Katelyn Kesheimer – Insects of Industrial Hemp: Year One

Katelyn Kesheimer – Insects of Industrial Hemp: Year One


– [Katelyn] Hi everyone, my
name’s Katelyn Kesheimer, and I’m an Extension entomologist
with Auburn University and Alabama Cooperative Extension Service. Today I’ll be giving a brief overview of insects that attack industrial hemp. Many of you are aware that
this is the first year that industrial hemp can
legally be grown in Alabama thanks to the 2018 farm bill that classifies it as an
ordinary agricultural commodity. And a few states outside Alabama have been growing hemp since 2015 or so with the passage of the 2014 farm bill. But prior to that, hemp
has not really been grown in any major capacity since World War II. However, lots has changed
in the past 70 years, and now that we’re back to
growing industrial hemp again, there is much to be learned. So today I’m gonna give a
quick background on hemp, and so far what we learned this first year about pest management in Alabama. So when I talk about industrial hemp, I’m talking about the
plant Cannabis sativa. The genus Cannabis
includes multiple species that produce these unique
compounds that are not found in any other plants
that we know of so far. And cannabis can be broadly separated into two distinct groups, and these include marijuana
and industrial hemp. Now, we all know that marijuana is illegal to grow in Alabama, but while these two groups,
marijuana and industrial hemp are used for two very different purposes, they are impossible to distinguish
from each other visually, and they will interbreed out in the wild. So talking about marijuana that is bred and grown
for its THC content, which is a psychoactive compound. These plants are almost exclusively grown indoors in greenhouses and cultivated for that THC content. On the other hand, we
have industrial hemp, and the major difference
here is the low THC content, is less than .3% THC. And industrial hemp can be grown indoors similar to marijuana, but
it’s also grown outdoors like when you think of a typical row crop shown in this picture here. And it’s bred and grown
for a variety of end uses including fiber, seed and cannabidiol which is used as medicinal
compounds, also known as CBD. So I mentioned there’s a
lot of different end uses, it’s a very versatile plant, and it can be grown for
seed and fiber production, seed can be used for human consumption, and it’s similar to growing
small grains in the field. Hemp grown for fiber can be
used for a variety of things such as clothing, paper,
rope, or building materials. And that’s one of the
reasons it was so popular about 100 years ago. And then hemp grown for fiber and seed are usually grown from seed in the field and have a much higher plant density in the field than those grown for CBD. And so plants grown for CBD is really the majority of the plants grown in Alabama right now. These are much lower density
plantings in the field, and are typically started as transplants, shown here in the greenhouse, and then moved into the field. And these are primary female plants which are the desirable plants as opposed to the male
plants that are also created. And there’s also a lot of variation just in the way that hemp is grown, it’s a very new crop, there’s no real kind of standard protocol for growing it as we’re still kind of
figuring things out. It’s grown outdoors in
the field, on plastic, pots, high tunnels, greenhouses, so there’s lots of variation with it. And with that variation
of growing methods, indoors and outdoors,
comes a lot of pests. These weeds and diseases and insects aren’t really gonna wait
for us to figure out the agronomics of the
crops before they show up, so here we are, and we have to kind of figure it out as we go along. For the next few minutes, I’m gonna focus primarily on insects, but I do just wanna mention
that as you’re growing, it’s really important to have a solid integrated pest
management program, that should be in place
for any type of pest. Especially with hemp because
we know very little about it and you’re gonna get inundated with weeds and diseases and insects. Any of these can hinder the
production of your crop. A lot of the questions this year have focused on pesticide usage and what can we spray to kill the weeds to stop this disease from
spreading, to kill this insect, but there are several other
things that are part of a good IPM strategy that you can do before you wanna even think about spraying that will really help your crop. And so when it comes to pest management, there’s all these different strategies. People usually think about
pesticides or chemical control as their first line of defense, but really, as shown
in this triangle here, it should be your last resort, it should be the last thing you consider. Because there’s a variety of strategies, and if you employ all these strategies and create a healthy crop,
if you have a healthy plant, it is more resistant to
these pests and diseases, it’s able to fight off
more of these problems and can maybe sustain some damage that isn’t going to be economical. And so starting with
cultural and sanitation, cultural control and sanitation, keeping your plants healthy, starting with good, clean seed, starting with a good
clean soil, clean field, making that environment
less hospitable for pests, making sure you’re not going into a field that’s already filled with
weeds or filled with pests that have overwintered and have
just a leg up on your crop. Another often overlooked
method is mechanical control. Just getting out there,
scouting for your pests and hand removing those insects,
creating physical barriers. Sticky traps are really good if you’re growing indoors
in the greenhouse. And then thinking about what are our free options for biological control? What are our natural enemies
that are gonna be out there that can help reduce some
of the pest populations? And so I mentioned pesticides
should be your last resort. If you end up spraying your hemp, it should be used as a
sensible control option. And most importantly, in
accordance with label directions. The label is the law, and so you have to make
sure to follow that label. And so I realized as
we’re in this first year, there’s a lot of confusion, a lot of misinformation
about what we can use in terms of chemicals on hemp. And so just a few things to think about before you put any chemical on your hemp. The number one thing to know is all pesticides used on
hemp have to be registered with the Alabama Department
of Agriculture and Industries. It’s the responsibility of the producer to make sure that the
pesticide can be used legally. And so this goes back to reading the label because that label is the law. And additionally, we have these rules that are put in place
by the state of Alabama, but then if you’re gonna take your hemp to a processor or a buyer, they may have a separate
set of regulations. And so I implore you before
applying any chemical to give your processor
or your buyer a call to make sure that they will still accept the product after the
chemical has been applied. Having this information
beforehand is crucial to ensure that you will pass, because a lot of these
processors have lists of chemicals that they
will and will not accept. They’ll also do residue tests for a lot of different substances and give the product a pass or fail, and so you wanna make sure
that if you put all this time and money into growing the
crop, that it’s going to pass. And finally, be very cautious of any lists that are not released by
the Alabama Department of Ag or Alabama Cooperative Extension. These have not been approved by the Department of Ag
in the state of Alabama. There’s some other lists going around that are approved by other states. And if you apply a product
that is on another state’s list but is not registered with the
Department of Ag in Alabama, it will result in your
crop being destroyed. If you have any questions
or are confused about this, feel free to give me a call, my contact information
will be at the end of this, or call the Alabama Department of Ag to verify the acceptability
of this chemical. Okay, now I’m just
gonna briefly go through what we have seen as some of
the major economical pests so far that are likely going to be major problems moving
forward with industrial hemp. This is not a comprehensive
list and it will likely change. I mentioned this is the first year, and so things may be very
different a year from now, but I imagine that these will
continue to be a problem. And so the first one is fire ants. These have been a major pest of hemp across the entire state of Alabama. Whether it’s grown in
open field conditions, in plastic, in pots, in
high tunnels, et cetera. What they’ll do is they’ll build mounds near the base of the plant underneath the pots,
underneath the plastic, and then they’ll tunnel into the stem as you can see in some
of the pictures here. Chewing and killing the seedlings, especially really young
plants are very vulnerable, and then after they kill a plant, they will quickly move to nearby plants. And then in many cases, it’s been so dry that you don’t see those stereotypical fire ant mounds that
you’re used to seeing, ’cause the ants get so
deep into the ground because it’s so hot. And so the picture on the bottom left here shows the yellowing and wilting
of a plant from ant damage, and you can see some of the tunneling and stripping of the bark that they’ve been doing
in fields this year. So recently we put out a pest alert about some of the products
that were approved through the Department of
Ag for fire ant control. These are all contact insecticides, which means they have to
find the fire ant mound and apply the chemical on
the mound to kill the ants. There is one bait in there, and that’s Extinguish Professional. And the bait means you put out the food, the ants go get it, and they
bring it back to the nest and feed it to all the
workers and the queen. The bait will obviously
be the most effective for long term control. But before applying, again,
check with your processor before to make sure that
they allow it even though this one has been approved
by the Department of Ag. And just one thing, when
using these products, especially the oils and the pyrethrins, these are all natural products and they’ll break down with UV exposure. And so you want to make sure you’re not applying them in full sun. Also, fire ants, they don’t wanna be out in the heat of the day,
they’re not gonna be foraging, they’re not gonna be at
the top of their mounds, they’re gonna be deep down in the deep part of the ground when it’s really hot in their tunnels. And so the best time to
apply these mound treatments is first thing in the morning
before it gets too hot or late in the day when it cools off. The other thing to think about is, these do need a lot of water to get into their
extensive tunneling system, so don’t cut back on water when you’re applying
some of these products. Our fire ant pest alert can be found at the URL at the bottom of this slide. The next major pest
that’s gonna be causing economic damage both indoors and outdoors are the hemp russet mites. These are a special type of
mites that’s very, very small. And what we know so far, these are a specialist on cannabis plants, and so they’re only gonna be
found on hemp or marijuana. When you’re getting plants
or scouting for them, I would highly recommend
investing in a hand lens or a magnifying glass if you have one, because you won’t see these mites without magnification
because they are so tiny on the plant unless
you’re looking for them, but you will see their
characteristic damage. So these pictures show characteristic hemp russet mite damage
with this upward curling of the leaves, yellowing, brittle leaves that can break off. And you can tell these are
different from spider mites if you’re familiar with
spider mite damage, because hemp mites do not produce the characteristic webbing
that spider mites do. However, they are similar to other mites in that
they are very prolific and they can explode in
populations if left unchecked. So you can see in this picture, it’s really bad mite damage, there’s thousands if not millions
of mites on these plants, and the bud’s already
starting to turn brown. So hemp mites can also
infest the flower tops and feed on the pistils, which will render the
female flower sterile. In the picture on the left, you can see the pistil is
healthy and white or green and hasn’t been damaged by mites. To contrast, the pistil on the right is turning brown from a
severe mite infestation. Unfortunately, we don’t
have a lot of information on the life history of hemp mites. Since they’re a specialist
on cannabis like I mentioned, there just hasn’t been a lot
of research done on them. For plants grown outdoors, they may overwinter on infested seeds. For indoor plants, they can
remain on plants year round. Anyone who’s grown plants
in a greenhouse or inside knows just how difficult it is and how much a pain in the butt mites are. And as the mite population increases and starts to kill the plant, they will crawl to the top of the plant to be dispersed naturally
by wind or water. And this is why early control and sanitation are so important. If you are receiving
transplants from a greenhouse, this is where you need
to get out your hand lens and inspect your plants very carefully. This is likely one of the main sources of hemp mites as they’re moving
around through the state. In terms of control, we don’t know a lot about biological control agents yet. That isn’t to say some
generalist predators won’t work, we just don’t know what they are yet. We have some data on what won’t work, but this is a very specific,
unique type of mite, and it behaves differently
than other mites that we have more experience with. And so it’s gonna take a
lot of time and research just to figure out what are the best
biological control agents. And there is some information about using oils like horticultural oils, and they are effective
against some russet mites like tomato russet mites, but they may or may not be effective against the hemp russet mites. Again, we just don’t have this research, and so the best option is to
scout your plants regularly and inspect anything coming from an indoor growing situation, because that’s really where you can have year-round mite infestations. Okay, and finally, there’s a whole host of caterpillars that are known to infest hemp and that we’ve already started to see around the state of Alabama. Historically, European corn
borer was the most destructive, but that really hasn’t materialized yet. But that’s not to say it isn’t a problem or won’t be in the future. There are defoliating caterpillars that we don’t think is gonna
cause a lot of problems, a lot of economical damage
as they chew the leaves. There’s also a hemp borer that hasn’t shown up yet in Alabama. It may be here, I just
haven’t found it personally. One of the main problems
we’re dealing with right now at the end of the season, it’s mid-September right
now, are the bud feeders. And these are feeding on the buds of the more mature hemp plants, both causing economic yield loss and then opening that bud up to infection which can cause bud rot, which will also lead to more yield loss. One of the other more abundant
caterpillars we’ve seen is the yellow-striped armyworm. Corn earworm is also really common. In a lot of instances,
proximity to other crops has determined both the abundance and severity of damage
by some of these pests, and so kind of look at your landscape and see what’s around you, is
there a lot of corn nearby, and use that to gauge
what the threat might be in terms of the caterpillar pests. But the point of this
slide is just to show that there’s a lot of different
species of caterpillars that may feed on hemp at
any given growth stage, and so it’s vulnerable to attack, and we’re still trying to figure out what is gonna be the most damaging, but right now it looks
like these bud feeders are having the biggest impact in terms of economic yield loss. So what can you do? The best thing really is just to be out there scouting your crops to control the caterpillars early. You’ll likely see the feeding damage or frass, which is insect poop, before you see the worms
because they’re really small, they can be cryptic, they
might hide under the leaves in the heat of the day. And sometimes even giving the lack of chemical control options
that we have right now, hand removal may be your best option. But keep in mind that as we get into these later growth stages of these caterpillars, they become increasingly difficult to kill. Bigger caterpillars do more damage, they feed more, and
they’re harder to kill, even if we had all the
chemical options available, a lot of them don’t even
touch these late instar fourth, fifth instar caterpillars. And so the best thing you can do is find them when they’re really young, when they’re only 1/4
inch or smaller at most. And so you really need to be
out there inspecting your crop to make sure that you don’t
have these caterpillars. And so I mentioned it a minute ago, but one of the biggest
problems we’re seeing right now is with corn earworm. They’re still around, the corn
either has been harvested, or even some of the late planted corn is past that silking stage, and so the corn eraworm moths do not want to lay eggs
in the more mature corn, and so the most attractive
crop to them right now is all the hemp that’s around. The hemp has these beautiful flowers and it’s just really attractive
for these moths to lay eggs, for them to hatch and have these nice buds for them to feed on. And once that bud gets a wound
from caterpillar feeding, it now becomes vulnerable
to infection from pathogens, and so this is where we’re
seeing a lot of bud rot in the last couple weeks
with this more mature hemp. So looking ahead, we are seeing some pests that are
causing economic damage, fire ants, mites, caterpillars,
namely yellow-stripe armyworm and corn earworm. But there’s a lot of information gaps. We don’t know what the
relationship between these insects and yield loss is quite yet, and as a result, we haven’t
developed economic thresholds. Just because we have
some insects on the plant doesn’t necessarily mean it’s a problem, it doesn’t mean it’s gonna
lead to economic yield loss. But hopefully some of these questions we can answer moving forward. We expect very much so in 2020, and in coming years
there will be an increase in the acreage of hemp grown
in Alabama and other states, and this will likely lead to an increase in the number and diversity of insects, weeds, and diseases that
can move into the crop. And so it’s important
just to stay vigilant. In 2019, we had approximately 10,000 acres approved for
growing hemp in Alabama, and I imagine that will
go much higher in 2020. And so just stay on top of your scouting and proper identification of
any pest we see in the field. And I understand that we have a lot of legal uncertainties
regarding pesticide usage between the state and federal government, the USDA is hopefully getting ready to release some rules in the coming weeks, and so hopefully that’ll add some clarity to this issue with pesticide usage. But if you have any questions or are confused about what product to use, if you can use it, please
get in touch with me. Please get in touch with someone from the Alabama Cooperative
Extension Hemp Action Team. We are happy to answer your questions. We’d much rather answer your questions than you apply something you can’t then have to deal with
your crop being destroyed. But right now we just have more questions than we do answers, and so as
a researcher, this is great, but there’s just a lot of information gaps that we need to fill moving forward. I hope this was helpful,
here’s my contact information. Please don’t hesitate
to get in touch with me. And hopefully we can get your questions on industrial hemp answered
moving forward, thanks.

How Do You Get Rid Of A Yeast Infection Under Your Breast?

How Do You Get Rid Of A Yeast Infection Under Your Breast?


How do I get rid of a yeast infection under
my breast? This is a question I’ve been asked a couple of times. Not so much as many of
the other ones, but it’s an important one to answer. First thing to determine is whether it is
a yeast infection or not, and sometimes a swab will do this. Sometimes a good visual
inspection will give you that idea, but generally in areas like the folds of the skin around
the belly or under the breast or between the buttocks or even around the thigh area, if
a person’s quite large, of course, this is going to be a perfect breeding ground for
Candida. You’ve got the darkness, the moisture, perspiration, all that in that area and Candida
is going to like to grow in that area. The most obvious thing to do is to if it’s
possible is to look at some kind of breast reduction or how we can stop this skin from
sort of like hanging together there creating that. Maybe a bra or some kind of a device,
but you’re going to spend regular attention to that area to help overcome it. This condition
needs to be treated both locally as well as systemically.
I’ve had many women from Australia, New Zealand; I’ve treated with this condition over the
past many years, and generally I find my satisfactory long-term resolution is weight loss. Weight
loss will help because it’s going to help the body generally strengthen the immune system,
increase digestive function, we can get the bowel back in order again, reduce the ability
of the body to grow Candida internally, and also help it, therefore, externally. And externally,
we apply things like calendula cream or tea tree oil. We have showers twice per day. We
can get a natural kind of a powder and put dry powder under the breast area there to
keep the moisture away from the region that’s causing it. I wouldn’t use fungal creams if
I were you. I’d probably use a tea tree oil cream, as you can get these kind of products
at a good health food shop, a good cream with tea tree oil.
So dryness, sunshine, these are enemies of Candida. Allowing sun exposure to that area.
Keeping the area dry. Maybe some form of barrier for a while. Weight loss. Local application.
Internal treatment. Internal treatment follow my Candida Crusher program. Go to yeastinfection.org.
Do my quiz on CandidaCrusher.com to determine if you’re mild, moderate or severe and then
definitely treat the outcome based on the quiz. The quiz is amazing. We spent a lot
of time and money on that quiz to get it perfect. It’s the best quiz online. So you’ll be able
to determine with a high degree of accuracy how bad this is affecting you internally as
well as around the breast region. So give those suggestions a go. Thanks for
tuning in.

