disease (ILD), but methotrexate does not accentuate that risk and may in fact be protective, new data show. These were among key findings of a pair of studies reported at the annual European Congress of Rheumatology, held online this year due to COVID-19.

Although a guideline-recommended cornerstone in the management of RA, methotrexate has been associated with both hypersensitivity pneumonitis and diffuse lung disease. However, its involvement in the development of ILD among patients with RA is unclear.

A Danish study of more than 30,000 RA patients reported at the congress found that their risk of ILD was about three to five times that of the general population. However, risk did not differ significantly whether they had filled a methotrexate prescription or not.

In addition, a multinational case-control study of more than 1,000 RA patients also reported at the congress found that, compared with never-users of methotrexate, ever-users actually had a 59% lower likelihood of developing ILD.

However, both studies were limited by their retrospective design, Elizabeth R. Volkmann, MD, codirector of the connective tissue disease–related interstitial lung disease program at the University of California, Los Angeles, cautioned in an interview. Hence, there was likely systematic bias and confounding.

“I would interpret the conclusions of both studies with caution,” she maintained. “To understand how a particular intervention, such as methotrexate use, affects the outcome of ILD development, a prospective design is needed, which adequately adjusts for known ILD risk factors, such as male sex and smoking.”

As to whether the new findings are practice changing and how they might affect patient counseling, “the answers to these questions are not straightforward and depend on other patient-related factors,” according to Dr. Volkmann.
 

Danish nationwide study

René Cordtz, MD, a clinical assistant at the Center for Rheumatology and Spine Diseases, Rigshospitalet‐Gentofte, Copenhagen, and colleagues conducted a nationwide population-based cohort study using registry data from 1997 to 2015 to assess lung disease among patients with RA by prescriptions filled.

Results based on 30,512 RA patients showed that, compared with peers filling no methotrexate prescriptions, patients filling at least one did not have a significantly elevated risk of ILD at either 1 year of follow-up (hazard ratio, 1.03) or 5 years of follow-up (HR, 1.00). (Findings were similar for sulfasalazine, with respective nonsignificant HRs of 0.88 and 1.14.)

In addition, patients with RA had a similarly sharply elevated 5-year risk of ILD relative to the general population regardless of whether they had filled neither methotrexate nor sulfasalazine prescriptions (standardized incidence ratio, 3.38) or had filled prescriptions for methotrexate only (SIR, 3.63), sulfasalazine only (SIR, 4.12), or both (SIR, 5.45).

“RA patients have an increased risk of ILD, compared to the general population, which was not surprising, but very importantly, that risk was not further exacerbated in those treated with methotrexate,” Dr. Cordtz concluded. “We do acknowledge that purchasing your medicine is different from taking your medicine, which is why we found it extra reassuring that when requiring at least two methotrexate prescriptions to be considered exposed, it did not change our results.”

Multinational study

Pierre-Antoine Juge, MD, a rheumatologist at Bichat-Claude Bernard Hospital, Paris, and colleagues performed a case-control study among 482 RA patients with ILD and 741 RA patients without ILD in three cohorts: a French discovery cohort, a multinational (Brazilian, Italian, Mexican, United Kingdom, and United States) replication cohort, and a combined cohort. Those with methotrexate hypersensitivity pneumonitis were excluded.

Results showed that relative to peers without ILD, patients with ILD had a lower prevalence of ever having used methotrexate and had received a lower cumulative methotrexate dose, findings that were consistent across all three cohorts.

Methotrexate ever-use was associated with a significantly lower adjusted likelihood of ILD in the discovery cohort (odds ratio, 0.46), the replication cohort (OR, 0.38), and the combined cohort (OR, 0.41). Furthermore, ever-users were less commonly represented among patients with ILD regardless of chest high-resolution CT pattern (usual interstitial pneumonia pattern vs. not).

Finally, methotrexate use appeared to delay the adjusted time to onset of ILD by 3.5 years in the discovery cohort (P = .001), by 3.2 years in the replication cohort (P < .0001), and by 3.5 years in the combined cohort (P < .0001).

“Outside of methotrexate hypersensitivity pneumonitis, methotrexate was not a risk factor for RA-associated ILD in our study. We observed an inverse relationship that was similar whatever the high-resolution CT pattern,” Dr. Juge commented. “But this possible protective effect should be confirmed through a dedicated prospective, randomized, controlled trial.”

