Avoiding COVID-19 when following the guidelines seems impossible

By now, we all know the drill: Maintain physical distance. Wear a mask. Wash your hands. Avoid people who are sick and stay away from others if you are sick. While these measures may seem simple enough, they are not easy to keep up month after month. Yet they are likely to be with us for a while.

But what about those who cannot comply? Certain conditions can make the standard measures to stay safe during the pandemic seem impossible. At the same time, some of those likely to have the most trouble following the guidelines — such as older people with dementia — are at higher risk for illness and death if they do become ill. And the risk for spreading infection to others by not wearing face coverings, washing hands regularly, and observing physical distancing remains very real.

Mitigation efforts are harder for some than others

People who may have the most trouble complying with pandemic-related restrictions include those with

• Dementia. Without constant supervision and reminders, people with cognitive problems may take off their masks or wear them incorrectly, and fail to maintain distance from others.
• Breathing problems. Although for healthy people there is no evidence that commonly worn cloth masks lower your oxygen levels or raise your carbon dioxide levels, those who have lung disease (such as asthma, emphysema, or cystic fibrosis) may find it particularly uncomfortable trying to breathe through a mask.
• Claustrophobia. Wearing a mask may make people with claustrophobia feel panicky or smothered. And this not a rare problem: claustrophobia is the most common phobia, affecting 5% to 10% of the population.
• Depression and anxiety. For people who struggle with mood or excessive worry, concerns about one’s health and the health of loved ones, and the limitations placed on social interactions, may make these conditions worse. According to recent National Center for Health Statistics data, symptoms of anxiety or depression have more than tripled since this time last year.
• Autism spectrum disorder. Difficulties with social skills, a need for routine, and a reliance on support services such as behavior or speech therapy are everyday challenges for many people with autism spectrum disorder. The pandemic has made these challenges even greater. A heightened sensitivity to touch and difficulty with nonverbal communication can make wearing a mask especially problematic.

Even the experts urging us all to wear face coverings to lower rates of illness and deaths recognize that some cannot comply. Still, there are steps that folks in these situations can take to reduce the risk of becoming infected with the virus that causes COVID-19 and spreading it to others.

What can be done?

There are no easy answers here. I know of at least one memory care center that has largely given up on requiring mask wearing for some of its residents (though staff are still required to wear them). While not ideal, it’s the most practical option. And other measures are still followed: every resident is surveyed about symptoms and has temperature checks daily, chairs and activities are set up to encourage physical distancing, and the number of people in a room is limited. Gentle and frequent reminders and redirection to prevent crowding, increase handwashing, and encourage mask wearing (if possible) are now part of the routine in most nursing homes and long-term care facilities.

The Alzheimer’s Association also recommends extra reminders to wear a mask and wash hands for people living at home with dementia. Visual cues around the home can help. Try tacking up images of people in masks — including their favorite actors or even superheroes — and written reminders in several spots explaining the rationale for all the handwashing and face masks. If possible, try to increase social support (while maintaining physical distance) for those with dementia living at home. For example, if someone living in a memory care center usually talks to family members on the phone once or twice a week, perhaps three or four times a week would be a good idea while social distancing restrictions are in place.

Those with breathing problems may be able to tolerate wearing a mask for short periods. If a particular mask seems too uncomfortable or restrictive, try another type. There are masks of many shapes, sizes, and fabrics out there, and it’s worth trying more than one type of mask before giving up on them. If wearing a mask still seems impossible, conscientious physical distancing and frequent handwashing may make face coverings less necessary. For anyone whose respiratory condition is so severe that wearing a mask is impossible, experts suggest that the safest course of action is to avoid public places rather than relying on “mask exemptions.”

People with depression or anxiety may need to consult more often with their mental health providers during the pandemic. Adjustments in behavioral therapies or medications may help. Claustrophobic people may find that wearing a mask at home for short periods, and gradually increasing the amount of time, may make it easier to consistently wear one in public.

Experts working with people who have autism spectrum disorder recommend a number of ways to help with mask wearing, including education about the rationale for wearing them, demonstrating the use of a mask on a favorite object or person, allowing the person to choose among different types of masks, and wearing the mask for only short periods of time to start. Transparent face masks that make the mouth or face of the speaker visible may be a good option.

The bottom line

While we should not have an expectation that people with certain medical or psychological conditions will be able to follow the guidelines perfectly, that’s one more reason we should maintain high expectations for everyone else.

For more information about coronavirus and COVID-19, see the Harvard Health Coronavirus Resource Center.

Follow me on Twitter @RobShmerling

The post Avoiding COVID-19 when following the guidelines seems impossible appeared first on Harvard Health Blog.