HEALTH SCARE EPIDEMIC TRUMP ADMINISTRATION NOT REPORTING~ MAY IMPACT 2018 MIDTERM ELECTIONS


Hi it’s Kim here, So I’m sitting in the
car about to drive home of my groceries away and I’m reading a change.org
petition and it says, sign this petition to take away Congress’s health care and
I was like dang, I signed it. Yeah it’s really sick, huh? Well guess what they
were about to do? These people a cut just a little while back we’re going to take
away 24 million people’s health care, ok. The petition was developed by a guy
whose father died because he didn’t have health insurance and he waited too long.
He died of cancer. He didn’t make it. So, apparently our
Congress people are so fucking immature and developmentally… just don’t know what
to say… They don’t get that… if you take away people’s health insurance that will
make them die. Ok so, I sign a petition saying I’m going to do it to them so
that maybe like a little three or four year old they’ll catch on that gosh
that’s not a really cool thing to do. We’re one of the only countries in the
world that’s considered a developed nation that doesn’t have universal health care.
What the fuck is wrong with our government? They’re supposed to work for
the people, Instead, they’re working to make themselves
wealthy and make themselves the elitists who run our country. you

Zombie Parasites | Nat Geo Live

Zombie Parasites | Nat Geo Live


( intro music )Parasites are not degenerates,they’re actually maybe the most
successful life form on earth.
And they do all sorts of
amazing things.
They were using their hostsfor all sorts of
nefarious purposes
to get what they needed.If you see a ladybug huddled
over some little bit of fluff,
you’re looking at a
zombie bodyguard.
( applause ) So originally when they were
organizing this talk, they were trying to
convince us to, dress up and I wasn’t quite
willing to do that. But, I did bring
my favorite T-shirt, so… If you can’t tell,
that’s a schistosome there. ( audience laughing ) So, my goal in this in photographing these
creatures was to… get past this visceral aversion
we all have towards parasites, and try to show how amazing
these creatures really are! So, if I’m going to try to
convince you that parasites are cool, I’m going to start with
the star of the show.So this is a ladybugstanding guard over
the cocoon of a wasp
and the way this works,
is that wasp lays an egg,
it injects an egg
into that ladybug
and the egg hatches and
it grows inside the ladybug and the larval wasp inside
actually knows to avoid the vital organs
of that ladybug because if it chews
on those vital organs it will kill the ladybug and
it will die too. So it avoids the vital organs
and when it’s ready to come out, it pushes its way out of the
abdomen of that ladybug and it spins its cocoon.
And the problem is this cocoon is a
very vulnerable stage in the lifecycle of this wasp.
It’s just sitting there immobile ready to be eaten by
any predator that walks by. So, that’s why it’s gotten this
ladybug to stand guard over it.And the amazing thing is
this ladybug will sit there
twitching for days over this,
this wasp
and if it’s able to survive
the seven days that the wasp takes to
develop into an adult the ladybug can
actually recover. The mind control can wear off and that ladybug can go to
re-grow its internal organs and go on to reproduce.This is the wasp
that’s responsible for that,
this is
Dinocampus coccinellae,
it’s, she’s barely
a centimeter long
and I can tell
she’s a female, both
because she’s got this
ovipositor at the end,
the stinger
that she uses
to inject the eggs
and also because this species
is parthenogenetic, which means it doesn’t need to fertilize
its eggs to reproduce, it can clone itself, and so it injects an egg
into the ladybug, It does not need to be
fertilized, and all of those eggs will
develop to be more females. The entire species is female. Actually there has been
four or five males that has been identified
over the course of studying this creature and frankly I don’t know
how that really works, I don’t know how
parthenogenesis works.
It’s crazy. and it will have to be the topic
of another discussion. Now ladybugs are
not the only ones that get turned into
bodyguards. There’s another wasp
in this family Braconidae that infects caterpillarsand in this case it injects
several dozen eggs
at the same time.Those eggs hatch
inside the caterpillar
and just like the ladybugthey know to avoid
the internal organs
of the caterpillar,
just like the ladybug
they have a virus that
helps them. It’s a different kind of virus but in this case the virus
tricks the immune system of the caterpillar to protect,
to hide these invaders and the virus actually
changes the metabolism of the caterpillar
so that it gorges itself and it prevents the caterpillar from transforming
into an adult, so the virus turns
the caterpillar into a feeding machine
for these wasp larva.So this is a video of this
process. It starts with the
adult wasp stinging and
injecting those eggs
into a newly hatched
caterpillar. Those caterpillars
then go about their normal life
for the next week
feeding and growingand waiting for those
wasp larva to emerge.
When they are ready
they chew their way
through the skin
of the caterpillar.
And they come out
by the dozens.
So they actually
spin their cocoon
as they are emerging
from the caterpillar.
The amazing thing
about this process is that
the caterpillar survives,
it wakes up,
it crawls on the top of the pile
of cocoons and it spins that
additional layer
of protective silk.
And the reason for this,the entire purpose
of the protection
is to prevent this.This is a hyperparasitoid waspinjecting its egg
into the parasitic wasp
that just emerged
from the caterpillar.
So an additional layer
of parasitism
above the
mind controlling one. It’s pretty cool. So this theme of
trying to protect that delicate larval stage…
that pupation, that’s a common theme. And there’s another wasp
in different groupthat uses a different approach
than the bodyguard style.
What it does is,
it catches the spider
and lays an egg on its back.So this is a spider
that lives in the
palm plantations of Costa Ricaand it’s got a wasp larva
hanging on its back.
This is one that
has hatched out
and it’s feeding on hemolymph,
the blood of that spider.
And what it does
when it’s ready to pupate, instead of turning that spider
into a bodyguard, it gets the spider to build
a special kind of web. And so normally webs are
designed to catch insects, this web is designed to support the weight
of the cocoon. And so the wasp larva waits until the spider’s done
building this web, it then kills it and
then hangs its cocoon safely off the floor
of the forest.So this is the stagewhere the spider has just
finished building that web
and the wasp returns the favorby killing it
and eating it.
And this is that
specialized web.
And you can tell
what the spiders built
because
the spider silk is white
and wasp silk is yellow.So this is a video
starting with,
after the spider
has been killed.
That wasp larva is feeding on
every last drop
of the spider’s blood in order
to store up enough energy
to transform into an adult.And then when it’s ready
to transform,
it’s finished digesting
that spider
it then drops its own silk
off of the spider web
and spins its cocoon.And you can actually see
how it uses its head
to hollow out the cavity
inside of that cocoon.
These… these wasps
have figured out this mind control thing
pretty well. And the, the queen of
all mind controlling wasps isthe emerald cockroach wasp.So this is a wasp that hunts
cockroaches to feed its young
And it is more cunning
and sophisticated
than your typical predator like
a lion or a shark. So what it does is, it starts
by paralyzing the cockroach.It stings it
right behind its head,
paralysis the cockroach
and then it snakes
its stinger into the brain
of the cockroach
where it has special censorsso that it can grope
around the brain
and find exactly the part
that is responsible
for generating the motivation
for movement.
And it disables that part.
And what that means is the cockroach is
fully functional, all of its muscles work but it cannot generate
the will to move on its own. Instead it takes its queues
from the wasp. So the wasp comes back,it holds the antenna of that
cockroach,
with its mouth
and it leads it
as if walking a dog
to its burrow,
where it lays an egg
on its belly and buries it to be
eaten alive by its babies. And those wasp larva
just like the others they know how to avoid
the internal organs they can keep it fresh
as long as possible and on top of that, they actually smear this
disinfecting substance on the inside of the cockroach
to keep it from rotting.This is a
horsehair worm,
it’s using its host as bothhousing and transportation.
So in this case,
the worm grows up
inside the cricket
and once it gets
a little cramped in there,
it wants to come out.
And really this worm has a free living part
of its life stage. It doesn’t live his whole life
in the cricket. But the problem is
where it comes out, it has to be wet,
it’s an aquatic worm when it comes out. So if it came out in dry land
it would dry up and die. So it makes the cricket
go find water so that it can jump in,
commit suicide and that worm can go on
to continue its life cycle. So, in that pond
or in that stream the worm will go find a mate,
it will lay a bunch of eggs, those eggs hatch and they
burrow into mosquito larva. And they insist themselves
in a mosquito larva, so when the mosquitoes emerge
and they fly out, their cysts are still there and that mosquito lives
its normal life, it dies on land and
it gets eaten by a cricket. And the worm cyst
actually knows when it’s inside of a cricket
and that’s when it knows, it can start developing. That’s
how the life cycle continues.This is an ant
that has been infected by
‘Ophiocordyceps’.And this fungus,
it gets the ant
to crawl up
the stalk of a plant
out till the end of a leaf
and it kills the ant there
so that when the fungus sendsits reproductive
structures out
those spores are
better able to disperse
onto the forest floor.This is actually a really
diverse group of fungi and each species of fungus
has its own host and it gets its host
to clampdown in different parts
of the plant. Some of them are
at the tip of the leaf, some of them are
on the underside, some of them are
at the base of a tree and it’s thought that they
are manipulating their host to maximize the ability
to disperse on to more ants. And so they’ve actually shown
there are places where the fungus is
getting the ant to die above the foraging lines
of its colony. So that when those
spores come out, they’re more likely
to get in contact with more ants.And actually the white eye
you see here,
that’s fungus as well.So what the fungus does is,it hollows out
the entire inside of that ant
and it just so happens
that the exoskeleton
right in front of eye,
it’s thin enough
that you can see
the fungal tissue
through the eye membrane.So this is a video of an antthis is a
different species of ant.
That’s also been
infected by this
cordyceps fungus–
Ophiocordyceps fungus.
It’s in its last hour of life.It’s just twitching thereand the fungus has forced it to
bite down on edge of this leaf.
And what happens is that
first night
after that fungus
kills the ant
it bursts through,
the weaker joints
of the exoskeleton
and spends the next week,
growing a reproductive stockout of the back
of the ant’s head.
Now… my favorite parasite
that I photographed is the Rhizocephala.The Rhizocephala is a
tiny little parasitic barnacle
that infects sheep crabs.
This is a sheep crab here.
And what it does is it
gets into the sheep crab
and if the sheep crab
started off as a male it turns it into a female.
It feminizes the crab and that’s because
only female crabs have this structure
that can house eggs. And so the parasite waits
for this feminized male to grow this egg chamber,
it lays its own eggs in that egg chamber
and then it activates the maternal care instinct
of this crab so that it thinks
it’s pregnant and it will care for
the eggs of the parasite. Then every two weeks, those eggs mature
and they hatch out and they go on to infect
more crabs. So what you see here isevery little speck
in this photo
is a newly hatched
parasitic barnacle
that is going out to infect
a new crab.
So let me, let me back up
and tell little more about
where the story came from,
where the idea came from.
So I was working
with my editor Todd James and you know, he just said
look we got to figure out a fresh approach to this, it’s got to be
something different. And you know, I agreed,
the pictures of parasites I had seen to that point
were like jars of leeches or a worm getting pulled out of
somebody’s eye and its like– They were very successful
in grossing you out, but they really failed
in getting you to appreciate how incredible
these creatures are. But then there’s also
the sake of this, this problem of okay, what,
how do I light these creatures, these parasites in a new way. Because up until that point,
macro photography for me was find a cool bug,
shine some light on it, take a picture. You know, you could make it
a sharp light, you could make it soft light, you could light if from
this way or that way, that’s about it.
I mean how do I, how do I take this
to a next level? How I find a
more interesting way to light these creatures? And I had this idea
while I was sitting in my friend Stacy’s apartment
in Oakland. And I don’t remember
what we’re talking about because I was distracted by the quality of light
on her face. She was sitting
in front of a window.This is Stacy in front of
her window in Oakland
and the window light was
coming around her head,
lighting the sides of her
cheeks and her nose
and showing
the topography in a way,
that I never really
thought about before.
I thought how do
I scale this down to a parasite level. Can I use this
to light parasites and show the shape and
contours in a new way? And so I had my Stacy light,
I had my volcano light I had this idea of how to
light backgrounds to emphasize the drama and action going on, but you know,
what does that really look like to implement in the field. Well, let me show you.Most of the work was done
in hotel rooms.
So this is a hotel room
in Costa Rica,
where I’m trying to
photograph this
spider being parasitized
by a wasp
there’s buckets of spiders
everywhere
that I’m trying to hide from
the housekeeping staff
so they won’t throw them out.And then, you know,hotel rooms really aren’t
well-designed for photography,
so there is a lot of
moving furniture around
and in this case,
what I’m trying to do is
I’m trying to set up
a time lapse
of these fungus flowers
in South Dakota, growing,
and I borrowed this light
that had been confiscated
from an illegal marijuana
growing operation in Spearfish
( laughter ) And had been
donated to the University
who then lent it to me.
And after all this effort,
it totally failed.
It was not useful at all.And I ended up building
a lot of my own contraptions,
lighting contraptions
in this case
I was trying to use this
fiber-optic linelight
to build a makeshift scanner,
to scan this plant
because there’s a
beautiful quality of light
that flatbed scanners
produce on flowers
and I wanted to try to
make that and it
again totally failed.
It was
a pain in the butt to use,
it didn’t really workout.
This is the setup
I used to photograph the cover
in a lab in Montréal.And so I was able to set up
in some research labs,
which has some advantages
and disadvantages.
The main disadvantage
is sometimes
you don’t have a lot of space,this is in Boulder
at P. Johnson’s lab
where I’m trying to photograph
this deformed frog.
Of all of these creatures,
though, the most difficult
to photograph was actually that cricket, and I visited this lab
in New Mexico, a couple of times
where Ben Hanelt had these infected crickets
in his lab. And the first time
they all died the night before I got there,
the second time they weren’t ready
the worms took too long to, to mature
so they weren’t ready when I got there
and I just said you know what, forgot this
and I packed them into my bag and I flew back with them
to California. And so my housemates
at this point are used to this
kind of nonsense and one of them is a
documentary film maker and so he filmed me, photographing these
crickets, so…I kept them in the,in the hot water
heater room,
where they would stay warm.
This is my kitchen.
And the thing about these
crickets and the worms
is that you can actually tellwhen the worms are
ready to come out.
They actually turn dark brown,and you can see them
coiled up
inside the belly
of these crickets.
And so I’m setting up
my fiber-optic lights
and getting ready to
photograph these things.
Not my best hair day.( laughter )Most of this stuff happensat 2 o’clock in
the morning and so I
sort of didn’t remember that
he was filming me that day.
And so, I’m actually putting
a layer of Rain X
down on the glass
and so that
beads up the water nicely.
And then I put the crickets
in the fridge,
for a few minutes
to cool them down
so they wouldn’t hop
all over the place.
And the liquid that I’m using
is not actually water,
it’s called cricket saline,
it’s a solution that mimics
the internal chemistry
of the cricket.
So, that when the worms
come out they don’t freak out.
They think they’re still
inside the cricket.
So that picture took me abouttwenty-three days
to figure out.
Now, a lot of that I did at
home and so it was not like
I was working on it,
24 hours a day, some days it was only
a couple of hours, but all the tricks with the Rain X,
with the fridge, with the cricket saline.
These are not things that I knew about
ahead of time. There are things that
I just had to work out on the fly, through one
iteration after the next. And you figure out a problem,
or, you come across a problem you just have to
figure out a solution. The cricket’s too jumpy,
the worm’s freaking out, the water
doesn’t look right and you just have to take what,
what you’ve solved and build on that. And so there was a point
early on in the story where my editor, Todd
wanted to see my… my progress on
the story and… you know, he didn’t really
have time to look through all my pictures,
he wanted to send me– he wanted me to send him
a small selection. And really I wanted him to see
all my pictures because I wanted to show him all the
different variations I did. I assumed
he was going to tell me, oh, go back and shoot that
from another angle and I wanted to be
able to tell him, ‘look man,
I tried all the angles.’ So, but he asked for,
he asked for a limited selection and so I was scanning
through these pictures, it was late at night
I was listening to some electronic music
to keep me awake. And all of a sudden this,
this images on my screen started to sync up with the music
I was listening to and I had this idea that
‘wait a minute!’ If I can just take
all of these images and I can create
a stop motion by playing them all
at 15 frames a second. That way in five minutes Todd can see every image
I have taken and all the iterations
and variations I did in between
and I just threw the layer of music on top
just for, for kicks. By the end of the story
I had 33,000 pictures and even at
15 frames a second, that’s a very long video so I cut that down and
here is the edited version of that original… Dubstep parasite music video.
( laughter ) ( dubstep music ) ( applause ) ( outro music )

Can I File a Medical Malpractice Claim For the Infection I Got in an Iowa Hospital?