“Methotrexate should not be considered as a causal factor for RA-associated ILD, and its [discontinuation] should be discussed through a multidisciplinary discussion,” he recommended. In addition, “this study does not investigate the impact of methotrexate use on RA-associated ILD prognosis.”

The Danish study did not receive any specific funding, and none of its authors reported having any financial disclosures. The multinational study did not receive any specific funding. Dr. Juge disclosed that he had no relevant conflicts of interest, but many of his coauthors reported financial relationships with industry. Dr. Volkmann disclosed consulting for Boehringer Ingelheim and Forbius, and receiving grant support from Forbius and Corbus.

SOURCES: Cordtz R et al. Ann Rheum Dis. 2020;79[suppl 1]:147-8, Abstract OP0232; Juge P-A et al. Ann Rheum Dis. 2020;79[suppl 1]:25, Abstract OP0236.

Patients with rheumatoid arthritis (RA) have an elevated risk of interstitial lung disease (ILD), but methotrexate does not accentuate that risk and may in fact be protective, new data show. These were among key findings of a pair of studies reported at the annual European Congress of Rheumatology, held online this year due to COVID-19.

Although a guideline-recommended cornerstone in the management of RA, methotrexate has been associated with both hypersensitivity pneumonitis and diffuse lung disease. However, its involvement in the development of ILD among patients with RA is unclear.

A Danish study of more than 30,000 RA patients reported at the congress found that their risk of ILD was about three to five times that of the general population. However, risk did not differ significantly whether they had filled a methotrexate prescription or not.

In addition, a multinational case-control study of more than 1,000 RA patients also reported at the congress found that, compared with never-users of methotrexate, ever-users actually had a 59% lower likelihood of developing ILD.

However, both studies were limited by their retrospective design, Elizabeth R. Volkmann, MD, codirector of the connective tissue disease–related interstitial lung disease program at the University of California, Los Angeles, cautioned in an interview. Hence, there was likely systematic bias and confounding.

“I would interpret the conclusions of both studies with caution,” she maintained. “To understand how a particular intervention, such as methotrexate use, affects the outcome of ILD development, a prospective design is needed, which adequately adjusts for known ILD risk factors, such as male sex and smoking.”

As to whether the new findings are practice changing and how they might affect patient counseling, “the answers to these questions are not straightforward and depend on other patient-related factors,” according to Dr. Volkmann.
 

Danish nationwide study

René Cordtz, MD, a clinical assistant at the Center for Rheumatology and Spine Diseases, Rigshospitalet‐Gentofte, Copenhagen, and colleagues conducted a nationwide population-based cohort study using registry data from 1997 to 2015 to assess lung disease among patients with RA by prescriptions filled.

Results based on 30,512 RA patients showed that, compared with peers filling no methotrexate prescriptions, patients filling at least one did not have a significantly elevated risk of ILD at either 1 year of follow-up (hazard ratio, 1.03) or 5 years of follow-up (HR, 1.00). (Findings were similar for sulfasalazine, with respective nonsignificant HRs of 0.88 and 1.14.)

In addition, patients with RA had a similarly sharply elevated 5-year risk of ILD relative to the general population regardless of whether they had filled neither methotrexate nor sulfasalazine prescriptions (standardized incidence ratio, 3.38) or had filled prescriptions for methotrexate only (SIR, 3.63), sulfasalazine only (SIR, 4.12), or both (SIR, 5.45).

“RA patients have an increased risk of ILD, compared to the general population, which was not surprising, but very importantly, that risk was not further exacerbated in those treated with methotrexate,” Dr. Cordtz concluded. “We do acknowledge that purchasing your medicine is different from taking your medicine, which is why we found it extra reassuring that when requiring at least two methotrexate prescriptions to be considered exposed, it did not change our results.”

Multinational study

Pierre-Antoine Juge, MD, a rheumatologist at Bichat-Claude Bernard Hospital, Paris, and colleagues performed a case-control study among 482 RA patients with ILD and 741 RA patients without ILD in three cohorts: a French discovery cohort, a multinational (Brazilian, Italian, Mexican, United Kingdom, and United States) replication cohort, and a combined cohort. Those with methotrexate hypersensitivity pneumonitis were excluded.

Results showed that relative to peers without ILD, patients with ILD had a lower prevalence of ever having used methotrexate and had received a lower cumulative methotrexate dose, findings that were consistent across all three cohorts.