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Smoking and vaping can make covid-19 more severe

Getty Images photo via University of Ky.

By Audrey Darville
Associate professor of nursing
University of Kentucky

Though studies are still ongoing, more is known about the risks of smoking and covid-19. Early reports found people sickened with covid-19 had worse outcomes if they smoked. Recent studies have found that people who smoke have double the risk of severe infection compared to those who do not smoke.

Smoking and vaping:

• Damage to the lungs' natural defenses against invasive bacteria and viruses.
• Expose users to chemicals that weaken the immune system and limit the body’s ability to fight infection.
• Increase the risk of heart and lung disease, conditions which increase the risk of severe complications from covid-19.

The hand-to-mouth action of smoking and vaping can increase the risk of exposure to bacteria and viruses. Smoking one pack a day results in around 300 hand-to-mouth contacts. Smoking and vaping also decrease mask-wearing time, limiting protection from virus exposure.

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The lowdown on the low-FODMAP diet

Irritable bowel syndrome (IBS) is a common intestinal disorder that produces distressing symptoms like abdominal pain, significant bloating, and altered bowel movements that can shuttle between diarrhea and constipation.

While changing what you eat won’t cure you, an evidence-based approach called the low-FODMAP diet is the most frequently prescribed food plan to help relieve IBS symptoms. Studies show it can reduce symptoms for the majority of patients. However, because of certain challenges and risks associated with the low-FODMAP diet, it’s worth talking to an expert before you try it.

FODMAP basics

 The low-FODMAP diet addresses four types of fermentable carbohydrates: oligosaccharides, disaccharides, monosaccharides, and polyols (collectively referred to as FODMAPs). While the names sound somewhat abstract, the foods found within these groups are often too familiar to those with digestive woes.

Oligosaccharides are present in foods like wheat, beans, garlic, and onions, while the disaccharide lactose is prevalent in dairy products like ice cream and milk. Monosaccharides refer to foods with excess fructose, and are found in items like apples, mangos, and honey. The final group, sugar alcohols, are found in some artificially sweetened products like chewing gum, and are naturally present in foods like avocados and mushrooms.

Though the FODMAP carbohydrates can trigger digestive discomfort for anyone when consumed in large amounts, much smaller portions can worsen symptoms for those with IBS.

A multiphase approach to a low-FODMAP diet

The low-FODMAP diet is meant to be undertaken in three phases. In the first phase, all high-FODMAP foods are eliminated from the diet for an extended period of time, often four to six weeks. In phase two, you systematically reintroduce restricted foods, noting how well you tolerate increasing quantities of the foods you’re reintroducing. Phase three is the personalization phase, in which you only avoid foods in quantities that cause symptoms.

This multiphase process can be complex and confusing, and requires substantial food knowledge. For instance, most varieties of soymilk are high-FODMAP. Extra-firm tofu, on the other hand, while also made from soybeans, is low-FODMAP. Guidance from a dietitian can be helpful for navigating this diet, but insurance coverage and medical referrals can be barriers to scheduling an appointment. As a result, some patients simply receive a list of low- and high-FODMAP foods.

Risks associated with not reintroducing some high-FODMAP foods

While avoiding high-FODMAP foods can be difficult, adding the carbohydrate groups back systematically to test tolerance can be even more challenging. Some people become hesitant to reintroduce items, especially if they have experienced significant symptom relief during the elimination phase. This increases the potential for nutritional risks. For example, it’s common for people avoiding dairy to have inadequate calcium intake.

Other lesser-known nutrients, like magnesium, are also a concern. Some of the best dietary sources of magnesium come from beans and nuts like almonds and cashews, which are usually restricted during the initial phase of the diet. In addition, people with IBS may already be at increased risk of magnesium deficiency due to digestive symptoms like diarrhea.

There is also concern that long-term restriction of high-FODMAP foods changes the makeup of bacterial colonies in the gut, which may negatively impact intestinal health and possibly worsen digestive issues over time. Oligosaccharides, in particular, are an important energy source for beneficial bacteria. This is particularly worrisome for individuals with IBS, who have been shown to have lower levels of protective intestinal bacteria and higher levels of potentially harmful inflammatory microbes. Probiotics have been suggested to restore such bacterial imbalances, but this remains contentious, and the American Gastroenterological Association recently published guidelines that recommend their use in IBS only when participating in a research study.