Can I File a Medical Malpractice Claim For the Infection I Got in an Iowa Hospital?


♪ (music) ♪ I’m attorney Farl Greene with RSH Legal. Let’s talk today about hospital-acquired infections. According to the Center for Disease Control and Prevention, or CDC, about 1 in 25 hospital patients is diagnosed with an infection. Additionally, over 99,000 deaths yearly can be attributed to these healthcare associated infections. So why don’t you hear about Iowa medical malpractice lawsuits being filed because of these infections? Let’s talk first about what you need to do in order to prove your medical malpractice claim: Number one: you must prove that the hospital’s infection prevention measures were below the standard of care. The medical standard of care is a term that is used to measure the care a reasonably skilled medical professional would use in the same situation that led to the malpractice. In this case, if the majority of hospitals have infection prevention standards, and the hospital that hurt you did not have these standards, or the standards were not followed, then you may be able to prove that the hospital did not meet the standard of care. Number two: you must prove that this breach in the standard of care directly caused your infection. If the level of care was below the standard but there is not enough proof that it directly caused your infection, then it is unlikely you will be able to win your case. No Iowa medical malpractice attorney can say that malpractice occurred. Only an expert with the same qualifications and background as the health care professional who hurt you can testify that malpractice occurred. The expert must agree to testify that both of the statements above were met in your case. If they cannot, it’s unlikely your medical malpractice case will move forward. There are usually notes in your medical records that you have an infection and that it is being treated. However, it’s rare that the records would explain how you got the infection. It is unlikely your medical records contain information that confirms negligence happened. Without proof in your medical records, an expert is unlikely to say that your infection was clearly caused by sub-standard medical care. Infections occur all the time in hospital settings, even when the standard of care is met. This is an unfortunate but common issue for hospital patients. As you can probably tell, proving your infection happened because of the hospital’s negligence is a nearly impossible task. Because of this, it is unlikely that an Iowa medical malpractice attorney would take your case. There is one instance when you may be able to sue. If your infection is misdiagnosed or goes untreated and causes serious or permanent damage, you may be able to sue for malpractice, but the same standards above will apply. Again, your attorney will have to hire an expert to prove that a breach in the standard of care directly led to your infection getting worse and causing permanent harm. If you have further questions about hospital-acquired infections and Iowa medical malpractice, call RSH Legal at 1-800-433-0283 and speak with one of our personal injury attorneys today. ♪ (music) ♪

Catheter-associated Urinary Tract Infection (CAUTI) with Case Studies (Part I).

Catheter-associated Urinary Tract Infection (CAUTI) with Case Studies (Part I).