Methotrexate ever-use was associated with a significantly lower adjusted likelihood of ILD in the discovery cohort (odds ratio, 0.46), the replication cohort (OR, 0.38), and the combined cohort (OR, 0.41). Furthermore, ever-users were less commonly represented among patients with ILD regardless of chest high-resolution CT pattern (usual interstitial pneumonia pattern vs. not).

Finally, methotrexate use appeared to delay the adjusted time to onset of ILD by 3.5 years in the discovery cohort (P = .001), by 3.2 years in the replication cohort (P < .0001), and by 3.5 years in the combined cohort (P < .0001).

“Outside of methotrexate hypersensitivity pneumonitis, methotrexate was not a risk factor for RA-associated ILD in our study. We observed an inverse relationship that was similar whatever the high-resolution CT pattern,” Dr. Juge commented. “But this possible protective effect should be confirmed through a dedicated prospective, randomized, controlled trial.”

“Methotrexate should not be considered as a causal factor for RA-associated ILD, and its [discontinuation] should be discussed through a multidisciplinary discussion,” he recommended. In addition, “this study does not investigate the impact of methotrexate use on RA-associated ILD prognosis.”

The Danish study did not receive any specific funding, and none of its authors reported having any financial disclosures. The multinational study did not receive any specific funding. Dr. Juge disclosed that he had no relevant conflicts of interest, but many of his coauthors reported financial relationships with industry. Dr. Volkmann disclosed consulting for Boehringer Ingelheim and Forbius, and receiving grant support from Forbius and Corbus.

SOURCES: Cordtz R et al. Ann Rheum Dis. 2020;79[suppl 1]:147-8, Abstract OP0232; Juge P-A et al. Ann Rheum Dis. 2020;79[suppl 1]:25, Abstract OP0236.

Second only to the American Society of Clinical Oncology, the volunteer leaders of the American College of Rheumatology with ties to industry received the highest median payment amounts, a new cross-sectional study reveals.

Total research payments exceeded $54 million to ASCO leaders and $20 million to ACR leaders, for example. The investigators identified the 10 most common and costly conditions in the United States – including heart disease, trauma-related disorders, mental disorders, and others. They then used a new national database to explore the financial relationships between pharmaceutical and device manufacturers and the leaders of “influential U.S. professional medical associations active across these disease areas.” Steven Echard, executive vice president of the American College of Rheumatology, responded to the study findings, published in the BMJ. “We require our leaders to tell us about any payments they receive as part of their professional and personal activities that may pose actual or potential conflicts, post this information transparently to our website, and adjust what projects and initiatives they can participate in to avoid any undue influence,” he said in an interview.

“Many of the disclosures included in the study were due to individuals participating in research projects to move the needle forward in the care of rheumatology patients,” he added.

There remains an ongoing debate about how close the relationships should be between medical associations and industry, wrote lead author Ray Moynihan, PhD, assistant professor in the Institute for Evidence-Based Healthcare at Bond University, Gold Coast, Australia, and colleagues.
 

Majority report relationship with industry

Dr. Moynihan and associates conducted the first study to evaluate these relationships in such detail. Using the U.S. government’s Open Payments database, established in 2013, they assessed research payments and general payments for consultancy, royalties, and hospitality. The study included the current year of board membership, as well as the 4 years prior and 1 year after membership.

Overall, out of 293 physician association leaders, 235 or 80% had a financial relationship. None of the associations in the study featured a leadership free of financial ties.

Payments totaled almost $130 million, including nearly $25 million in general payments, almost $105 million for research, and about half a million in other payments. The research payments went primarily to institutions with leaders named as principal investigators, they noted.

“The most common misperception [in the BMJ study] is that all the funding identified represents personal payments to the individuals,” Mr. Echard said. “Because research dollars are included, almost 80% of the payments referenced in the article – sometimes more – go to individuals’ academic institutions.” These funds cover overhead, lab materials, protected time for said research, research assistant salaries, and other expenses.

“We have other board of director members who have no industry relationships at all,” he added.
 

Part of business model

“Faculty members are expected to bring in funding to support research, so most academic institutions receive industry funding, and it’s considered part of their business model,” Mr. Echard said. “For this reason, we generally do not consider these payments the same as being on advisory boards, speakers bureaus, or going to dinners, etc.”

The median total amounts linked to individual leaders varied between associations. For example, the median amount was $518,000 for ASCO leaders, as previously reported by Medscape Medical News.