Low-FODMAP is not for everyone

The low-FODMAP diet is not intended for individuals without IBS, nor is it appropriate for everyone with the condition. It should be avoided by anyone with an eating disorder, as it may worsen food fears and diet restrictions. This is particularly notable because those with gastrointestinal issues appear to have a higher prevalence of disordered eating compared to the general population. In addition, people with already restricted diets, such as vegans or those with food allergies, may be unable to meet their nutritional needs on the diet. Those who are already malnourished or underweight are poor candidates, as well. The diet is not as well researched for other gastrointestinal conditions, so it’s generally best to avoid the diet if you don’t have IBS, unless otherwise advised by a doctor or dietitian.

Finding an alternative approach

 If the low-FODMAP diet is not a good option for you, simply cutting back on high-FODMAP foods in your diet, without entirely eliminating any food groups, may be an alternative. If your diet contains many common offenders like garlic, onions, beans, apples, milk, mushrooms, and wheat, a simple reduction may help decrease symptoms.

To find a list of registered dietitians who can help you to safely make changes, click here. Or contact a nutrition practice to ask if they have someone knowledgeable about the low-FODMAP diet.

The post The lowdown on the low-FODMAP diet appeared first on Harvard Health Blog.

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Data and health directors' observations suggest that pandemic lockdown increased overdoses, which declined as state reopened

Graph from Kentucky Injury Prevention Research Center, University of Kentucky

By Melissa Patrick

Kentucky Health News

Opioid overdoses reported by Kentucky hospitals and ambulance services shot up in the two months after Gov. Andy Beshear declared a state of emergency because of the covid-19 pandemic, and have been on a downward trend since the state started reopening in mid-May.

"I don't want to give false hope," Dana Quesinberry, research core director for the  Kentucky Injury Prevention and Research Center, said as she explained the data on hospital emergency departments' and emergency medical services' reports of "overdose encounters," a term KIPRC uses because overdoses may be suspected but not necessarily confirmed.

"We are still at higher levels than we've ever been, but the fact that we are seeing that decline over the last few weeks is very important," Quesinberry said. "There is hope that we are making progress again, so whatever triggered the increase is being managed or mitigated in some way." 

She said the data coincides with preliminary reports that also shows an uptick in overdose deaths during April and May. Quesinberry said official 2020 overdose death numbers are not yet available, but "Preliminary data indicates that we have had increases in drug overdose deaths during covid."

For April, "We are still looking at a monthly count that exceeds at least anything in the prior couple of years, in a month total." She added later, "We are seeing increases in May as well." 

Quesinberry said researchers will need to explore what triggered the peak in overdose encounters and then look at what slowed it down.  

"We know that there has been an impact on the opioid epidemic during covid and we are working very hard to understand what that impact has been," she said, adding later, "This is a time of tremendous uncertainty driven by the pandemic. It's important to understand that it has consequences beyond the spread of infectious disease."

Quesinberry is also an assistant professor for the Department of Health Management and Policy at the University of Kentucky. 

Public health reports coincide

Christie Green, public-health director of the Manchester-based Cumberland Valley District Health Department, said she had heard anecdotally that there were several overdoses about three weeks ago related to a batch of pressed pills that were being sold as Xanax, but were mostly fentanyl -- a synthetic opioid that is much stronger than heroin. 

"This is the first time that I've gone through something that is socially stressful like covid . . . while working so closely with people who are active in substance-use disorder, and it's just been really hard on them," Green said. "A lot of their social supports are gone. I really worry about them, honestly."

Marcy Rein, public-health director of the Whitley County Health Department, said her health department signed up for a system called ODMap in May to track overdoses in the community, along with about 40 other counties and health departments in the state.

"The system allows us to look at the big picture, to look at the maps to see if we have hotspots in a particular area or not," she said. She said a rash of overdoses in May prompted them to join the system. 

Rein said preliminary data shows that the pandemic is having an impact on rates if suspected overdoses: "We're not saying that covid causes the increase in overdoses, but certainly some of the factors that go along with covid most certainly put people at higher risk, like the isolation and also the economic impact."

Andrea Brown, public-health director of the Bourbon County Health Department, said it saw an increase in overdoses in April, and started keeping track of those numbers more diligently in May after signing up for ODMap, which she said only records EMS-related encounters, at least for now.

She said the EMS-only data shows that from from May 5 to July 19, almost two and a half months, Bourbon County had 28 overdoses and five fatalities. Brown estimated that the county had 11 overdoses in April but wasn't sure how many died.

"We are still getting overdoses," she said. "I feel like last year we may have had 12 overdose deaths, something in that ballpark, so if we've already had five between May and July, then I think we are really, once the data actually comes out, we're probably going to see a much higher increase." 

Brown said the health department's harm-reduction syringe exchange has been giving out more Narcan, which can block the effects of an overdose, "so I think the word on the street is probably getting around that there has been an increase of overdoses in our community. The Narcan is definitely a hot ticket item right now."