[ Silence ]>>Good morning everyone and
welcome to our third and final day of the 2014 NHSN Training Course. We want to acknowledge again, all of you here who have given your undivided
attention and great participation. Everyone in the room as well as
everyone watching the live web-stream, we do appreciate your participation. I have multiple updates that I’ll give
throughout the day but I have a couple of important things that you’ll
need to know first thing. We wanted to remind you that the
evaluation forms are in the back on the back table outside of this room. I was told that if you are getting CE’s,
well, when you apply for that you’ll be able to do the evaluation on the computer so you
don’t necessarily have to complete it today. But if you aren’t going to be
applying for CE’s then we ask that you do complete the evaluation form today,
and leave it on the table before you have to go. We really appreciate your feedback and
your input and it is important to us, so we do ask that you complete that
if you are able to give your input. With regards to feedback and input we wanted
to let you know, we know some of the people in the front have a hard
time with the bright lights. We can’t unfortunately dim the lights any more than we already have because
of the live web-streams. So we apologize if they’re a little
bright or hot on the tops of your heads. We also know that the round tables
haven’t been ideal for you in the room. Again, hoping that you’ve been able
to see the presentations with all of the drop-down slide viewing but I know
it’s difficult if you have to have your back or have to turn around to face the front. Just so you know, the reason we chose to
do it this way was because we really wanted to maximize the amount of people we could get in
a room and get here to this in-person training so that you’d be able to actually
be in the room if you wanted to. So many people enroll and register to try to get
on the random list that we felt that we should, you know, try to do this so that we
could maximize to the 300 or over, but we will evaluate for next year to see if there’s any way we can fix
that or get a bigger room. Let’s see, I wanted to remind you that the team
outside the door is in the back to help you with your transport to the airport. So, they can help you with all of that but they
need you to sign up on a sheet and let them know when your flight is so that
they can group people together and make sure everybody gets
to the airport on time. And if you are leaving early, which we
want you to stay today as late as possible to hear all the important information being
presented today, but if you do need to leave and you know that it’s going to be ahead of
schedule, please let them know now or as early as possible so that they can make sure
to set you up front aside to get you out early for the transportation. We ask that — oh, yes this is very important. So, you have met many of the individuals
who answer the NHSN mailbox for you. There is a group of user support
team that you were not able to meet because they were not presenters and they’ve
actually been working behind the scenes to continue to answer the mailbox of questions
that come in over the course of this training and are always the front line
individuals that help you. So there’s a group of those. The individuals, the infection preventionists,
a lot of the data analysts, data analyst methods and analytics team, you’ve met here, so
now you know that there’s not hundreds of people behind the scenes
available to answer your questions and when we give the training we always know
that there’s going to be a hike in the mailbox because of all the important
information that was presented. So over the next few weeks the
mailbox is going to double. Over the next two weeks we’re actually down
one IP because she’ll be away for two weeks, so we ask that you give us a little
bit of leeway and understanding if it takes a little bit longer to
answer questions in the next few weeks and give us your support with that, just
to make sure that we catch everybody back up with all the information
that’s been presented. So we just wanted to bring that
to your attention because I know when you ask questions it’s very important and you need those answers
because you need to do your job. We do recognize that too, so we will do the
best that we can to keep up with the questions that already have begun to
come in in these past two days from viewers watching the live web-streaming. And a reminder for these
presentations, they’ve all been taped. They will be archived and posted. We expect them to be up by mid to late April
and this way for your reviewing pleasure, and anyone that you want to pass the information
on to — individuals who couldn’t come, people who weren’t able to get
onto the live web-streaming. They will be broken up into
sections and sessions by topic so that individuals can watch them when
it fits into schedules and do it even in a little more piecemeal
than three days in a row. Because I know it’s a lot
of information to take in. There’s something you might want to watch
again, it’ll be available for you to watch. So I think with those, I will have
Kathy come up and talk about CAUTI, and we’ll give some more
announcements right before lunch. Thank you. [ Applause ]>>Good morning. Well, today we’re going to talk
about catheter-associated UTI’s, and we’re going to try to have a little bit of
fun today so, since you’ve had two long days. Hopefully you’ll enjoy this
morning’s presentation. So, I’m am going to have to cover a little
bit of information that I’ve already covered, such as HAI definitions, POA’s, because we
have people tuning in for the web-streams that may have not listened to
the [inaudible] definition. So if you want to tune out in those situations
you can, and hopefully you’ll tune back in when it’s something new for you,
but just a little bit of a warning. So, today we’re going to go over
the CAUTI, definitions and key terms that are utilized in CAUTI surveillance. We’re going to talk about how to collect
the urinary catheter and patient data. We’re going to again identify the data
collection forms and then we’re going to apply the definitions to
some patient case studies. So, same general overview
that we’ve done in the past. And we’re going to cover the epidemiology,
the definitions, and the changes for 2014. Talk about denominator collection
and I’ll provide you some resources, we’ll do case studies, and then lastly I
do want to give you an update on, you know, what’s going on with the CAUTI definitions. You probably have heard that we
are reviewing those definitions. We’ve actually been reviewing them since the end
of 2012 and hope to have some changes for 2015. I might not be able to give you a
lot of specifics because I’ve learned that don’t give specifics until it’s
actually totally done because as sure as you know what it’s going to change. So — but I can tell you what, you know,
what is being done and then for those of you that are coming to APIC I’ll also be going
a presentation there and maybe I’ll be able to give a little bit more
details at that time, so. So again, we’re not going to go over in-depth
today requirements for the Centers for Medicare and Medicaid Services Inpatient Quality
Reporting Program or the Oncology, the Cancer Exempt Hospitals Reporting. All that information’s available
on our website or through the QIO’s and I’ve provided you those resources here. Also, we will not be going through step by
step data entry and Maggie’s been covering all of the data analysis for us very
well, so we don’t have to do that. So, CAUTI’s, who cares about CAUTI’s? Right? Who cares? Urinary tract infection is tied, believe
it or not, you probably know this, with pneumonia as the second most common
type of health care associated infection, and it’s really only second
to SSI’s in overall incidents. And we know that the majority of them
are associated with indwelling catheters. I don’t know if you’re aware but a
little over 5% of ICU CAUTI’s result in bloodstream infections and in
non-ICU CAUTI’s that is up to about 7.4. So, interestingly enough, higher
secondary BSI rate outside of the ICU. 13,000 people die every year for UTI’s,
so you know, it does cause some morbidity and mortality, and interestingly, up to
1/3 of asymptomatic bacteriuria is treated with antimicrobials even though this is, you
know, in conflict with published guidelines and results in a lot of unnecessary
antibiotic usage, C. difficile infections, adverse reactions. And so, that’s one of the main reasons that
ASB was removed back in 2009 from our criteria. So, it’s important for us to shine a light, sort
of, on CAUTI and what we can do to prevent that and how we can treat it and
identify it correctly. And a lot of people are saying now that, you
know, CAUTI’s may be a proxy measure for the overall general quality
of care for patients. So, you know, that’s another reason that we might be concerned
about what happens in this area. So again, we just want to make sure that
all of our data that we enter is good data. And so, things to consider
for CAUTI surveillance. So, nice thing is that unlike SSI
surveillance, all CAUTI’s are going to require a positive urine culture. So you can start with your laboratory
as your basis for case finding. So hopefully you’re all able to
get a routinely generated report of your positive urine cultures
and that’s your starting point. But I do want to point out that
it’s really important for you to know your laboratory’s urine
culture reporting policies. Specifically, what are the ranges of
colony-forming units that they’re reporting? Some facilities don’t report down to
10 to the third, which is, you know, part of the definition for UTI’s. Some of them don’t quantify yeasts, and so your
facility’s not able to meet all the criterias that are currently written since we include
yeast as a pathogen for CAUTI’s at this time. Sometimes positive urine cultures are reported
for the unit on which they were collected and not necessarily on the
unit that the patient is on. So you may need to check to make
sure that you’re attributing that CAUTI to the right location. It seems to happen a lot with
patients that are discharged. Sometimes the discharge location — or
location for the culture is not accurate. So just — you need to consider
the transfer rules and how the laboratory report
might be affecting that. And finally, you know, just to take into account
that you need to account for positive cultures from the Emergency Department because those
could really represent CAUTI’s from patients that had recently been discharged
and might be — should be attributed to that
discharging location. So again, what are you going to look at first
and where is it going to be on the record? Those are, you know, things
that you need to think about. You’re going to be looking for your urine
culture results and your laboratory results. And then probably what you want to look
for — unless you’re in Pennsylvania, most facilities — not a lot of
facilities are doing surveillance for non-catheter associated UTI’s,
so you know, you’re going to look — maybe the next thing you look at is whether or not they had a urinary catheter
in place in the time period. You know, and you’re going to be
looking for nursing documentation and graphic sheets for those
types of information. This is a sample worksheet that, you know, that
we put out for your use for data collection. You guys — some facilities create their
own data collection sheet, which is fine, just as long as it collects all of
the information you need for NHSN, but this one is available
on the website for your use. And then, you know, the old spiel about making
sure that we’re all doing things the same way. I went over this pretty well with CLABSI. You know, we need to all be
consistently applying the definitions. Standardizing your chart review will
help you to be consistent over time. So if you get into a routine
of how you collect data and how you identify cases,
that will really help. Maintain the focus on the criteria
and don’t deviate from that. CAUTI is one of those areas sometimes where
people feel that maybe they’re not capturing all of the patients that they
clinically believe have a UTI. We hear this a lot with patients that are on
ventilators or spinal cord injury patients, maybe because, you know, they’re not
able to communicate, for whatever reason, suprapubic tenderness or CVA pain. Surprisingly, though, honestly only —
well, 80% of our patients that are reported as CAUTI’s have fever as their only symptom. That may be surprising to you or it may not be. So, if you think about it that way,
the spinal cord injury patients or the ventilated patients
are maybe not that different. I mean, most patients when we identify
it it’s through the use of a fever. You know, the other thing to think about
with that, I always tell people is that just because a patient is ventilated doesn’t
mean they can’t communicate pain. Especially with these sedation vacations
and depending on the level of sedation, patients can exhibit signs of pain if
their physical assessments are done. So, I don’t — I always hate for people to
just say, “Well they’re on a ventilator, we can’t tell whether or not
they have an suprapublic pain. So that’s not always the case. So again, think about surveillance definitions
versus clinical definitions and the fact that sometimes the two are not going to meet. You know, we’re looking — we’re using
the definitions for surveillance different than clinicians are using to make
determinations about what’s going on with a patient and what they should do. And our data elements are going to be limited. They’re going to be finite
and the clinicians are able to use everything that’s available to them. So, it’s okay if they don’t always match. We obviously try to make our criteria so that
they are as close to clinical definitions as possible, but we have a long way
to go, especially in CAUTI, I know. But we are definitely working on that now. Was that a laugh [laughter]. So, sometimes, you know, sometimes it’s
helpful to remind your staff about surveillance or to educate staff about
surveillance in clinical definitions. How many people here have had to have
this conversation in their — yeah. Yeah, yeah. Yep. And surprisingly, sometimes it’s infectious
disease physicians that you have to have that conversation with, which
is always surprising to me because I would have thought
they understood that. But we always want to make sure obviously
that we’re using the surveillance definitions as a determinant of what we report. And we’re always here at
[email protected], as Dawn told you, to receive your questions
and try to help you out. Oh! So, I want to make a disclaimer. I thought it would be fun if I
shared some of the funny emails that we get from users, because we get some. I didn’t include any identifiers
on these, so if it’s from you and you recognize it don’t
tell anybody [laughter]. And they will not know. So I’m going to share — as we go
along today I’m going to share a couple of funny emails that we have gotten. So, here’s one that I got from a user. She said, “I am looking at a patient that
presented to our facility on 2/15/13. A Foley was placed in the
ER on the admission date. During her stay she was afebrile
and symptom-free with one exception. A temp of 102 was documented at midnight. The nurse manager feels that this is possibly a
misdocumentation and would like some guidance. Do we still call this a CAUTI?” No, you can just discount that [inaudible]. Don’t worry about it. It’s probably a mistake. Yes, you have to still call this a CAUTI. All right, so we’re going to get into
the nuts and bolts of the definitions and we’re not really going to be talking about
non-catheter associated UTI’s here today. As you may or may not know, they
have their own criteria designated as the B criteria’s for SUTI. The A criterias are all catheter-associated, the
B criteria’s are all non catheter-associated. And I want to identify that ABUTI
can also be non-catheter associated or they can be catheter-associated. And if you are determining
whether or not an LCBI, BSI is secondary to a non-catheter
associated UTI, you have to make sure that you use non-catheter associated
definitions and you’ll see as we go along, if you don’t already know, why that’s important. So, there are basically two
specific types of UTI. Symptomatic UTI, or SUTI, or
an asymptomatic bacteremic UTI, or ABUTI, as we like to refer to it. I do want to point out sometimes people are
confused between asymptomatic bacteremic UTI and asymptomatic bacteriuria or
ASB, which we used to have in 2009. Asymptomatic bacteriuria just means
that there are organisms in the urine, but an asymptomatic bacteremic UTI is one
where there’s not only organisms in the urine but there’s also a matching
organism in the blood stream. So the patient has a blood stream infection
as a result or concurrently with the UTI. So that is the difference,
they’re not the same animal, and it’s important that you understand that. Both types of infections, both SUTI’s and
ABUTI’s, if they’re catheter-associated, need to be reported as part of any CMS,
CAUTI surveillance that you’re doing. That’s another thing that’s sometimes
people don’t quite understand. You can’t just report the SUTI’s,
you also have to report the ABUTI’s. So, you know, over the years as
I’ve presented this information, I’ve presented it in different ways
and sometimes it’s hard for people to understand the logic of why
the definitions are as they are. Sometimes they seem like they’re really
complicated, so I’ve tried to present it in different ways and this
time I thought I’d tell you — just present the logic behind
the SUTI definitions. And one of the important points is that the
symptoms of a true UTI are going to vary whether or not the patient has a Foley in place. If the patient has a catheter in place they’re
going to have urgency sometimes, you know. I mean, how many people have had a patient and
they said, “I’ve got to go to the bathroom.” And you say, “You’ve got a
catheter in, just relax.” You know, “You can go.” So, that foreign body causes urgency, it can
cause burning, a burning sensation sometimes. You shouldn’t be having frequency,
so we took those out of patients — you know, they used to be in the
criteria for patients that had Foleys and they didn’t make any sense to be in there. So that’s why we’ve taken
them out of the criteria for patients that are currently catheterized. Infants, we know exhibit different
symptomatology as well for infections and that’s why we provide some infant-specific
criteria, and those additional ones are apnea, bradycardia, lethargy, vomiting, or hypothermia. Because, you know, patients can have instability
in temps when they have an infection. So, these are sort of the two big concepts of
why we have some complexity to our UTI criteria. So this is sort of an overview
of the UTI definitions. So, we can see that I’ve
divided these by age groups. SUTI one and SUTI two are
for patients of any age. SUTI three and SUTI four are for infants. And then we have our ABUTI’s, which
again, are for patients of any age. Now, I told you yesterday that infants not only
can meet these but they can meet any of these. It’s just the patients that are over one
year of age that cannot meet three or four. Okay. Within each of these different
types of UTI’s we have catheter-associated or non-catheter associated UTI’s. Make sense? All right. So now we’re going to look at how the
colony-forming units are applied to these. So, for SUTI one and SUTI three
we’re dealing with patients that have at least 100,000 colony-forming units. And I have an asterisk here, you’ll
notice that it goes down to — they have to have no more than two
organisms in that urine culture. And that’s because we want to make sure that
this is not a contaminated urine culture. If there’s three or more organisms
the chances are pretty high that that’s been just a poorly
collected culture, we don’t want to use it to
say that somebody has a UTI. We don’t want to over-call these UTI’s. ABUTI also requires greater than 100,000. You’ll never have an ABUTI that has less
than 100,000, and that’s for a reason. You know, we — this patient is asymptomatic,
so we want to have a high degree of — as high a degree as we can of
confidence that this is truly a UTI and so that’s why we’re going to require
a high colony-forming unit count. You’ll notice, though, there’s two
stars there and that means that not — we don’t use organisms, we use uropathogens. So there cannot be more than two uropathogens and we provide you a list of
what those uropathogens are. It’s a pretty broad list, but there are a
few organisms that are not on that list. That list is included in
the NHSN CAUTI protocol. I’m trying to remember. I think we have it on our organism
list, too, that’s on the website where we have MBI and we have common commensals. People are nodding, so. So that leaves SUTI two and SUTI four. So you’ll notice that one of the infants,
the SUTI three, has 100,000 or more. One of the infants has greater
than 1,000 or less than 100,000. So we have adult and child, adult and child. Or, I say adult — any age
and child, any age and child. So this group here, SUTI two and four
have a lower colony-forming count, 1,000 or more, but less than 100,000. Again, no more than two organisms
in the culture. Because this is a smaller colony-forming
count, we are going to require some symptoms — I’m sorry, some supportive positive
UA to give more credence to the fact that this is truly a good culture
and indicative of an infection. So that’s why this criteria requires this lower
level colony count and a supportive positive UA, again, within a time period of no more than
a single gap day between adjacent elements. Okay. Is this a good way to present this? Does this make sense? Okay. Good. Thank you for the feedback. Okay, so when we’re looking at a symptoms really
the main question that you have to ask yourself, and I went over this a little bit, was the
catheter in place at the date of the event? If the answer is yes, then you’re going to have
a limited number of symptoms that you can use. You can only use suprapubic tenderness,
costovertebral angle pain or tenderness, or fever greater than 38 degrees Celsius. If it’s a baby you can additionally
use hypothermia, less than 36, apnea, bradycardia, lethargy, or vomiting. Okay? You’ll notice what we’ve taken
out of there when you look at the no. So there was no catheter in
place on the date of the event. You’ll see here I bolded. You now have dysuria, frequency,
or urgency that you can utilize. And then you have all that
you had for the yes answer. You have your suprapubic tenderness, CVA pain or
tenderness, fever, and then the infant criteria. So we simply remove these
three, dysuria, frequency, or urgency if the catheter is in place. As I said, when there’s more than two species
of microorganisms that’s routinely regarded as a contaminated culture and we
don’t want to use it for NHSN. We do get questions about culture
reports that come back as mixed flora, and generally mixed flora represents
more than two organisms, two species, so if you have mixed flora and you
have any additional organism recovered from the same culture that’s going
to have more than two organisms. So, for example, if you have to
report that maybe there’s a greater than 100,000 Pseudomonas
aeruginosa, and there’s mixed flora, clinically we probably would
believe that greater than 100,000, but unfortunately we have mixed flora
in there so we can’t utilize that. This is one of the issues that we’re kind of
talking about with the new definitions also. You know, can we say if there’s
a preponderant organism, can we say that that should be utilized? As it stands right now, in that situation
you would not use that culture report. If the organisms are the same
genus but two different species, they’re considered two different organisms. So if you had a Pseudomonas and aeruginosa — aeruginosa and a Pseudomonas stutzeri
[assumed spelling], that’s two organisms. If you add anything onto that you’re
not going to be able to use the culture. And kind of the flip side of
that, if you have an organism that has just simply the same organism but has
different susceptibility pattern such as MRSA or MSSA, those are considered just
one organism because, you know, we know that how the laboratory works those
up they may just pick different colonies from, you know, that — cultures or colonies
that represent the same organisms and there is some variation
and resistance within those. So, we don’t want to say that those
are different organisms all together. So those will be considered just one organism. Okay. Sometimes, obviously patients will
have a positive urine culture — excuse me — shortly after their catheter is removed. So, for those patients if
the event date, the UTI date, is on the day of device discontinuation or the
following calendar day, just like for CLABSI, these are going to be considered
device-associated. As long as the device had already
been in for greater than two days. And, for this criteria you are
able to utilize urgency, frequency, and dysuria because the catheter
has been taken out. So I’ve given you two examples. First one, the Foley is placed and
it’s there, it’s placed on day one. Day two it’s still there. Day three it’s in place for part
of the day and then only for part of the day and then it’s removed. The next day the patient meets UTI criteria,
this is going to be considered a CAUTI. Unlike here, where the Foley’s placed
on day one, it’s taken out on day two. It was there for part of the day, taken out. The next day they have no Foley
and they meet criteria on day four. That is going to be a health care
associated UTI, but it’s not going to be considered a catheter-associated UTI. Whether or not you clinically agree with that
or not, that’s the definitional interpretation. Okay. So let’s just go over
the criteria as a whole here. So these are the A criteria
for SUTI’s, symptomatic UTI’s. A, meaning that these are going
to be catheter-associated. On the first you’ll see its split,
the first half of this is for patients that have the catheter in
place on the day of event. The second half are for those that
had it in for greater than two days but had it removed the day of
or the day before the event. Okay? So for the first ones, it’s in
place, it’s been in place for greater than two days on the day of event. They can have fever, suprapubic
tenderness, CVA angle pain or tenderness, and they have to have a positive urine
culture of greater than 10 to the fifth, and no more than two species of microorganisms. And again, the gap day for
— single gap day does apply. If the catheter had been in place for greater
than two days and it was removed the day of or the day before the event, then we add in
dysuria, urgency, frequency, and then, again, fever, CVA, suprapubic/SP tenderness, and the
same requirements for the positive urine culture of greater than or equal to 10 to the
5th and no more than two microorganisms. Now, you’ll notice that there is an asterisk
here for with no other recognized cause and for those astute clinicians, you’ll
notice that it’s not there for fever. And this is one of the questions that
we get the most and one that, you know, we are discussing how best to approach this. The reason it’s not there is because, to allow
— and this happens more with CAUTI than it does with CLABSI because, you know, with CLABSI
one you don’t have to have any symptoms. But you know, if the patient has a pneumonia
and they have a positive urine culture because they’ve pan cultured the patient,
if the fever is there the fever has to be utilized to meet the UTI criteria. If you’re doing pneumonia surveillance, you’ll
also have to use it for the pneumonia criteria, and that’s because at this point
we haven’t figured out a good way to operationalize clinical
judgment about where that UTI go — or where that fever is responsible for. And it may be responsible — it
may be due to both infections. If the patient has both infections they
may be running a fever because of both. I mean the body doesn’t —
does the body differentiate? I don’t know. So, the only way I think that we could
get around this would be if we were to identify a hierarchy of infections. Okay, if they have this and they have
this infection and this infection, you apply the fever to this infection. But you see that quickly becomes very complex. And so, that’s what we’re wrestling with. So for now the fever is a non-specific
symptom and you have to apply it to all potential infection types. Criteria in two, again this is in A so these
are catheter-associated infections you’ll see. Two, again, is for those patients that have
less than 100,000 but greater than 1,000. If the catheter is in place the symptoms
are exactly the same as they were for A. You’re going to have those symptoms
minus dysuria, frequency, and urgency. Additionally, however, you’re
going to have to have a positive UA and by positive we mean a dipstick that’s
positive for leukocyte esterase or nitrite. Or pyuria, that means greater than
or equal to 10 WBC’s of unspun urine. How many of you know whether or
not your lab spins your urine? Okay, how many of you don’t know? Yeah, so you need to see if it’s being reported
out to you or if not you need to clarify that with your laboratory because if it’s
spun urine, it’s greater than or equal to 10, if it’s unspun urine they’re going to be
looking at it under a high-powered field and it’s greater than five WBC’s to be positive. Okay? And, you could also
meet this using a gram stain if there’s microorganisms seen on unspun urine. Not many laboratories do this anymore. Questions that we do get
sometimes is what is trace? Is trace positive? Yeah, trace is positive. So if you have a trace leukocyte
esterase, it’s positive. Just like with one A; you know, we have
this top portion that was in place. We have the bottom portion that the catheter
was taken out the day of or the day before, that means that we’ve added back
in urgency, frequency, or dysuria. Just as above, this is the ones that have equal
to or greater than 1,000 but less than 100,000. And they have to have one
of the same positive UA’s. So the only difference between the top and the
bottom is the additional criteria of urgency, frequency, and dysuria, if the
catheter had just been removed. Clear? Yeah? Looks like everybody’s with me. Yay. So I’m not going to go over this diagram, I just want to point out
that it is in the protocol. Some people are very, you
know, they do much better with a flow chart than they do all of the text. So we do have it there. One is for — this one it happens
to be if the Foley is in place. We have one if the Foley is removed. There are similar flow charts
for three and four and for ABUTI. Now the criteria for the infants, one
year of age or less, is very similar. You’ll notice that three is very similar to one in that the colony-forming units is
greater than or equal to 100,000. The only difference between the adults — or
the all-age criteria and one and the three is that we’ve added, again, hypothermia,
apnea, bradycardia, lethargy, and vomiting. Other than that it’s exactly the same. The one difference that I’m going
to say is that you’ll notice that we have two asterisks down here. Rather than splitting this up, we have
simply said between those patients that have the catheter or those that had
it removed, we’ve just asterisked down here that if they had the catheter in place for
greater than two calendar days with the day of device placement being done and the
catheter was placed on the date of event, that they can utilize these symptoms here. Four is very similar to two, it’s the analogy of
two in that the colony-forming count is lower, it’s greater than 1,000 less than 100,000. Because of that you need a positive UA. The positive UA results are no different
for children than they are for adults. And, again, those additional
symptoms that I mentioned above. So, this, just to point out that this
double asterisks is how you’re going to determine whether or not this is a
catheter-associated device — or UTI or not. Asymptomatic bacteremic UTI — I’ll give you
a little bit of background for those of you that don’t know how this definition came about. Back in 2009 when we removed ASB, asymptomatic
bacteriuria, we didn’t anticipate a problem that would occur from that, and that was that
if a patient had a positive urine culture, but they didn’t have any symptoms,
it could no longer be called an ASB. It used to be that that could
be reported as an ASB. If it was recorded as an ASB, then it could be
said that an LCBI that occurred at the same time with a matching organism was secondary to that. Well, when we took away ASB, we now
had these positive blood cultures that matched a urine culture but
they couldn’t be called secondary and so if the central-line was
in place they became CLABSI’s. And that didn’t sit well with
people, it didn’t sit well with us. So, we developed asymptomatic bacteremic UTI. So this is for a patient that has a urinary
catheter in place or doesn’t have one, it could be catheter-associated
or not, and any age patient. So, we don’t have an infant one. They can have none of the symptoms that we’ve
mentioned for any of the other criteria. Okay? So, I’m not going to go through all those. They simply can’t have any
of the earlier UTI symptoms. Additionally, they have to have a positive
urine culture or greater than 10 to the fifth. Again, no more than two species, and a list of
specific uropathogens that have to be involved. And we’ll go over those in just a second. There has to be an accompanying,
matching blood culture with at least one organism to the urine culture. If all that occurs within a time-frame that
doesn’t exceed a gap of one calendar day between two adjacent elements, then this is an