Volunteer leaders for the ACR received a median $251,000. Not all ACR board of director members receive funding in this range, Mr. Echard said. “We have board of director members who work at academic institutions that can receive funding that high due to their participation in research studies, particularly when looking over a 4-year period prior to their leadership role, as the study did.”

At the lower end, median total payments were $404 for leaders of the American College of Physicians and $212 for those of the American Psychiatric Association.

In an accompanying editorial, Jake Checketts, DO, and Matt Vassar, PhD, of the Oklahoma State University Center for Health Sciences, Tulsa, proposed five actions that “could mitigate or even eliminate the overwhelming presence of financial conflicts of interest among medical societies and associations. This would protect these groups from producing biased documents or policies, which in turn would protect all physicians and the patients they treat.”

They made five proposals:

• Each association must take the initiative to evaluate its present conflicts using open payments.
• Associations should alter their recruitment processes to yield balanced and diverse groups of physician leaders largely free from financial conflicts of interest.
• The creation of standards for promoting medical associations that are free from financial conflicts of interest, similar to the framework within the Institute of Medicine’s standards for producing clinical practice guidelines we can trust.
• Greater reliance on the Sunshine Act and open payments in the United States (and elsewhere for countries with similar data) could eliminate the need for the traditional “honor system” of financial self-disclosure, which is ineffective and inaccurate at best.
• All medical associations, guidelines groups, and policy makers provide links from their documents and websites to open payments data for each U.S.-based physician contributor. Such links would make it easier for anyone, including patients, to evaluate any risk of bias.

On a final note, the ACR prohibits key college leaders, including the ACR president, ACR president-elect, foundation president, and others from having direct financial ties to commercial entities in their conflict of interest guidelines.

“We agree that actively managing conflict of interest is important to maintaining the integrity and reputation of an association with the medical community and with the public,” Mr. Echard said. “And all actual, potential, and perceived conflicts of interest should be addressed and managed through a disclosure process.”

Several authors of the study reported receiving grants from the Australian National Health and Medical Research Council. Mr. Echard, Dr. Checketts, and Dr. Vassar had no relevant disclosures.

SOURCE: Moynihan R et al. BMJ. 2020;369:m1505.

Second only to the American Society of Clinical Oncology, the volunteer leaders of the American College of Rheumatology with ties to industry received the highest median payment amounts, a new cross-sectional study reveals.

Total research payments exceeded $54 million to ASCO leaders and $20 million to ACR leaders, for example. The investigators identified the 10 most common and costly conditions in the United States – including heart disease, trauma-related disorders, mental disorders, and others. They then used a new national database to explore the financial relationships between pharmaceutical and device manufacturers and the leaders of “influential U.S. professional medical associations active across these disease areas.” Steven Echard, executive vice president of the American College of Rheumatology, responded to the study findings, published in the BMJ. “We require our leaders to tell us about any payments they receive as part of their professional and personal activities that may pose actual or potential conflicts, post this information transparently to our website, and adjust what projects and initiatives they can participate in to avoid any undue influence,” he said in an interview.

“Many of the disclosures included in the study were due to individuals participating in research projects to move the needle forward in the care of rheumatology patients,” he added.

There remains an ongoing debate about how close the relationships should be between medical associations and industry, wrote lead author Ray Moynihan, PhD, assistant professor in the Institute for Evidence-Based Healthcare at Bond University, Gold Coast, Australia, and colleagues.
 

Majority report relationship with industry

Dr. Moynihan and associates conducted the first study to evaluate these relationships in such detail. Using the U.S. government’s Open Payments database, established in 2013, they assessed research payments and general payments for consultancy, royalties, and hospitality. The study included the current year of board membership, as well as the 4 years prior and 1 year after membership.

Overall, out of 293 physician association leaders, 235 or 80% had a financial relationship. None of the associations in the study featured a leadership free of financial ties.

Payments totaled almost $130 million, including nearly $25 million in general payments, almost $105 million for research, and about half a million in other payments. The research payments went primarily to institutions with leaders named as principal investigators, they noted.

“The most common misperception [in the BMJ study] is that all the funding identified represents personal payments to the individuals,” Mr. Echard said. “Because research dollars are included, almost 80% of the payments referenced in the article – sometimes more – go to individuals’ academic institutions.” These funds cover overhead, lab materials, protected time for said research, research assistant salaries, and other expenses.

“We have other board of director members who have no industry relationships at all,” he added.
 