Jamey Whaley, harm-reduction and-peer support specialist with the Maysville-based Buffalo Trace District Heath Department, said some of his syringe-exchange participants have reported an increase in overdoses where they have had to administer Narcan. He said he is also seeing people relapse and return to the program. 

"I don't know if that's because of the covid and the mental-health side of it that has made them decide to go back to using," he said. 

Scott Lockard, public health director at the Hazard-based Kentucky River District Health Department, said Eastern Kentucky has seen an influx of pressed tablets with fentanyl and carfentanyl, noting that Lee County saw a huge uptick in overdoses from a substance called "smurf dope" just a few weeks ago. WLEX-TV reported July 1 that smurf dope is a bright blue substance that is a mixture of methamphetamine or heroin and fentanyl. 

"I think any time you see a different substance than what people normally utilize, there is an adjustment period in how they use it and the strength, the purity level of it when it is a fentanyl or carfentanyl," Lockard said. "If somebody has been abusing Suboxone, which is a pharmaceutical-grade substance, and then now they are dealing with these pressed tablets, that's where I think it increased a lot of the issues that we were seeing with the increase in overdoses."

He said anecdotally, based on what he hears from EMS, law enforcement and harm-reduction people, there have been fewer overdoses near the end of June and in July.

John Moses, team leader for harm reduction services at the Lexington-Fayette County Health Department, said the county is on pace to equal the number of overdose deaths in 2017, which were the most ever. 

"Last year Lexington-Fayette County had a total of 122 overdose deaths; we are already at 107 for the year," he said. "Last year we did a really good job of getting the overdose rates down, but thanks to covid, I believe that we are seeing more overdose deaths." 

"Covid has had a huge impact on substance use because it has led to more isolation," Moses said. "I have a feeling that we are seeing a lot more people relapse and go back to using again. I think that people who maybe work full time and only did drugs on the weekend were laid off and now may be doing drugs seven days a week. We know that when people are isolated like that, there is a lot more depression and that always has an effect on drug use."

Moses also noted that anytime there is an interruption in the drug supply, which has been seen during the pandemic, more fentanyl comes into the community.  He said it is being mixed in with heroin, methamphetamine, cocaine and even THC vape cartiridges, and "This disruption in the drug supply has caused more fentanyl to be here, and more overdoses."

For help in finding treatment for substance-use disorder for yourself, a friend, or loved one, the state has a website: findhelpnowky.org.

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Pandemic depresses vaccination rates; doctors and insurer say parents should feel safe taking children for health-care providers

By Lisa Gillespie
Kentucky Health News

Not as many Kentucky children are getting critical vaccinations as they did previous years, tracking a nationwide trend of parents staying away from health-care centers to avoid the coronavirus.

Last April, 27,906 Kentucky 1-year-olds were vaccinated for diseases such as Hepatitis B, influenza, polio and measles/mumps/rubella. But only 17,463 1-year-olds were vaccinated in April 2020.

And only 4,219 4- to 6-year-olds, a crucial age range for key vaccinations, were immunized in Kentucky in April 2020, fewer than one-fourth the 18,394 vaccinated in April 2019. That’s according to data compiled by the state Cabinet for Health and Family Services. The data is voluntarily reported, so the actual numbers may be higher.

According to the U.S. Centers for Disease Control and Prevention, vaccination rates nationwide are down. On average, about two-thirds of infants at 5 months old from 2016 to 2019 received vaccinations, but only half did in May 2020.

The CDC reports similar trends among all Americans under 18, with non-influenza vaccination rates decreasing by 21.5%. Jones said the trend puts children and babies at higher risk for diseases like the measles, whooping cough, chicken pox and others that can be prevented with vaccinations.

WellCare, a health insurer in Kentucky, is urging parents to get their child’s vaccinations now that health-care providers are fully open for business.

“Now that some requirements have been eased in the state, it’s likely that a catch-up period will coincide with the usual summer rush of students needing updated immunizations for school and college,” WellCare CEO Bill Jones said in a press release. “We encourage all parents to schedule immunizations now, to ensure children are protected from vaccine-preventable diseases and outbreaks.”

Dr. Sean McTigue of Kentucky Children’s Hospital told Kentucky Health News in June that most doctor's offices have created ways to minimize virus exposure. These include conducting well-child visits only in the morning, and sick child visits in the afternoon. Health providers are also having patients wait in their cars instead of waiting rooms.

Tigue also said it’s very important for children under 2 to get immunized because the majority of childhood vaccinations are recommended during those early years.

"For a child who may have been born in the month or two preceding the health emergency,” he said, “you could have a child who has received essentially no vaccines and is really unprotected against many infections that are quite deadly and are fully preventable by vaccine.”

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