ABUTI, and you would not call it primary BSI. Okay? That list of uropathogens are listed
here, as I told you it’s pretty broad — gram negative bacilli, staph
species, yeast, beta hemolytic strep, enterococcus, gardnerella vaginalis. We took these lists from —
I can’t remember the source, but we didn’t make this list up [laughter]. I can get you the list at
the source if you want it. Aerococcus urinae and choroni bacterium. You know, it’s very seldom that I hear
of an organism that doesn’t fit in here. So, and that complete list is,
you know, listing up the species as well as the genus, is on our website. Okay. So, just to say again, only the events for
ABUTI that had catheters in place for greater than two calendar days prior to the date of onset are catheter-associated
otherwise they are none. And then UTI’s is one of them that we get
a lot of questions about the recurrence. Is it new or is it a recurrence? Do we have to report a whole separate UTI? And the guidance here is no
different than it was for LCBI. We say look to see what evidence
of infection is still occurring, does it appear that the infection
has resolved clinically or are they still being treated
for the first UTI? If either of those is yes, then we would not
assign a UTI, we would say it’s a continuation. And that is irrespective of whether
or not it’s the same organism. So, I always use yeast as an
example because it happens so often. Somebody’s being treated for E. coli UTI and four days later they have a
positive urine culture for yeast. They’re probably still being treated at
four days and in that case, if they are, then you’re just going to add that yeast onto —
if you’ve reported the UTI, you’re going to add that yeast on as a pathogen to that, rather
than calling it a separate infection. Okay, you ready for another email? They get funnier as we go along. So, this is one we got. “Good afternoon. I have a patient who met all the criteria for
CAUTI on 1/21 when she spiked a fever, however, she was declared brain-dead on
1/18 and was only being kept around so her organs could be harvested. Would she be considered a CAUTI.” I thought, that’s a really
strange way to phrase that. She was only being kept around
so her organs could be harvested. The answer is yes, we do include
patients that are in hospital, you know, they’re organ-donation patients, because we
shouldn’t be giving them UTI’s even though, you know, they’re here for organ-donation. So, and we actually have reviewed
that decision with our patient — our organ transplant team and they
were in agreement with it, so yes. That got people talking. Okay, now we’re going to go on to key terms. So, obviously all CAUTI’s have to HAI. So we’re going to talk about POA versus HAI. Here’s where you might want to tune out if
you’ve heard this all more than you want to. A POA infection is one that
all criteria, all criteria, are present during the two calendar
days before the day of admission, the first day of admission,
and/or the day after admission, and are documented in the medical record. If it’s POA, you shouldn’t be reporting
it to NHSN, we are only interested in health care associated infections,
and acceptable documentation, again, does not include that reported by the patient. If the patient says I was
febrile, you can’t utilize that. You can if a report comes from the other
hospital that the patient’s febrile. And something I didn’t mention
is that we really, you know, we’re trying to balance what we
require for you to know and whatnot. We didn’t want you to have to go back
and ask the facility what the fever was. So, as long as it’s documented
that the patient was febrile, you can use that to meet
that part of the criteria. Physician diagnoses is not a
part of the CAUTI definition. So, a patient coming in and a physician says
he has a UTI, that is not sufficient to say that the patient had a UTI on admission. Okay? Patient is going to have to meet
the criteria during that time period. So here’s the unlucky family again. Grandpa Unlucky has been in an inpatient rehab
facility following multiple fractures sustained in a multi-car pileup when Atlanta sustained
the Snowmageddon of 2014 [laughter], otherwise known as a half
an inch of snow [laughter]. Yep. He’s now transferred by the way, to your
hospital with a Foley catheter which has been in place for two weeks and
reported by health care worker of fever the day before transfer
and a change in mental status. He’s afebrile on admission and his urine
cultures collected on admission are positive for greater than 100,000 CFU’s of E. coli. So, we’re going to vote again this morning. Which of the following is most accurate? He does not have a UTI. Has a UTI attributed to the new hospital. Or he has a UTI attributable to the rehab
facility and is POA to the hospital. Okay. Let’s see how you’ve done. Couple more seconds. So, 96% of you think that the patient has
a UTI attributable to the rehab facility and POA to the hospital, and
that is the correct answer. And let’s see why. So, he — on the date that he’s admitted
to your hospital there was a report of fever the day before transfer, which
was reported by a health care professional. And he had a urine culture collected,
which was greater than 100,000 of E. coli. So he meets SUTI one A, present on admission. Actually, attributable to the other hospital
and we do encourage you to communicate with other facilities to let them know when
you identify an infection that is attributable to them and if I was you I certainly would,
because I don’t want to be compared to somebody that was not collecting all of their data. Definition of a health care associated
infection, again, it’s considered HAI if all of the infection’s specific criteria were not
present during the POA definition time period. So, not POA, but they were all present on or
after the third calendar day of admission. Again, they have to occur within a
time period that does not exceed a gap of a single calendar day between
any two adjacent elements. And, did we define a gap day
as a calendar day in which none of the infection criteria are present. The transfer rule, as you all know, is if
the patient meets the criteria on the day of transfer or the next day,
we’re going to attribute that back to the transferring location. If it occurs after that time period,
after the day of transfer, the next day, it’s going to be attributable
to the receiving facility. And, you know, this applies also
to patients that are discharged. If they go home and then you find out
the next day, they come back and you find out that they have — even if they
don’t come back, if you find out, maybe you have communications
with your medical offices. But if you’re aware of it you’re going
to attribute that back to your facility if it occurs on the day of
transfer, the next day. I’m sorry, I said transfer, I meant discharge. Okay, warning. The next slide is very important. Does this work? [Ambulance sound] All right, here’s an example. And I say it’s really important because we
actually get this question all the time. I know that people don’t understand
this as well as they should. So this is an example that is not
present on admission, it is an HAI. Day one, the patient’s admitted. They’re asymptomatic. They have, however, a urine culture that’s
collected for 10,000 CFU’s of E. coli in the urine, but they’re asymptomatic,
as I said, and there’s no documentation in the two days prior that
they were symptomatic either. Second day they’re asymptomatic. The third day they run a fever. And the fourth day they have a culture, again, and they’re now 100,000 colony-forming
units of E. coli in the urine. This meets the symptomatic UTI criteria. They didn’t meet it in the POA. They had a positive culture but
they didn’t have any symptoms. You left that catheter in,
you know, for four days. It doesn’t say they had one
here, but you’re only going to report it if they did, probably, so. So, this is a UTI that’s got to
be reported for your facility. Okay? This is one of those examples
where it’s neither POA nor HAI and you’re not going to report anything. Patient came in and they were asymptomatic. They had a fever on the second day. The third day they’re asymptomatic again. The next day, I don’t know why, but
they do a culture on the patient. It happens. And it’s positive for 100,000 of E. coli. Asymptomatic five and six. So, we didn’t meet the criteria in the first
two days, and we didn’t meet them after that and we only had a positive
culture on day three or later. Day seven would be too long because there
would be a gap day here — two gap days here. So, this is one of those cases where
they don’t meet either criteria and it’s not going to be reported. Although, you and I believe they
have — may believe they have a UTI. Okay. Good news is we probably also would
think that they probably came in with it. Okay, I’ve covered this, the gap
day rule or the gap day definition. So, I’ll give you an example
of the gap day again. Patient is admitted on April 1st to the ICU. They put in the Foley Six
days later they had a temp. On 4/8 they’re asymptomatic, they’re afebrile. This is a gap day. They don’t have any suprapubic tenderness,
they have no CVA pain, they have no fever. It’s a gap day. The next day they have a positive urine culture. So, because there’s a single gap day here
and the Foley’s been in longer than two days, this is going to be a catheter-associated UTI. Again, if 4/9 had been asymptomatic, and 4/10 the urine culture had been
collected it would not be considered a UTI. Because there would have been two gap days. Okay. Our definition of an
indwelling catheter has not changed. That’s good to hear, hey? So it’s simply a tube that’s inserted into
the urinary bladder through the urethra, that’s left in place and is
connected to a collection system. It includes those patients
that are getting irrigations. Those patients are probably at higher risk of
UTI’s, so we include those patients as well. It doesn’t include straight, in and out
catheters, nor suprapubic catheters, no nephrostomy tubes, but if a patient has
suprapubic catheter or nephrostomy tubes, which happens sometimes, and a Foley, they are included in your
catheter-associated UTI surveillance. If the Foley’s there, they’re included. I got a question this week from
somebody that they had a patient, I think it was a spinal cord injury
patient, that they were doing — he was doing intermittent self-caths and
then at night the nursing staff was putting in a Foley catheter, and they
were taking it out every day. Is this something that you guys see? No? Okay, so she wanted to know if they were
eligible for CAUTI and my answer is yes, because the catheter was
in place each day for — an indwelling catheter was in
place some point of each day. So on the third night, they now
become eligible for a CAUTI. We get all sorts of crazy questions. Okay. And I think we’ve pretty much covered what
is the definition of a catheter-associated UTI. So, the only thing I want to highlight is it
is the date of the event that you’re looking at to determine whether or not
the catheter had been in two days. The date of the event, the date of the
last element used to meet the criteria. Discontinuation and reinsertion. We get this all the time, and as I said, we’re coming out within the
newsletter with guidance for this. But if the Foley catheter is discontinued and a full catheter day passes before a
Foley is reinserted then the day count for determining catheter-associated
UTI begins anew. Otherwise, it continues from
the previous catheter. So, I have two examples. Patient has a Foley, day three, day four. They took it out on day five. They put it back in on day six. And — I’m sorry, they took it out
on April 2nd, and they put it back in on April 3rd, this becomes day six. Continues from day five for Foley because there
was not a full calendar day without a Foley As opposed to this example down here where
they took the Foley out on April 2nd. There was no Foley for the whole day on
April 3rd and they replaced it on April 4th, this becomes new Foley day one, Foley day
two, and Foley day three on April 6th. On this date they’re eligible for another CAUTI. Okay? Again, somewhat arbitrary
but just trying to make a rule so that we all do it all the same. We just pretty much covered this; the date
of the event is the date of the last symptom. So if you have a temp on one day and a
urine culture the next day, this is — you’ve now met criteria,
this is your date of event. So, quick examples of a device-associated. Patient has a Foley inserted on
day one, they’re asymptomatic. The Foley remains in place and
they spike a fever on day two. They still have a fever on day three and they
have a positive urine culture on day four. That meets criteria, E. coli. Because they didn’t meet the
criteria in the first two days, even though they had a fever here, this
is a device-associated, this is a CAUTI. Okay? They would have had to have their culture
in the first two days for this to be a UTI but not a catheter-associated UTI. You’re just going to ignore this fever
then and utilize day three or day four. I’m sorry, I want to correct that. You can count the fever in here because what we
tell you to do is to look at the date of event. So scratch what I just said
because I don’t want to confuse you. It’s easy to do. It’s easy for me to get confused,
so just look at your date of event. Your date of event is day four here. It’s the date of the last element, because
that day is not in the first two days of the catheter, this is considered
a catheter-associated UTI. That’s really the easiest way to do it, and
it’ll get you into the least amount of trouble. And I can get in trouble sometimes,
in case you hadn’t guessed that. All right. This is not a CAUTI. Foley is inserted on day four. They have a temp of 100.6 the next day. They send the urine culture and it’s positive
for 100,000, they meet the SUTI criteria on this date, day five, but the Foley
hadn’t been in place for greater than two calendar days on
the date of event here. It had only been in, it was on its second day. So this is not catheter-associated UTI. This is also not a catheter-associated UTI. Foley inserted on day four, removed. They’re asymptomatic four days later, day eight. On day nine there’s still
no Foley, they have a fever. And on day 10 they have a
fever and they have candida. The date of event in this case
is day 10 and it was not the day of removal nor the next day, it was after that. So, it’s not considered CAUTI. Last example, I think. Patient comes into the ICU,
has a Foley put in on day four, removed on day eight, reinserted on day nine. And on day 10 they meet criteria. This is one of those reinsertion ones. This is going to be considered
a catheter-associated — oh wait, this patient has a Foley in place
for some part of each calendar day for greater than two days, and there was not a full
calendar day without a Foley in place. So this is a CAUTI. Is that clear? Location of attribution for CAUTI
is the same as it was for LCBI, it’s the location where the patient was
assigned on the day of the UTI event. And, again, the date of the
last element for the criteria, with the only exception being the transfer
rule which, I think, we’ve pretty much covered. If it occurs on the day of transfer
or discharge and the next day, it goes back to the attributing location. I’m just going to go over one example
here that we get a lot of questions about and that’s the small tie transfer rule. So in this case, patient is
in the ICU on day one of admit and on day two they’re also in the ICU. On day three they start in the ICU, then
they go to five west, then they go to CCU. And the next day they have
an HAI, in this case a UTI. This HAI is going to be attributable to the ICU since that was the first
location the day before the event. So this is, you know, your transfer rule time
period here, the day of transfer, the next day. And so this is the ICU here. Trying to expand that incubation
period, you know, to the longest time we can in those two days. Okay. Oh, this came through [inaudible]. I wanted — this was supposed to
come through in two different pieces. So we send out an email to people that said,
“It appears a user from your organization with user name XXX is in the process of
updating their SDN digital certificate. CDC is in the process of reviewing their status and will notify the user via email
when the process is complete. At that time the user will be able to log in.” So we get an email back from this person
that says, “I’ve already installed it on two computers a couple of weeks ago. You better make sure it works right
because it is a hassle to get this done and I did it all myself and it worked fine. Please do not screw it up.” [ Laughter ] Apparently, she’s worked
with us before [laughter]. Aren’t you glad those digital
certificates are going away? Has anyone here been Sammified
[assumed spelling]? Okay. Do you like it?>>Yes.>>All right, cool. All right. Sammified is a new system that you
guys will all be moving over to. Instead of digital certificates they
give you these cool little Bingo cards that they’ll have you put in codes
for and they’re good forever. So, I like this. Okay, now we’re just going to
very, very quickly, like I said, I’m not going to spend a
lot of time on data entry. I do just want to highlight three
fields here on this section. Urinary catheter — we’re going
to ask you to identify whether or not there is a urinary catheter in place
greater than two calendar days on date of event or if it had been removed but was in
place for greater than two calendar days. Or neither. There was not urinary catheter in place on
the day of event or not in place greater than two days on the date of event. Okay? This is going to drive
the system to identify this as either catheter-associated
or non-catheter associated. The location for device insertion
is optional, if you want it. Sometimes we get questions from facilities that
say, “Well, they put one in and they took it out then they put another one in. And there are different units
what do we put in?” We say, “You can make your own determination,
your own policy about what you want to do with that because we don’t
utilize that field right now. So, you know, you get to make your decision. And the date of device-insertion
is also optional at this point. I did get a question this week from somebody. It looks like on the form — I don’t see
it on here, maybe it’s on the screen. It actually says urinary catheter at time
of specimen collection and that’s an error. We missed pulling that off when we
changed the definition, so this is correct and it’s been there for a year
and a half and nobody noticed it until a user emailed me yesterday. So, just know that it’s at the date of event, is what we’re concerned about
with a catheter presence. Not the date of specimen collection. Okay, your summary data is collected pretty much
the same way it’s on the same forms as for LCBI. Again, you’re going to collect the number
of patients that are present at the time of the count, each day on the unit,
and enter that in this field here. And then the number of patients that have a
urinary catheter that are there at that time on that unit and enter it here for each
day, and then you’ll sum the numbers at the bottom at the end of the month. For NICU, I do want to point out that there
is no in-plan CAUTI surveillance for NICU’s. We no longer allow that because
they’re just used so infrequently in that patient population the
data’s not really that meaningful. But some facilities are opting
to continue to do this off-plan. So if you’re doing that,
those will be entered here. URC days and you’ll be stratifying
it by the different birth weights. And again, birth weight, not weight at that
time, but the weight of the baby at birth. Special care areas, there’s no difference
in how the data is collected here between a special care area
and an ICU or a ward. Unlike, you know, CLABSI’s you have permanent
or temporary central lines for LCBI’s, here it’s just a urinary catheter and it’s
enter — I do again, for all of these events or all of these location types you are going
to have to tell us if you’ve had no events for this month and that’s where you’re
going to check it here — CAUTI. If you don’t check that and you don’t enter any
CAUTI events you’ll get an alert and it’ll say, you know, we don’t know, do
you really not have any UTI’s or have you just forgotten to enter them? You’ll also get an alert if you
don’t enter your patient days or your urinary catheter days for that month. And so, this is the example of the alert. In-plan denominators are reported for
these locations with no associated events. So in this case the ICU, you entered summary
data, you told us how many patient days you had and how many urinary tract days you
had but you didn’t enter any CAUTI’s and you didn’t tell us that
there were no events. So you can — handy-dandy little thing here. You can just go down here
and check these if that’s so. A smart person might wait and do that. Probably not a good idea,
but you could do that, so. Again, if you want to collect your data
electronically, we’re happy to have you do that. We just ask that you concurrently
collect your data manually. You go on the unit or have whoever does
it on the unit collect it manually, do the patient count and the catheter day count at the same time each day and
collect it electronically. Also, compare those two for three months. As long as there’s no difference more than 5%
in either direction, you can then do that for that location, just use your electronic methods. If there is a deviation of greater than
5% than you got to start all over again and try to figure out where the problem
is, get it right, until you, you know — make changes until you are able to
get an accurate count electronically and then you can move ahead with that. So, you need to do it in location
for three months, minimum. Just another sign. I do want to say that oncology hospitals have to
report separately for all locations and units. Anybody from an oncology hospital here? Nobody. Okay. And to remind you that you’re
CMS reportable data has to be included in your monthly reporting plans. If you don’t put it in your monthly
reporting plan it will not be sent to CMS and you won’t be happy, they won’t be happy. Here’s your resources. This is the training site for
urinary tract infection information. We have Lectora, which is a self-paced
software program and does have self-testing, and there’s questions in there and
you have to score greater than 80%. We do expect that people will do the training
at least once before they utilize the system. And then we have — these webinars will be
on there as people have told you in April. I believe, I hope this one is down,
I think it is because it’s outdated. These are just the forms that you’ll use to
report your data, and more resources for you. This is a summary online listing of
all the training that’s available that would be pertinent to
you doing CAUTI training. Okay, so another funny email. So we sent this out, you know, we sent
— this is what we call blast email, to everybody that’s a participant, you know. We said, “We will be restarting NHS application
in a few minutes, please plan accordingly.” You know, because if people have
got data on there we want them to save it so it doesn’t get lost. And somebody reported back, “I haven’t started
baking yet, I don’t know if I’ll get to it.” [ Laughter ] I’m not sure what that meant, but [laughter]. I don’t know what she was referring
to, like baking the data, you know, like she didn’t get it in or if she was thought
she was talking to somebody else or what, but we weren’t really sure how to respond, so. Okay, so we have finished about 15 minutes
early and I’m going to look to Courtney to see before we get into the case studies. Do you want to take a break now or do
you want me to start for 15 minutes. [ Inaudible Speaker ] What’s that? [ Inaudible Speaker ] I’m sorry? Keep going? [ Inaudible Speaker ] For 15 minutes? Okay. We’ll keep going for 15 minutes.>>[Inaudible] questions.>>I can, but I would rather wait because
we might cover the question in the — you’re going to be extra special, you’re the only person that’s
going to get to ask a question. How do you like that? Go ahead. Go ahead [laughter]. [ Inaudible Speaker ] Page 23. Okay. Gap day. Page 23, oh my page is different
— my page is different than your page.>>I’m trying to resolve your three-day Foley
rule plus the gap day example of symptomatology. So you said that you have to
have the Foley in for three days by the last day of symptomatology. So in your gap day example you have a
temperature on 4/7, like Monday, whatever, and then you have a gap day, day two. And then you have a culture
on day three, Wednesday. You’re saying that if the
Foley was inserted on Monday?>>This one?>>This would count?>>No I didn’t [laughter].>>On the same day that they
had the first element or some –>>Thank you, is it this one?>>Yes.>>Okay, so –>>So, if instead of the
Foley being placed on 4/1 –>>Yes.>>The Foley was placed on 4/7.>>Okay.>>Because I’m trying to determine if the
Foley has to be in place for three days on the first day of symptoms, or on the
last day, and you just said the last day. Okay. So that means in this example,
this Foley can be placed on 4/7, the day of the temperature,
and then there’s a gap day, and then the day of the urine is the
third day, that’s three or more days.>>That is correct.>>So this would be counted as a CAUTI. Foley placed on the day of the
first symptom, that makes no sense.>>Well, hopefully, if the patient has
the fever they’re going to be looking to find out why the patient has a fever. Okay?>>Correct, but they placed the Foley on the
same day so it shouldn’t be related to that.>>And, clinically, I’m going to agree with you. And the hope is that most of the time if they
have a fever they’re probably going to try to figure out why they have
the fever and they’re going to collect that culture sometime sooner. There will be rare instances — we can sit
here and try to come up with situations that don’t work and those
situations do happen rarely. Okay?>>This is not an uncommon
situation, where they place a Foley because a patient is having problems. Not having problems due to
having the presence of a device.>>It’s a surveillance definition
and we made these rules because people asked for
them, users asked for them. Because before we had no minimum time period. Right? So, in that case it
still would’ve been a CAUTI.>>Without the ability to have some clinical
correlation, we can’t use these numbers to be able to drive performance improvement. I’ll just –>>I understand.>>Okay.>>I understand. Okay, so let’s — we’ll keep going. No, I don’t think so. Well — [ Applause ] [ Silence ] Okay, let’s start with our case study. Oh. So actually we’ll — so before we start
the case studies I wanted to share something that on the web that highlights the
importance of making good methodology when performing HAI surveillance. So, here we go. Escape — oops, that’s right. That’s not right, here. Here. Okay.>>Hi, I’m [inaudible] and my
CEO says I should talk to you because you’re hospital has zero health
care associated infections for three years.>>Yes, as the infection
preventionist I can say that’s true.>>Wow, that’s amazing. I mean, I have my organization [inaudible]
zero infections and we have had some ruts but we had a month here or there where we
have had none, but zero for three years. That’s incredible.>>Yes. We did it. I have zero infections, for three years.>>How? I mean, don’t you ever
have bacterial trans-location where the patient has no infection but the pathogen escapes the GI
tract and appears in a blood culture?>>We have those cases but my ID
doctor throws those out [laughter].>>Your ID doctor? What is he doing surveillance for?>>He always does surveillance after I
find the cases that meet the definition.>>Has he done any online training
on how to use the definitions or done any [inaudible] trainings on the NHSN
definition or gone to a [inaudible] training?>>No he is an ID doctor.>>So, despite the fact that you have
cases that meet the NHSN CLABSI definition, you don’t count them because your ID physician,
who has no training on epidemiologic definitions or NHSN training doesn’t
think they are NHSN cases?>>Yes. He is an ID doctor [laughter].>>Does he say they don’t meet
the NHSN CLABSI definition?>>He is an ID doctor [laughter].>>You already said they met the
definition why even have them look at them?>>He is an ID doctor [laughter].>>We established that. Have you been to training
on the NHSN definition?>>Yes, I have done many classes and do the
[inaudible] training on the definitions.>>So, you are having someone who is incompetent at using the definition override your
judgment as a trained epidemiologist.>>He is an ID doctor [laughter].>>Yes, and if I had a central
line infection I would want him to give advice on how to manage that infection. Why does he even want to
look at the CLABSI cases?>>He is very interested in CLABSI. As Chair of the Infection
Control Committee he gets a bonus for lowering the hospital’s
infections [laughter].>>Don’t you see that is a conflict of interest. Why would you allow that surveillance
to potentially be compromised like that?>>He is an ID doctor.>>Let’s talk about CAUTI. No CAUTI?>>We have zero HAIs. My ID doctor reviews them.>>Is your ID doctor’s name Dr. No? Let’s talk about SSIs. No small bowel infections? No colon surgery infections?>>I have had no HAIs for three years.>>How do you do surveillance for SSIs?>>I look at the microbiology results
and if there are none they are cleared.>>What about radiology results?>>I look at the microbiology results
and if there are none they are cleared.>>Why would a surgeon culture a gut leak, they
use the x-rays to find abscesses and then treat. How about MD notes, do you
read them on the cases?>>Doctors at my hospital write a lot.>>Yes, how do you assure yourself they
aren’t diagnosing a surgical site infection in their notes or describing a wound
infection if you don’t read the notes?>>Doctors at my hospital write a lot.>>Do you do a search for antibiotic therapy
post- surgery or returns to the O.R.?>>I have no HAIs for three years.>>I will take that as a no. So you never had a failed anastomosis
that resulted in an infection?>>We have those cases but my ID
doctor throws those out [laughter].>>Doesn’t he know that the definition
does not exclude them from being cases?>>Yes, but he disagrees with the definition.>>I can disagree with gravity but it
doesn’t mean that it no longer applies to me.>>He is an ID doctor. I have had no HAIs for three years.>>Liar. Oh, I feel an HAI coming on.>>I also have 100% hand hygiene compliance,
do you want to know how [laughter]? [ Applause ] [ Inaudible Speaker ] All right [laughter]. So, I don’t think I want to take
comments after that [laughter]. [ Inaudible Speaker ] Oh, the author’s here? Oh! [ Applause ] Oh, Bravo! Bravo. Who is the author? [ Inaudible Speaker ] Greg Meyers [assumed spelling]. Okay. Nice job. So that was just a little light-hearted. I thought you guys would enjoy that. I enjoyed it. Somebody sent it to me and, you know, I think
it’s really — it does drive home, you know, that we all need to do what we’re supposed
to do and I understand that there are — that the definitions are not perfect. Believe me, we get emails all the time
and we understand it and we are — I hope that you heard in the last two days
that we do listen to you and that we are trying to improve them, you know, where we can. So, we can go ahead and start one case
study and we’re going to just look at these, we’re not going to get into
surveillance versus clinical. We’re just going to learn, make sure that
we’re accurately reporting the definitions or applying the definitions and
we’ll try to optimize the consistency and that application and improve data quality. So, as I said yesterday, when you’re looking
through these case studies you might want to consider looking at them in this order. Is it a POA? If it’s a POA and they haven’t been
discharged in the last two days you can stop, we don’t need to have it reported at
NHSN, we’re only interested in HAI’s. Is it an HAI if it’s not POA? If it’s not an HAI — remember
we talked about there’s some that are not POA, that are not HAI — then stop. Finally — next you’re going to ask
yourself is it catheter-associated UTI. And then you’re going to need to look at where
to attribute it if it is a CAUTI So case one. Mama Unlucky is admitted unconscious
after she fell when three deer ran out in front of her while skiing. She has a broken femur. A Foley and a peripheral IV are inserted. On day three her Foley is removed, she’s
awake and making good recovery progress. On the fourth day she’s up with assistance
but she complains of pain on voiding, has a UA collected and it has
slight leukocyte esterase, negative nitrites, and 15 WBC’s on spun urine. The next day they collect a urine
culture which has 10 the fourth, or 10,000 CFU’s per ml of E. coli. So, questions for you is does this
patient have a CAUTI and if so what type? Choose yes, a SUTI one A. Yes,
a SUTI two A. Yes, an ABUTI. Or, no CAUTI at all. You can vote. A couple more seconds. Okay, so let’s see what you all say. Oh, we have some difference of opinions here. We have 50% say it’s a CAUTI two A,
and some people, 38% say no CAUTI. This is no CAUTI. Okay, so criteria were not met in the POA time
period and the patient does not meet criteria for UTI with dysuria and positive urine culture
and a UA — I’m sorry that do meet that, but the date of event was later
than the day after removal. Right? So, the Foley was removed on day three. The patient didn’t meet criteria
the date of event, until day five. Okay? So, it’s a UTI but it’s
not a catheter-associated UTI. Okay?