Part of business model

“Faculty members are expected to bring in funding to support research, so most academic institutions receive industry funding, and it’s considered part of their business model,” Mr. Echard said. “For this reason, we generally do not consider these payments the same as being on advisory boards, speakers bureaus, or going to dinners, etc.”

The median total amounts linked to individual leaders varied between associations. For example, the median amount was $518,000 for ASCO leaders, as previously reported by Medscape Medical News.

Volunteer leaders for the ACR received a median $251,000. Not all ACR board of director members receive funding in this range, Mr. Echard said. “We have board of director members who work at academic institutions that can receive funding that high due to their participation in research studies, particularly when looking over a 4-year period prior to their leadership role, as the study did.”

At the lower end, median total payments were $404 for leaders of the American College of Physicians and $212 for those of the American Psychiatric Association.

In an accompanying editorial, Jake Checketts, DO, and Matt Vassar, PhD, of the Oklahoma State University Center for Health Sciences, Tulsa, proposed five actions that “could mitigate or even eliminate the overwhelming presence of financial conflicts of interest among medical societies and associations. This would protect these groups from producing biased documents or policies, which in turn would protect all physicians and the patients they treat.”

They made five proposals:

• Each association must take the initiative to evaluate its present conflicts using open payments.
• Associations should alter their recruitment processes to yield balanced and diverse groups of physician leaders largely free from financial conflicts of interest.
• The creation of standards for promoting medical associations that are free from financial conflicts of interest, similar to the framework within the Institute of Medicine’s standards for producing clinical practice guidelines we can trust.
• Greater reliance on the Sunshine Act and open payments in the United States (and elsewhere for countries with similar data) could eliminate the need for the traditional “honor system” of financial self-disclosure, which is ineffective and inaccurate at best.
• All medical associations, guidelines groups, and policy makers provide links from their documents and websites to open payments data for each U.S.-based physician contributor. Such links would make it easier for anyone, including patients, to evaluate any risk of bias.

On a final note, the ACR prohibits key college leaders, including the ACR president, ACR president-elect, foundation president, and others from having direct financial ties to commercial entities in their conflict of interest guidelines.

“We agree that actively managing conflict of interest is important to maintaining the integrity and reputation of an association with the medical community and with the public,” Mr. Echard said. “And all actual, potential, and perceived conflicts of interest should be addressed and managed through a disclosure process.”

Several authors of the study reported receiving grants from the Australian National Health and Medical Research Council. Mr. Echard, Dr. Checketts, and Dr. Vassar had no relevant disclosures.

SOURCE: Moynihan R et al. BMJ. 2020;369:m1505.

Second only to the American Society of Clinical Oncology, the volunteer leaders of the American College of Rheumatology with ties to industry received the highest median payment amounts, a new cross-sectional study reveals.

Total research payments exceeded $54 million to ASCO leaders and $20 million to ACR leaders, for example. The investigators identified the 10 most common and costly conditions in the United States – including heart disease, trauma-related disorders, mental disorders, and others. They then used a new national database to explore the financial relationships between pharmaceutical and device manufacturers and the leaders of “influential U.S. professional medical associations active across these disease areas.” Steven Echard, executive vice president of the American College of Rheumatology, responded to the study findings, published in the BMJ. “We require our leaders to tell us about any payments they receive as part of their professional and personal activities that may pose actual or potential conflicts, post this information transparently to our website, and adjust what projects and initiatives they can participate in to avoid any undue influence,” he said in an interview.

“Many of the disclosures included in the study were due to individuals participating in research projects to move the needle forward in the care of rheumatology patients,” he added.

There remains an ongoing debate about how close the relationships should be between medical associations and industry, wrote lead author Ray Moynihan, PhD, assistant professor in the Institute for Evidence-Based Healthcare at Bond University, Gold Coast, Australia, and colleagues.
 

Majority report relationship with industry

Dr. Moynihan and associates conducted the first study to evaluate these relationships in such detail. Using the U.S. government’s Open Payments database, established in 2013, they assessed research payments and general payments for consultancy, royalties, and hospitality. The study included the current year of board membership, as well as the 4 years prior and 1 year after membership.

Overall, out of 293 physician association leaders, 235 or 80% had a financial relationship. None of the associations in the study featured a leadership free of financial ties.

Payments totaled almost $130 million, including nearly $25 million in general payments, almost $105 million for research, and about half a million in other payments. The research payments went primarily to institutions with leaders named as principal investigators, they noted.