The Opioid Epidemic in America

The Opioid Epidemic in America


Michael Botticelli: The
most urgent task we have is really dealing with
Opioid Epidemic and its consequences. You know, we are– we have
about 120 people dying every day in the United States as
a result of a drug overdose. You know, we haven’t seen
this kind of mortality in a long time. We are now approaching
mortality rates that kind of parallel the height
of the AIDS epidemic. And so we’re losing
far too many people, and it compels me every day. And every day I think
about, you know, what can I do to
make a difference. What can I do to make a
difference in this epidemic. And to save people’s lives. Part of our goal here is
widespread criminal justice reform. In making sure that people
who are encountering the criminal justice system
are actually referred and deferred to the treatment
system to get help and support for their disorders. And it’s really been
remarkable I think. Our local law enforcement is
talking about public health strategies, and they know
that we need good prevention and good treatment. And they want alternatives
other than just arresting and incarcerating people. So we all know we’re seeing
a dramatic increase in heroin use across the
country and that’s been driven by the
overprescribing of prescription
pain medication. When we have law enforcement
folks who understand that every life is worth saving. And that we need to do a
better job at getting people into care and treatment. I think that’s really
incredibly important. Male Speaker: And this
euphoric feeling of “That’s cool. I just saved somebody’s life,” you know. And you’re standing around
looking at your buddies, and then the
administration comes in, and it’s like “Hey,
that’s pretty cool.” And so you know, it
kicks in like “Hey, we’re actually going to
give this person a second chance.” We’re going to
give this 14, 15, 16-year-old kid who may have
accidentally at one time done it a second chance
to get into that treatment path. Michael Botticelli: You
want, at a community level, to hold our people
in recovery. Because that’s
what the hope is. That’s what the person with
addiction needs to know on the other side. That there is hope for
me if I go to treatment. One of the things that I
love about this field is watching and listening to
the radical transformation of people’s lives
when they get care. And listening to
their testimonials, listening to the
testimonials of their family. Who get their loved
ones back as a result of treatment. You watch people just
develop before your eyes and reach their full potential. Female Speaker: (inaudible)
is a huge support system. I’m here every day doing
something with somebody. Male Speaker: I wouldn’t be
here right now, for real, for real, if it
wasn’t for them. Male Speaker: My recovery
process is my main focus right now. Michael Botticelli: I’m just
one of 23 million people in recovery and I’ve often said
I couldn’t imagine 26 years ago, you know, I’d be the
President’s advisor on national drug
control policy. But I think that my
story is not unique. It just really shows what
treatment and recovery are all about. And how people can be
restored to really full and happy and productive lives. You know, when we give them
the care and support that they deserve. I hope to use my office and
my story to kind of champion and encourage and empower
other people to be open and honest and public about
their own recovery and their own struggles. Female Speaker: If he can
do it, we can do it too. It’s real. It’s real.