“The most common misperception [in the BMJ study] is that all the funding identified represents personal payments to the individuals,” Mr. Echard said. “Because research dollars are included, almost 80% of the payments referenced in the article – sometimes more – go to individuals’ academic institutions.” These funds cover overhead, lab materials, protected time for said research, research assistant salaries, and other expenses.

“We have other board of director members who have no industry relationships at all,” he added.
 

Part of business model

“Faculty members are expected to bring in funding to support research, so most academic institutions receive industry funding, and it’s considered part of their business model,” Mr. Echard said. “For this reason, we generally do not consider these payments the same as being on advisory boards, speakers bureaus, or going to dinners, etc.”

The median total amounts linked to individual leaders varied between associations. For example, the median amount was $518,000 for ASCO leaders, as previously reported by Medscape Medical News.

Volunteer leaders for the ACR received a median $251,000. Not all ACR board of director members receive funding in this range, Mr. Echard said. “We have board of director members who work at academic institutions that can receive funding that high due to their participation in research studies, particularly when looking over a 4-year period prior to their leadership role, as the study did.”

At the lower end, median total payments were $404 for leaders of the American College of Physicians and $212 for those of the American Psychiatric Association.

In an accompanying editorial, Jake Checketts, DO, and Matt Vassar, PhD, of the Oklahoma State University Center for Health Sciences, Tulsa, proposed five actions that “could mitigate or even eliminate the overwhelming presence of financial conflicts of interest among medical societies and associations. This would protect these groups from producing biased documents or policies, which in turn would protect all physicians and the patients they treat.”

They made five proposals:

• Each association must take the initiative to evaluate its present conflicts using open payments.
• Associations should alter their recruitment processes to yield balanced and diverse groups of physician leaders largely free from financial conflicts of interest.
• The creation of standards for promoting medical associations that are free from financial conflicts of interest, similar to the framework within the Institute of Medicine’s standards for producing clinical practice guidelines we can trust.
• Greater reliance on the Sunshine Act and open payments in the United States (and elsewhere for countries with similar data) could eliminate the need for the traditional “honor system” of financial self-disclosure, which is ineffective and inaccurate at best.
• All medical associations, guidelines groups, and policy makers provide links from their documents and websites to open payments data for each U.S.-based physician contributor. Such links would make it easier for anyone, including patients, to evaluate any risk of bias.

On a final note, the ACR prohibits key college leaders, including the ACR president, ACR president-elect, foundation president, and others from having direct financial ties to commercial entities in their conflict of interest guidelines.

“We agree that actively managing conflict of interest is important to maintaining the integrity and reputation of an association with the medical community and with the public,” Mr. Echard said. “And all actual, potential, and perceived conflicts of interest should be addressed and managed through a disclosure process.”

Several authors of the study reported receiving grants from the Australian National Health and Medical Research Council. Mr. Echard, Dr. Checketts, and Dr. Vassar had no relevant disclosures.

SOURCE: Moynihan R et al. BMJ. 2020;369:m1505.

A World Health Organization (WHO) official is walking back her comments characterizing the spread of SARS-CoV-2 by asymptomatic individuals as “rare.”

Maria Van Kerkhove, PhD, WHO’s COVID-19 technical lead and an infectious disease epidemiologist, caused a stir June 8 when she said that countries are reporting that many of their asymptomatic cases develop into cases of mild disease. For patients with truly asymptomatic disease, countries are “not finding secondary transmission onward. It’s very rare,” she said.

Suppressing symptomatic cases, on the other hand, would result in a “drastic reduction” in transmission, she noted. “But from the data we have, it still seems to be rare that an asymptomatic person actually transmits onward to a secondary individual,” she said.

But on June 9 – following a day of confusion and criticism – Dr. Van Kerkhove sought to clarify her comments on asymptomatic transmission during a live social media Q&A. She noted that while “the majority of transmission that we know about” is through individuals with symptoms, “there are a subset of people who don’t develop symptoms, and to truly understand how many people don’t have symptoms – we don’t actually have that answer yet.”

Between 6% and 41% of individuals may be asymptomatic based on estimates, she acknowledged.“What we need to better understand is how many of the people in the population don’t have symptoms, and separately, how many of those individuals go on to transmit to others,” she said.

Dr. Van Kerkhove also emphasized that her initial comments were made in response to a question raised at the press conference, and called it a misunderstanding. “I wasn’t stating a policy of WHO or anything like that,” she said. “I was just trying to articulate what we know.”