The Early AIDS Epidemic in the United States: Views from Atlanta and Hollywood

The Early AIDS Epidemic in the United States: Views from Atlanta and Hollywood


Booker Daniels: Good afternoon, everyone. How are you today? Outstanding. I’m Booker Daniels. I’m a member of the staff at the Division of HIV/AIDS Prevention at CDC. It’s my esteemed privilege to be somewhat moderating or just introducing these incredible individuals for this panel session today. The title of our session today is The Early AIDS Epidemic in United States Views from Atlanta and Hollywood. And throughout the course of the conference there will be many sessions where people say there are two individuals that don’t require any introduction. These two individuals certainly do not. But I will introduce them, nonetheless. Seated to my right immediately is Dr. Harold Jaffe, Associate Director for Science at CDC. And prior to this role he served 27 years as most notably as a medical epidemiologist and part of the initial AIDS investigation team and a former director of NCHHSTP. We’re also joined by Dr. Jim Curran, who is currently the dean of the Rollins School of Public Health at Emory, Rollins University, Rollins School of Public Health at Emory University. Prior to this role, he had a career at CDC for 24 years and he was the initial director of the Regional AIDS Task Force on the initial outbreak of the epidemic. With that, I’ll turn it over to the panelists and we’ll get underway. [Applause] Harold Jaffe: I wanted to thank Booker for the kind introduction. I thought he was going to say: If there are two people who shouldn’t be introduced, it would be Jim and me. But it’s a pleasure to be here, and it’s a pleasure to be on this session with Jim who played such a key role in the investigations of the early history of the AIDS epidemic. I guess the first question is why should you care? What difference does it make what went on 30 years ago? And I guess I can think of a few reasons. First of all, judging by the looks of at least some of you, you were too young to have remembered this epidemic and may not have been born. So this is a bit of a history lesson. Secondly, for those of you who are physicians but only have cared for AIDS patients after the mid-1990s, this is a reminder of what a terrible disease this was in the pre-treatment era. And, thirdly, I think this is an important illustration of the power of epidemiology and the epidemiological method to understand a new disease, to understand how it’s transmitted and even prevent it without even knowing what the cause is. So we’re going to try to do this both through a lecture, which I hope is going to be more or less factual, and also clips from this film “And The Band Played On.” It’s less factual but I think it’s helpful in understanding the main events of the time. The film was released by HBO in 1993. And it was based on the book of the same name published in 1987 by Randy Schultz, who was an openly gay reporter for the San Francisco Chronicle, and very sadly died of the disease himself. The film uses actors, I think some of whom you’ll recognize, playing the parts of real people. And Jim Curran is one of the real people, and I’m going to be periodically asking him to make comments as we go along. So here I’ve listed some of the main characters you’re going to see in the film. Obviously many, many more people were really involved, and the movie, I guess, picked people for dramatic effect. The roles of some of the people, particularly Jim Curran and Don Francis, are quite distorted. Again, I think for dramatic purposes. The film starts with a scene from the intensive care unit at UCLA Hospital in the fall of 1980. This scene was of special interest to me because I trained in medicine at UCLA and had left just six years before and had spent many nights in that intensive care unit. So let me show you that first clip. [Video] >> Thank you. Thank you very much. Thank you. Thanks very much. Thank you. >> Doctor? >> Here we are. [Crowd cheering] >> No T. cell count. I’ve got to tell you, Dr. Gotlieb, this is weird, man, he doesn’t have any. >> How can he not have any T cells? >> His immune system’s gone. [Typing. Phone ringing] >> Good morning. Good morning, Dr. Gotlieb. [Knocking on door] >> Can I talk to you for a minute? I just got this in the mail from our man in LA, Dr. Shandera, got it from a Dr. Gotlieb, I think you ought to look at it right away. >> Jim, looks like there’s a very weird epidemic breaking out among gay men in Los Angeles. There have been five cases of pneumocystis with no contributing disease within the past few months and already two fatalities. Plus I made calls to New York San Francisco and it seems they’ve had similar cases. I think this ought to go into the weekly newsletter as soon as possible. What did you do that for? >> I don’t decide what goes into the newsletter. I can only recommend. But, Mary, we’ve got a new administration; you want to see this published so people can read it, or do you want to see it killed? Harold Jaffe: Well, the article was in fact published, but it didn’t even make the cover of the MMWR on June 5th, 1981. As mentioned in the film, the article described five young previously healthy homosexual men who were treated for biopsy-proven pneumocystis pneumonia at three hospitals in Los Angeles. Two of them had already died. These cases seemed very unusual in several respects. First, virtually all previous reported cases of pneumocystis in the United States, at least in adults, were in persons with an obvious cause of immune deficiency such as an organ transplant recipient or someone receiving cancer chemotherapy. But these men did not have those risk factors. Secondly, it was a mystery as to why they were all homosexual men and, third, why were they coming from Los Angeles and possibly San Francisco and New York. So let me first ask Jim for his thoughts when this article was published. Did you cross out the title? Jim Curran: Well, as cute as the guy is, I’m not him. The context, Ronald Reagan was elected President over Jimmy Carter, and it was very high inflation and unemployment. And there was an immediate domestic hiring freeze and a travel freeze on CDC staff. We were fortunate to have a mentality at CDC where everybody wanted to work on the new problem. And this was a new problem. So there was a lot of enthusiasm among the staff. But very little money and inability to hire new people. So the context was a very dire economic environment in which to study a new problem. But the CDC was a fertile place to do it. It’s always painful to watch movies. The real history behind the MMWR was that there was a clerk named Sandra Ford who was handling requests for pentamidine-isethionate, which is a second line drug to treat pneumocystis. She noted some requests which had almost always been in people with cancer, underline immune deficiency, coming from requests for people with no underlying disease in New York and California. Called attention to her supervisors in the Parasitic Disease Division, and they couldn’t get any information out of New York. They were trying to hold the information back, and Dr. Gotlieb, Dr. Wayne Shandera, the EIS officer and others, accumulated the information and sent it into CDC to the Parasitic Disease Division. The title and stuff had already been decided actually by the head of the MMWR at the time, Mike Gregg, before Harold and I saw it. It was kind of delivered to us and we were asked because we had been studying hepatitis B and hepatitis B vaccine in gay men in the STD division, to talk to our contacts in the gay community. So, in fact, we actually at the time would be maybe the only part of CDC other than parts of the hepatitis division that had any programmatic context and contact with the gay community. And it should have been left in homosexual men. Harold Jaffe: Just a month later, the mystery became even more mysterious. Let me show you the next clip which depicts a CDC staff meeting. >> Okay. What we’ve got in Los Angeles, San Francisco and New York is a number of gay men who have been hit with a variety of opportunistic infections and really that’s all we know. I’ve asked Don to join us because for the last three years he’s been tracking hepatitis B virus in gay men and before that worked on the ebola fever epidemic in Africa. >> Thanks for joining us. >> What we’ve got to do is hit the phones, spread out and contact all the departments in all major metropolitan areas as usual so they can do a hospital-to-hospital search for cases. >> Make sure of the epidemiology. >> Talk to the patients, talk to doctors who may have treated those patients, friends, relatives. No question too stupid or too personal. >> Sexual relationships, too. >> Household chemical cleaning, diet. >> Could be a bad batch of street drugs. >> Pets. >> Maybe they all got the same kitty litter. >> John, I’m going to go to New York this afternoon, take a look at this disease. Can you come with me? >> Sure. >> If I knew these blotches would turn purple, I would have brought some bags to match. Here. Look at my book. When I was still human. I was the best in the business. Ask anybody. Leave it to me to get some disease nobody ever heard of. Kaposi’s sarcoma. Even my doctor had to look it up. Nothing to worry about, he said. Usually happens to Italian men in their 60s who continue to live a normal life until they die of something else. Do I look like an Italian man in my 60s? Now I do. 160. Why do they make things like this that nobody can ever solve? Harold Jaffe: So just a month later, July 1981, we started to hear about young men with malignancy Kaposi’s sarcoma. Some had also developed pneumocystis pneumonia and others had other forms of opportunistic infections, things like cerebral toxoplasmosis or cryptococcal meningitis. Now up until this time Kaposi’s sarcoma was a very rare disease in the United States. It had been described about 100 years earlier by the dermatologists Morris Kaposi, and the disease he described was one that had a male predominance. And typically occurred in men age 70 or older. Based on cancer registry data, it was estimated that in the mid-70s there were only three or 400 cases occurring each year in the United States. When it did occur, it was most often in men from southern Europe, Italy, Greece and those of Ashkenazi Jewish ancestry. The disease that Kaposi described, which is called classical Kaposi sarcoma, looks just like this. It’s a typically kind of raised plaque lesion, most often on the lower extremity and progresses very slowly. So if you read the textbooks at the time, they would say that an elderly man is more likely to die with this disease than from this disease. What was being seen, though, in these young gay men, even though pathologically or histologically — thank you very much — nice to have a moment of levity during this. Pathologically, you couldn’t tell the difference, the two forms of the disease looked the same, but clinically they’re quite different. The form that was being seen in these young gay men was much more aggressive. So here’s a man with these multiple skin lesions. If you saw them in clinic one week he might have two or three. A few weeks later he might have ten or 12. And a few weeks later he might look like this. And the disease was not limited to the skin. So here’s an example of a patient who has an oral lesion. These same lesions could be seen farther down in the gastrointestinal tract. They were seen in the lung and they were vascular. They could bleed. So some patients were actually bleeding out into their lungs or into their intestine and dying of the disease, which was extremely rare before the AIDS epidemic. Now there was a clue in the literature. If you look at the cancers that occur in people following organ transplant, particularly renal transplants, Kaposi’s sarcoma occurs at increased frequency. In contrast to what we were seeing with these young gay men, there’s no male predominance. And the most interesting feature is that there are case reports where it was possible to either taper the level of immune suppression or actually stop the drug or the disease would go into remission or sometimes even disappear. So there was clearly some very tight link between the immune system and this malignancy, although at the time we really didn’t know that was. Early in the summer of 1981 we were getting case reports simply by physicians calling us and saying: I think I saw one of those cases that you’re interested in. And we would very dutifully write down all the information we could by hand and stick it in a file. That was our system. And at that point we said, well, that’s not really very good, is it? We really need a national surveillance system. And to do that you need a case definition. So we made one up. Notice that the disease was not called AIDS at the time. It actually had no name. We were using KSOI for Kaposi’s Sarcoma Opportunistic Infection. The case definition that we made up said that we wanted to know about individuals who had proven Kaposi’s sarcoma or one of about a dozen severe opportunistic infections. We weren’t interested in this form of Kaposi’s sarcoma in the elderly. So we said patients less than 60. And, of course, we excluded anyone who had a known form of immunosuppression. So we made this definition available to major teaching hospitals, oncologists, infectious disease specialists and health departments. We said if you see a case like this please report it to your health department who will in turn report it to CDC. So let me ask Jim at this point what your thoughts were kind of in the middle of the summer of ’81. Jim Curran: I think in retrospect, one of the most important things that was done was the development of this case definition, which was highly, highly, highly specific. We knew it was insensitive. And we made a bunch of iceberg slides and sent them around saying that this was only the tip of the iceberg. But these conditions were so uncommon and they required, in the case of pneumocystis, open lung biopsy at the time to make a diagnosis. It required a pathologic diagnosis for both Kaposi’s sarcoma and the infections. And they were so rare in the developed countries that you could be sure that this was going to be part of this new epidemic. And that allowed us to determine whether a new case was part of it or not part of it, whether it was occurring only in gay men, was it occurring only in New York and California, and ultimately led to the definition — I mean, the determination of the epidemiologic patterns which led to prevention recommendations and convinced virologists and others that this was caused by a blood-borne and sexually transmitted virus. Harold Jaffe: Let’s move ahead to a little bit later in the summer of 1981. [Video] >> Do you have many gay friends? >> Not too many, no. Two doctors I know in medical school, I still stay in touch with them. >> Are they a couple? >> Yes, actually. 15 years. >> Kiko — Kiko is my lover — we have a wide circle of friends and most of them are in relationships, or want to be in relationships. >> So what are you saying? >> Lots of men go to these bathhouses, but there are tens of thousands of gay men in this city, maybe a couple hundred thousand, cops, and waiters, and teachers and lawyers and ditch diggers and athletes. >> Don’t talk loud, so they can’t hear you down the block. >> I’m sorry. I don’t mean to lecture. I just don’t want you to come away from your tour of the bathhouses thinking that’s how all gay men live. >> Last night we lost another one. In three weeks this handsome young, guy turns into the elephant man. We found out it was caused by some rare parasite that only sheep get. So I called a vet to ask what they do when sheep get it. They shoot them. >> Good luck. Thank you. >> Hi, Bill. Madrid Department of Public Health. >> Let me see if I can find the boss. [Music] >> Those two guys there, are they strangers? >> Maybe. Probably. >> They just met and now they’re going to go in — >> Right. >> It’s interesting. >> Listen to me. Imagine yourself in a place like this. It’s only filled with women, I mean, really beautiful women. Imagine one of those Penthouse women, she wants to go into that little room with you, nothing between you but a little towel, are you going to tell me you wouldn’t go into that little, consider dropping that towel? Yeah, I know men would give up food for it. >> How are you? >> Good. >> [Inaudible] from the Centers for Disease Control. >> So what’s the problem? >> There may be some kind of an epidemic spreading in the gay community, and I’d like to just come in and have a look around. >> I’m sorry, that’s impossible. We have to protect the confidentiality of our clients. >> I know, but, Eddie, you know I speak on behalf of the Gay Liberation Committee, the city council, the state assembly, I can tell you without fear of contradiction you are regarded second only to Abe Lincoln as a citizen that would fight to the death to protect civil liberties. So let’s cut the crap, it’s 10:00 in the morning for God’s sake. Let us in. >> Thelma, only for you. >> Thank you. Thanks, Eddie. >> How many men come here a night? >> Hundreds, every night of the week. Some bathhouses more than a thousand. >> What’s this? >> Poppers. They’re a quick, cheap high. Harold Jaffe: You probably recognize some of the actors there, Serena McKellen and Lily Tomlin and Phil Collins. The actor who played me is a person named Charles Martin Smith, whose previous big role was Terry the Toad in American Graffiti. So that probably tells you everything you need to know. This is based on a visit that Bill Darrow, our research sociologist, who you will see later in the film, and I made to a bathhouse in Atlanta, the club baths. The reason we went was we had learned from talking to some of the early cases that many had visited bathhouses and many of them had used nitrate inhalants and we wanted to learn more about it. We got permission from the owner. We turned up one night. We were fairly obvious because we were the only ones wearing clothes. We were sitting there in our government blue blazers at a table and saying, excuse me, I wonder if I could talk to you. Quite amazingly, almost all these men were perfectly happy to sit down and talk to us. And, as I said, we were particularly interested in learning about the use of these inhalants. You can see some of these in some of these labeled bottles. Locker room is a good name, because they smell like sweat socks. You could buy these in the bathhouse. In fact, it was popper night when we went. You could get them for a discount. We also discovered, though, that you could buy them in bars and bookstores in these much more mysterious looking unlabeled brown bottles. And we wondered: What’s in this stuff? In theory, it should be amyl butyl or isobutyl nitrite used to enhance gay sex, but we really didn’t know. So we bought some of these and brought them back to Atlanta, had them tested chemically to look for a contaminant. We didn’t find any. We even had them used in animal experiments where they were aerosolized to see whether they would suppress the immune system of, I think, rats. I’m not sure. And they didn’t. So it didn’t entirely exclude the possibility that these played a role. But I think it made it a little less likely. I think maybe we were thinking gosh, this is it, we’ll get rid of this stuff. End of epidemic, we’ll all be heroes. But it unfortunately didn’t turn out to be quite that easy. Let me ask Jim, at this point in time, did you think it was likely there was an environmental cause of the disease, or did you think it was more likely it was infectious? Jim Curran: I had been coming from the STD world and we had been working on hepatitis B vaccine trials. And from the beginning this suspiciously looked a little like hepatitis B, a lot like hepatitis B. So that always, I think, was for most of us was most likely that it was due to a sexually transmitted agent. Whether it was some sort of mutant cytomegaly virus or some kind of concatenate of agents. I think most of us believed that was the most likely cause. It would have been a thrill and a wonderful thing for the world if something as simple as poppers could have been it and we could have turned into Carrie Nation and gone through and broken all the bottles in the country and saved 30 million lives. But it wasn’t to be. Harold Jaffe: Let’s move on now to a CDC in the early autumn of 1981. [Typing] >> What do we think, what do we know, what can we prove. >> Zip. >> Only gays. >> Think but can’t prove. >> Only males. >> Think but can’t prove. >> Semen depositors. It’s in the semen, unless there’s something specifically unusual about this disease, it shouldn’t make a difference where the semen is deposited, whether in the anus or in the vagina, which could mean that women will be getting it also. >> Good point. Focus on that. >> All we know so far is that the immune system stops functioning completely, all cases. >> No but can’t prove. >> What we have here looks more like a sexually transmitted disease than syphilis does. >> Think or prove? >> I can’t prove that the sun isn’t going to turn into a bran muffin next Tuesday. After 20 years of doing this I know what I know. >> That’s not what I’m talking about. >> It’s pure supposition, but it’s more than strong enough to justify a definitive study. >> I agree with Phil. >> Single infectious agent with high probability of sexual transmission. >> Viral or bacterial? >> Just think and prove it’s viral, but it’s only a guess. >> Guess. >> Let’s assume it is a virus. Now, the question is, is it one that we already know that has become lethal, or is this some kind of brand new virus we haven’t seen before? >> Here’s a stat to chew on. In seven months the number of cases jump from five to 152 in 15 states. >> Seven months. >> But the spooky part is that so far the mortality rate has been 40 percent. >> 40 percent? >> According to the doctors taking care of these patients the mortality rate could ultimately turn out to be 100 percent. >> 100 percent. >> My God. >> Let’s set up a case control study based on the premise it’s sexually transmitted. Harold Jaffe: Having worked for Jim Curran for many years I can say with great confidence he never said think or prove even once, did you? I don’t think so. But anyway we did the case control study. Selecting the cases was pretty straightforward. We decided that we would try to interview every living reported case in one of four cities in person that had to be homosexual men with either pneumocystis or Kaposi’s sarcoma or both. But it wasn’t so obvious how to select the controls. Did we want men and women? Just men? Heterosexual men? Homosexual men? Both? We finally decided that we would recruit apparently healthy homosexual men who were within five years of the age of the case that they were matched with. They had to be of the same race and live in the same city. But then how do you do that? So we spent a long time thinking about the best way to do it. And I’m not sure we ever came up with a good solution. First we thought okay we’ll ask the cases, the names of their friends who are not their sex partners. And less than half of them could do that, which was probably a hint right there. So then we decided we would go a different route and we would go, first of all, to the private practices of physicians who saw mainly gay male patients in their cities and ask them to recruit for us. And secondly we would go to public STD clinics that primarily served gay men. Now, we knew there was an obvious bias in this, because by definition a man going to an STD clinic must be pretty sexually active. We figured we know that. We’ll have to take it into account. But it was a relatively easy way to get controls relatively quickly. As Jim indicated in the film that was set up with the idea that we were probably looking for sexually transmitted disease, and obviously the fact that it was occurring in a number of highly sexually active gay men was consistent. But because these men frequently were using drugs, not just the nitrite inhalants but a variety of street drugs we couldn’t rule that out. As I mentioned, we interviewed cases and controls in person as is shown in the next clip. [Video] >> Stick around here. Coming right back. [Bell] >> Dr. Mary Guinan, please. >> I’m a friend of Dr. Konig’s. >> Your name? >> You can tell him. He has no idea who you are and we’ll pretend we never heard of you. >> You guys ahead of me? >> You can go ahead. We got nothing to do except go to a Halloween party, during rehearsal. >> I know. >> [Inaudible], but I happen to think you’re a genius. >> Double genius as a director and choreographer. >>You? >> Robbie Campbell. Self-appointed KS poster boy. You look surprised. >> No. Curious, maybe. >> If the gay community doesn’t start raising hell, do you think Reagan’s going to do a damn thing? >> I wish I had your courage. >> Courage. No. I’m scared to death. I just have this absurd determination to live, don’t you? [Knocking on door] >> It’s open. >> Dr. Guinan? >> Yes. >> I expected the neighborhood, the hotel, this room even, but I think it would take Filini to cast such a beautiful, young woman in a sweat suit as the doctor I’m supposed to reveal my most intimate sexual eccentricities to. >> I’m Mary Guinan. The reason for the sweat suit is somebody stole every piece of clothing I brought with me from the laundromat this morning. Would you mind signing these two consent forms? One is for the questionnaire and one is for the specimens I need to collect. >> What specimens? >> Blood, urine, a swab from the inside of your mouth and another from your rectum. In this study, some had the disease and some like you have no symptoms. >> I really don’t mind if you know all this about me. I’m just not too sure I want to know. Is there a name yet for this disease? >> The gay press calls it gay pneumonia or gay cancer and the straight press doesn’t mention it at all. >> I was hung up in traffic coming over here. Gay Halloween parade was on. Have you seen