The phrase “very rare” referred to a subset of studies and reports WHO had received from its member states following asymptomatic individuals with COVID-19. “I was referring to some detailed investigations, cluster investigations, case contact tracing, where we had reports from member states saying that, when we follow asymptomatic cases, it’s very rare – and I used the phrase very rare – that we found a secondary transmission,” she said.

Dr. Van Kerkhove’s initial comments drew criticism from medical and public health professionals, who said the statement was “confusing” and communicated poorly.

Eric J. Topol, MD, tweeted that WHO had “engendered considerable confusion” with the comments about asymptomatic individuals rarely transmitting SARS-CoV-2. Dr. Topol, the author of a recent analysis published in Annals of Internal Medicine that suggested as many as 40%-45% of COVID-19 cases may be asymptomatic, said that it was not possible to determine whether asymptomatic individuals in the cohorts he studied were capable of spread like pre-symptomatic individuals. “We only know the viral loads are similar from multiple reports. And we do know some spread occurs from [asymptomatic] people,” he said.

Andy Slavitt, former acting administrator of the Centers for Medicare and Medicaid Services, said in a tweet that he believed WHO made “an irresponsible statement even though it was based on legitimate observations.” Reports by Member States do not reach a “bar of rigor,” he said.

Natalie E. Dean, PhD, assistant professor of biostatistics at the University of Florida, tweeted that the initial comments by the WHO seemed to be trying to draw a distinction between asymptomatic individuals who never develop symptoms, and presymptomatic individuals who present as asymptomatic, but later develop symptoms. Finding that asymptomatic cases rarely transmit the virus could change how people exposed to those asymptomatic individuals are monitored, but “it seems more of scientific than practical interest,” she noted. “People without current symptoms could be infectious. Act accordingly.”

Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, also weighed in on the controversial WHO comments, telling Good Morning America on June 10 that Dr. Van Kerkhove's initial statement that asymptomatic SARS-CoV-2 transmission is a rare event is "not correct." 

This article was updated 6/10/20.

A World Health Organization (WHO) official is walking back her comments characterizing the spread of SARS-CoV-2 by asymptomatic individuals as “rare.”

Maria Van Kerkhove, PhD, WHO’s COVID-19 technical lead and an infectious disease epidemiologist, caused a stir June 8 when she said that countries are reporting that many of their asymptomatic cases develop into cases of mild disease. For patients with truly asymptomatic disease, countries are “not finding secondary transmission onward. It’s very rare,” she said.

Suppressing symptomatic cases, on the other hand, would result in a “drastic reduction” in transmission, she noted. “But from the data we have, it still seems to be rare that an asymptomatic person actually transmits onward to a secondary individual,” she said.

But on June 9 – following a day of confusion and criticism – Dr. Van Kerkhove sought to clarify her comments on asymptomatic transmission during a live social media Q&A. She noted that while “the majority of transmission that we know about” is through individuals with symptoms, “there are a subset of people who don’t develop symptoms, and to truly understand how many people don’t have symptoms – we don’t actually have that answer yet.”

Between 6% and 41% of individuals may be asymptomatic based on estimates, she acknowledged.“What we need to better understand is how many of the people in the population don’t have symptoms, and separately, how many of those individuals go on to transmit to others,” she said.

Dr. Van Kerkhove also emphasized that her initial comments were made in response to a question raised at the press conference, and called it a misunderstanding. “I wasn’t stating a policy of WHO or anything like that,” she said. “I was just trying to articulate what we know.”

The phrase “very rare” referred to a subset of studies and reports WHO had received from its member states following asymptomatic individuals with COVID-19. “I was referring to some detailed investigations, cluster investigations, case contact tracing, where we had reports from member states saying that, when we follow asymptomatic cases, it’s very rare – and I used the phrase very rare – that we found a secondary transmission,” she said.

Dr. Van Kerkhove’s initial comments drew criticism from medical and public health professionals, who said the statement was “confusing” and communicated poorly.

Eric J. Topol, MD, tweeted that WHO had “engendered considerable confusion” with the comments about asymptomatic individuals rarely transmitting SARS-CoV-2. Dr. Topol, the author of a recent analysis published in Annals of Internal Medicine that suggested as many as 40%-45% of COVID-19 cases may be asymptomatic, said that it was not possible to determine whether asymptomatic individuals in the cohorts he studied were capable of spread like pre-symptomatic individuals. “We only know the viral loads are similar from multiple reports. And we do know some spread occurs from [asymptomatic] people,” he said.

Andy Slavitt, former acting administrator of the Centers for Medicare and Medicaid Services, said in a tweet that he believed WHO made “an irresponsible statement even though it was based on legitimate observations.” Reports by Member States do not reach a “bar of rigor,” he said.

Natalie E. Dean, PhD, assistant professor of biostatistics at the University of Florida, tweeted that the initial comments by the WHO seemed to be trying to draw a distinction between asymptomatic individuals who never develop symptoms, and presymptomatic individuals who present as asymptomatic, but later develop symptoms. Finding that asymptomatic cases rarely transmit the virus could change how people exposed to those asymptomatic individuals are monitored, but “it seems more of scientific than practical interest,” she noted. “People without current symptoms could be infectious. Act accordingly.”

Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, also weighed in on the controversial WHO comments, telling Good Morning America on June 10 that Dr. Van Kerkhove's initial statement that asymptomatic SARS-CoV-2 transmission is a rare event is "not correct." 

This article was updated 6/10/20.

A World Health Organization (WHO) official is walking back her comments characterizing the spread of SARS-CoV-2 by asymptomatic individuals as “rare.”

Maria Van Kerkhove, PhD, WHO’s COVID-19 technical lead and an infectious disease epidemiologist, caused a stir June 8 when she said that countries are reporting that many of their asymptomatic cases develop into cases of mild disease. For patients with truly asymptomatic disease, countries are “not finding secondary transmission onward. It’s very rare,” she said.

Suppressing symptomatic cases, on the other hand, would result in a “drastic reduction” in transmission, she noted. “But from the data we have, it still seems to be rare that an asymptomatic person actually transmits onward to a secondary individual,” she said.

But on June 9 – following a day of confusion and criticism – Dr. Van Kerkhove sought to clarify her comments on asymptomatic transmission during a live social media Q&A. She noted that while “the majority of transmission that we know about” is through individuals with symptoms, “there are a subset of people who don’t develop symptoms, and to truly understand how many people don’t have symptoms – we don’t actually have that answer yet.”

Between 6% and 41% of individuals may be asymptomatic based on estimates, she acknowledged.“What we need to better understand is how many of the people in the population don’t have symptoms, and separately, how many of those individuals go on to transmit to others,” she said.

Dr. Van Kerkhove also emphasized that her initial comments were made in response to a question raised at the press conference, and called it a misunderstanding. “I wasn’t stating a policy of WHO or anything like that,” she said. “I was just trying to articulate what we know.”

The phrase “very rare” referred to a subset of studies and reports WHO had received from its member states following asymptomatic individuals with COVID-19. “I was referring to some detailed investigations, cluster investigations, case contact tracing, where we had reports from member states saying that, when we follow asymptomatic cases, it’s very rare – and I used the phrase very rare – that we found a secondary transmission,” she said.

Dr. Van Kerkhove’s initial comments drew criticism from medical and public health professionals, who said the statement was “confusing” and communicated poorly.

Eric J. Topol, MD, tweeted that WHO had “engendered considerable confusion” with the comments about asymptomatic individuals rarely transmitting SARS-CoV-2. Dr. Topol, the author of a recent analysis published in Annals of Internal Medicine that suggested as many as 40%-45% of COVID-19 cases may be asymptomatic, said that it was not possible to determine whether asymptomatic individuals in the cohorts he studied were capable of spread like pre-symptomatic individuals. “We only know the viral loads are similar from multiple reports. And we do know some spread occurs from [asymptomatic] people,” he said.

Andy Slavitt, former acting administrator of the Centers for Medicare and Medicaid Services, said in a tweet that he believed WHO made “an irresponsible statement even though it was based on legitimate observations.” Reports by Member States do not reach a “bar of rigor,” he said.

Natalie E. Dean, PhD, assistant professor of biostatistics at the University of Florida, tweeted that the initial comments by the WHO seemed to be trying to draw a distinction between asymptomatic individuals who never develop symptoms, and presymptomatic individuals who present as asymptomatic, but later develop symptoms. Finding that asymptomatic cases rarely transmit the virus could change how people exposed to those asymptomatic individuals are monitored, but “it seems more of scientific than practical interest,” she noted. “People without current symptoms could be infectious. Act accordingly.”

Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, also weighed in on the controversial WHO comments, telling Good Morning America on June 10 that Dr. Van Kerkhove's initial statement that asymptomatic SARS-CoV-2 transmission is a rare event is "not correct." 

This article was updated 6/10/20.