it? >> I didn’t know they had one. >> Yeah, they do. It’s really pretty amazing. [Music] >> Party’s over. Harold Jaffe: Well, I want to know why Richard Gere didn’t play me. [Laughter] [Applause] That sounds like a vote of support, or at least I’ll take it that way. Well, we didn’t interview Richard Gere and Mary Guinan only had her underwear stolen, not all of her clothes. But the rest of this is pretty realistic. We did interview these men in our government rate hotel rooms, which were not very luxurious. We did get 25 bucks in San Francisco. We did get funny looks from the desk clerks about why these young men were coming up to see the CDC doctors. But it was remarkable that these men, once we started talking, really were quite open and willing to talk about what had been going on in their lives. Think about it. What if I came to you now and said you know I don’t mean to bother you but I’m from the federal government and I’m going to ask you everything I can think of about your sex life, drug use and anything else, I’m not sure you’d be that happy to talk to me. But here, these men were really scared, appropriately so. Many of them had friends who had died or were sick, and they wanted to know what was going on. They wanted to know if they were at risk, maybe what they could do to help themselves. So they were remarkably open in talking to us about what they had been doing. So these next few slides come from the original case control study. First of all, to show you where the patients came from, the four cities I mentioned. The majority of cases, three-quarters, were white, which fit the demographic profile at the time. And let me go back here. Here’s some of the variables comparing the patients seen on the left with the two control groups. Remember the clinic control group comes from an STD clinic and the others come from a private medical practice. So in terms of history of sexually transmitted diseases, the cases were more likely to have gonorrhea or syphilis than either of the control groups. They also used more different street drugs and the use of poppers the nitrite inhalants, was essentially universal in both groups. Looking in more detail at some of the sexual activity differences, here we see the median number of sex partners for the cases was more than twice as many for either control group. Again, one of those control groups comes from a public STD clinic. The cases had a higher proportion of partners from bathhouses and they were more likely to start having sex at a younger age. In a mltivariate analysis, which I’m not showing you here, these same sexual variables seem to be the most important. But when we published the study we were fairly cautious. We said we thought the occurrence of Kaposi’s sarcoma and pneumocystis pneumonia in these homosexual men is associated with certain aspects of their lifestyle. We went on to say that sexual activity seemed to be the biggest difference. But because drug use was so highly correlated, so related to sexual activity, we really could not rule out a possible role for those drugs. Now, the next clip doesn’t come from the film, it actually comes from a national broadcast, NBC news. I wanted to show it to you because it shows you how the case control study was presented in the press and it also shows you the real Bobbie Campbell and the young or younger Jim Curran, who looks almost the same as Jim Curran today. [Video] >> Scientists at the National Centers for Disease Control in Atlanta today released the results of a study which shows that the lifestyle of some male homosexuals has triggered an epidemic of a rare form of cancer. Robert Bazell now in Atlanta. >> Bobbie Campbell of San Francisco and Billy Walker of New York both suffer from a mysterious newly discovered disease which affects mostly homosexual men but has also been found in heterosexual men and women. The condition severely weakens the body’s ability to fight disease. Many victims get a rare form of cancer called Kaposi’s sarcoma, others get an infection known as pneumocystis pneumonia. Researchers know of 413 people who have contracted the condition in the past year. One-third have died and none have been cured. >> Death didn’t scare me. It was living with this for a long time. That’s more frightening than death. >> Investigators have examined the habits of homosexuals for clues. >> I was in the fast lane at one time in terms of the way I live my life. And now I’m not. >> The best guess is that some infectious agent is causing it. Today, researchers here at the National Centers for Disease Control say they have found several cases where people who had been sex partners both had the condition. Scientists say this probably means they are dealing with some new deadly sexually transmitted disease. The investigators see this as a serious public health problem. >> From an epidemic point of view there have been more deaths from Kaposi’s sarcoma and pneumocystis pneumonia than have occurred with all the cases of toxic shock syndrome and the Philadelphia outbreak of Legionnaire’s disease combined. >> Researchers are now studying blood and other samples from the victims trying to learn what is causing the disease. So far they have had no luck. Robert Bazell, NBC News, Atlanta. Harold Jaffe: Jim, other than any comments about your youthful appearance, is there anything else you’d like to say about what you thought was going on at the end of the case controlled study? Jim Curran: Well, first of all, Harold Jaffee and Martha Rogers, Kelon Troy, many people were the leaders in the case control study and put together a rather complex study design and implemented it to include 75 or 80 percent of living gay men in the United States and published it rapidly. So that was quite a feat. I want to just give you a couple other contexts. One is we knew that the controls were matched. And by matched, we meant that they were matched for certain characteristics. They were matched by sexual orientation. They were matched by age, within three years. They were matched by the city where they lived at the onset of the case’s symptoms, and they were matched by race. All of the cases — all of the controls were interviewed by the same person that the case was interviewed by to try to minimize to some extent interview bias. And we thought that we would be overmatching by picking people who were symptomatic with STD symptoms and that would minimize the chance of finding a sexually transmitted variable. In retrospect, of course, many of the controls were almost certainly infected with HIV themselves leading to a lot more overmatching. So that made it even more remarkable that sexual variables were the most important ones. But in retrospect, that’s not remarkable at all, because when any new, rare epidemic occurs, and this was rare at one time in gay men, then the ones most likely to catch it are going to be the ones with the extraordinary number of exposures. And that’s how it was in the gay community in the mid-’70s, if you caught HIV. You were most likely from San Francisco and New York, most likely going to bathhouses. By the time the virus was discovered, however, half a million gay men were already infected, and the disease became endemic in the gay community and exposure became much, much more frequent and likely. The last thing I’d like to say is that people didn’t believe in this epidemic then. I mean, gay men who didn’t live in New York and California didn’t believe in the epidemic. Even gay men who did live in New York and California thought it occurred to other people, because it was relatively infrequent. At the time of the case controlled study, maybe the cases were occurring in 15 states. That left something like 35 states where they weren’t occurring. The Reagan Administration knew about this, of course. I interviewed only one case — Harold sent me to New York. So I was coordinating the New York work with EIS officers there. But there was one case that wanted to be interviewed by the head of the task force. That was the managing director of the Joffrey Ballet. A very busy man. He was so busy because the next week — he had pneumocystis pneumonia once. He was going to be hosting Nancy Reagan for the opening of the Joffrey Ballet in which her son, Michael, was a ballet dancer. Harold Jaffe: Ron. Jim Curran: Ron — Michael. Sorry. Wrong son, the right wing one. Ron was the ballet dancer. He did that and then the next, couple days later he was back in Bellevue Hospital with his final fatal case of pneumocystis. We know at least Nancy Reagan had some exposure to this five or six years before the president spoke about it openly. Harold Jaffe: The last bit of the newscast, it was mentioned that some of the cases were thought to perhaps be sexual partners. This information came to us from Dr. David Auerbach, who was a CDC medical officer assigned to Los Angeles County. Through his contacts in the gay community in Los Angeles he had learned that this was the case. And he wanted to interview these men to verify this. But he had never actually done this kind of work before and wanted some help. So we were able to send out Bill Darrow, our research sociologist, who had been previously a syphilis public health investigator, had done a lot of this, to help David out with the interviews. So the answer to the question about sexual relationships came just a few days later, as shown here. [Video] >> Jim, I got a call from LA. >> Wait, I am on the phone. >> I got a call from LA. This could be the first real lead to prove this thing is sexually transmitted. My plane leaves in 40 minutes. >> We don’t have the budget. >> Don’t sweat it, I’ll front the money. You’ll pay me back. >> If you think you have definitive proof it was brought in by a UFO, please send it in to us. Thank you. >> You don’t know a man from New York with a French Canadian accent, very handsome, sheik? >> I don’t think so. I very seldom — wait a minute. This might help somebody else, right? >> Right. >> Of course I know him, from the bathhouses. I never had sex with him. But almost everybody I know has or wants to. >> Fine. Then he gave me hepatitis, so it’s quite possible he gave me this, too. >> The moment I first spied him at the tubs, I was so crazy about him. He was so gorgeous. >> Can you just give me his phone number, address or any way I can get ahold of him? >> All I know, he’s French Canadian. He’s an airline steward based in New York. I don’t even know which airline. >> That’s okay. If you can just give me his name. >> I called him Dougie, nickname. >> And his full name? [Phone ringing] >> Hi, Mary. >> Hi. You back in town. >> Just for the night. I’m probably nuts, but I’m on my way to New York to try to find a very sexually active French Canadian airline steward. >> Gatan Dugas. Bill Darrow. >> Hello. >> Nice to meet you. >> Nice to meet you. >> Sit down. Take all the time you need. >> Thank you. >> Thank you. >> Thanks very much for coming in. >> Well, I’m very flattered to be asked. Although I have no idea what I’m here to discuss. Would it disturb you if I smoke? >> If you need to, go ahead. Mr. Dugas, did you have sex with any of these people? >> Is that what I’m here for, to talk about my beautiful lovers? Now I am flattered. If you don’t mind my saying, I can’t possibly imagine why you would be interested. >> We’ve been finding substantial evidence to suggest that one of the ways this disease may be transmitted is sexually. >> Wait a minute. All I have is skin cancer which is not contagious. And you know it. >> No one is accusing you of anything. We just need to know as much as we can. >> You know, I adore doctors, but I must say if this is an epidemic, this gay plague thing, it’s your fault for not stopping it. It’s not mine. >> That’s exactly what we’re trying to do. And we need everybody’s help. So if you could give me the names and addresses of all your lovers and start with the people on this list, please. >> My friend, we’re talking about thousands of men all over the world, whose faces I cannot even remember and you want names. >> As many as you can remember would help. >> My book’s in my apartment. Call me. >> What’s the number? >> I’ll call you. >> Listen: Help me, don’t help me, that’s up to you. But don’t fuck with me. I’m not playing games here. >> Not before six, and not after 6:30. >> Thank you. >> And remember something: Whatever it is, if I got it, someone gave it to me. >> All right. This is how it breaks down. This is Patient 0, an airline steward from New York and the starting point of this particular group. Now, these are the eight with whom he had direct sexual contact, these four in New York. These four in LA. This is LA 3. He had sex with LA 2. This man from Florida who in turn had sex with this Florida man. Two from Georgia, one from Texas and so on. In all, 40 cases in 10 cities are verifiably linked to Patient 0 which strongly suggests this is a sexually transmitted disease. >> That’s great. Absolutely terrific work. >> Bill, that is the first sign of real proof. >> Good job. Harold Jaffe: I recently came across an interview that Bill Darrow gave about this investigation. And he said, well, these three men, they never met, they never had sex, yet they named the same guy in New York. I actually dropped my pen. Auerbach’s mouth was just hanging open. He practically fell off of his chair. So these are the slides that Bill Darrow showed us in Atlanta. You can see that Gatan Dugas the out-of-California KS case, is linking together these two clusters of cases in Southern California. And here he’s linking together cases from Los Angeles to New York City and then the slide that you saw in the film where he’s in the center of this cluster of 40 cases, sexually linked between 10 North American cities. Now when we published this in a journal, we had a legend on it. And Gatan Dugas was indicated as 0 and there was one, two, three, four, five, and so on. When the American press saw this, they said Patient 0, he’s the guy who started it, he’s the guy who brought this disease, whatever it was, to North America, which, of course, was never our intent, and we have no proof that that was true. On the other hand, knowing what we know now that this is a sexually transmitted disease, it wouldn’t take that many people like Gatan Dugas, people who were very sexually active, very mobile, going to bathhouses all over North America, somebody like that actually could have spread a lot of infection relatively quickly. And I believe that two other members of the cluster were also flight attendants. So, Jim, I wonder at the conclusion of the presentation by Bill Darrow what you were thinking. Jim Curran: Well, you know, this was very convincing to us who didn’t much need convincing when it was published in the American Journal of Medicine and the MMWR, they did an analysis of what if five to 10 percent of men in the United States were gay and they had — how many had — what is the likelihood that these — this was like 40 percent of the cases that had been diagnosed in the United States that were alive in gay men. So what is the chance they would be linked in a cluster? And I think one of our statisticians said the chance was one times 10 to the minus 12th. But there’s still an awful lot of people that didn’t want to believe that this was related to sexual transmission. Because the implications of it or the fact that it could be caused by a virus was probably too great for people to deal with. But it was a very important investigation for that reason. Now, I’ve looked back on these things, and I’d like to think what we know about the pathogenesis of HIV and the transmission of HIV, and I think of this cluster and I also think of the cluster that we saw in the dentist, Kimberly Bergalis case, and the fact that we didn’t see things in other healthcare professionals. And it makes me think we had to have with this cluster and what we had to have in particular with the dentist case is a lot of highly pathogenic, high viral load early cases with short periods of time between infection and disease in order to do this. If the average case here went from 10 years after transmission, it would be extremely unlikely that you could link something like this up. So you had to have probably, in retrospect, high viral loads and high pathogenic titers. Harold Jaffe: I think as all of you who have ever worked at CDC, people at CDC walk around with these little green lab notebooks. I actually have no idea why. For those of you who will see the film “Contagion” that comes out in a few weeks, I think one of the key lead characters Kate Winslet, who plays the epidemiologist, has one. So I had one, even before Kate Winslet. So I took this photo of a page from my notebook. I think the date is November 1982. And it’s a phone call that I received from Dr. Art Ammann, who is a well-known pediatric immunologist at UC San Francisco, who wrote the book, literally, on congenital immunodeficiency. And what he told me over the phone was that there was a child born there in March of 1981 who had RH disease, incompatibility of blood type between the mother and the child, causing a severe anemia in the newborn requiring six exchange transfusions. The child left the hospital but then began developing a whole series of complications, recurrent infections, fat malabsorption and immunologic abnormalities, opportunistic infection with microbacterium and avium. So Dr. Ammann did a very extensive immunologic workup on this child and said: This does not fit with any known form of congenital immunodeficiency. It looks like AIDS, except no one’s ever described AIDS in children, how could that be. He also learned that all the blood from this child had been received from Irwin Memorial Blood Bank. This next clip will show you that investigation. This clip I think is the least accurate of the ones I’ve shown you. Art Ammann is morphed into a woman played by Angelica Houston. You’re going to hear a number of speeches that were never made. You’ll hear the term “GRID”, which stood for Gay Related Immune Deficiency which was the term we never used at CDC. [Video] [Baby crying] >> Harold Jaffe, CDC. [Baby crying] >> Hi. >> How do you do? >> Harold Jaffe. >> So it’s true? >> He was born here 20 months ago. >> An RH baby. >> Within a week his entire blood volume had been replaced six times. Now he has Zostera, practically zero T cell count, more opportunistic disease than we know what to do with. >> And he had 13 donors? >> All from Irwin Memorial. That’s all I could find out. They keep a lid on the place so tight it’s like the Pentagon. So forget about getting a list of donors from them. >> The first irrefutable case caused by transfusions and these people are stonewalling us. I know what we need. Somebody just to scare the hell out of them. >> Only Attila the Hun could. >> Selma Dritz. [Laughing] >> I got it. But there’s one problem, two problems. I’m freezing, that’s one problem. Let’s get some coffee. One of the donors died from the disease two months ago. >> We can’t prove that. >> What do you mean we can’t prove it? How can we not prove it? >> He was one of the richest, most socially prominent families in town. He swore to his dying breath he wasn’t gay. >> What’s the difference what he said? If somebody dies from it you can’t mistake it for whooping cough. >> According to his doctor he died from encephalitis. It’s on his death certificate. >> Talk to the doctor. >> Get him to say what, he lied? >> Somewhere in this town there’s got to be somebody that — a gay man he had sex with or what about his family, do they know? >> My brother wasn’t gay. And I can assure you no matter how hard you search you’re not going to find one shred of evidence to suggest the contrary. He was on the board of several corporations. He was the chairman of the fundraising community for Saint Patrick’s. He was meticulous. He was meticulous in concealing his other life, even from me. >> Excuse me. I would like to remind everyone — I’d like to remind everyone that these are not regulations. These are not regulations from the CDC. This is a workshop where every agency connected to the blood industry can evaluate the information that the CDC has found and together we are hoping to be able to arrive at some course of action. >> One option is to establish guidelines to keep people who are at high risk from donating blood to begin with. >> Banning homosexuals from giving blood won’t protect the blood supply. What it will do is stigmatize them. Reminds me of blood banks rejecting donations from blacks for fear of syphilis. >> Have you any idea of the civil rights implications — >> Civil rights, my ass. My son is a hemophiliac. And if homosexuals are infecting the blood supply, why not keep them from becoming donors? >> What do mean the entire gay community? Then what, separate drinking fountains, one for gays and one for humans. >> Don’t start that gay rights crap with me. There’s 20,000 hemophiliacs in this country and GRID has become the second leading cause of death amongst them. We have rights, too, and one of them is the right to stay alive. >> I know that we’re dealing with a very complex and highly emotional issue, but it would help for all — >> How can you expect us to be unemotional, when at least one person is dying every day from a disease that doesn’t even have a name. Now, if the CDC can’t bother to come up with a name, at least it should stop the media from calling it GRID. We have enough people hating gays without having the entire stigma of this disease placed on us. Especially since it has been shown that this disease is no longer merely gay-related. Now, I make a motion to officially call this disease Acquired Immune Deficiency Syndrome, or AIDS. >> Questions or discussions on this issue, please? >> I second it. >> All right. All in favor of Dr. Valor’s motion? Motion’s carried. >> The FDA Advisory Panel to the Blood Banks feels that the evidence for nearly all of this is inferential. The CD’s evidence of blood transmission cannot be warranted until the CDC shows definitively that an infectious agent causes this disease. Nothing about it even exists in the peer reviewed medical literature. Not one case. Evidence of such blood transmission is lacking. >> May I point out that the blood industry is under the jurisdiction of the FDA and the FDA, according to Dr. Bovey, does not acknowledge that there’s an epidemic because there’s no evidence that it’s a blood-borne disease. >> Suppose, for example, the small amount of blood by some unlikely chance is contaminated, with no tests to find out which blood is safe and which isn’t, what do you suggest we do? Destroy the entire blood supply in America, because some of it may or may not be contaminated? >> No, no. Well, in fact, testing — testing is the second option that we should discuss. Now, we at the CDC have found, we’ve found that the hepatitis B test is 88 percent effective in identifying patients with this disease. >> Is the CDC seriously suggesting that the blood industry spend $100 million a year to use a test for the wrong disease because we’ve had a handful of a transfusion fatalities and eight dead hemophiliacs. >> How many dead hemophiliacs do you need? How many people have to die to make it cost efficient for you people to do something about it? 100? A thousand? Give us a number so we won’t annoy you again until the amount of money you begin spending on lawsuits makes it more profitable for you to save people than to kill them! >> The disease called AIDS, Acquired Immune Deficiency Syndrome, sounds less deadly, more like a diet pill. >> Medical researchers are warning… the risk of contracting the disease AIDS. >> Henry Penia, who has AIDS, got into a minor traffic accident. So police called the hazardous materials team. >> The impact on blood banks could be disastrous. Harold Jaffe: As I mentioned, this scene isn’t very factually correct. For those who might have known her, Selma Dritz was a very nice lady nothing like portrayed in the movie. AIDS was not named at this meeting. And Don Francis, for those who knew him, recall that he made many passionate speeches during his career, but he didn’t make that particular one. Jim, you looked very nervous at the end of that meeting. Maybe you can tell us why. Jim Curran: The events, as I remember them, is the very careful investigation, we had a few cases of what looked like transfusion-associated AIDS. And indeed the blood banks were hiding behind confidentiality issues in New York and California in investigating them. The only one really that was investigated very thoroughly initially was the one that Harold was involved with in San Francisco with the baby. When the three cases occurred in patients with hemophilia, young men who had received essentially untreated factor concentrates pulled from tens of thousands of blood donors each year, it was a canary in the coal mine type of experience in the sense that if anybody was going to get a new virus, these men were likely to get it. And that really convinced most people that this was new. Now, there were two meetings. There was a meeting, a broad meeting of the blood banking community, and there were smaller — it was a smaller meeting in HHS. And the blood banking community, it is really true that the blood banking industry and the blood banking leaders were quite resistant to any change or any screening or any questioning, and Dr. Bovee, it was not his most proud moment. And he had, unfortunately, worse moments on behalf of the American Association of Blood Banks going forward. But there was really very little reaction from the gay community. We had pretty good contacts with many people in the gay community. And I think they were more or less convinced that this was really true and were not standing up in public and screaming civil rights and things like this at this blood banking meeting. The other thing about the name AIDS itself, is a lot of people had been looking for a name. And a lot of us had talked to several people. There was a guy named — several doctors in New York and a lot of us at CDC thought Acquired Immune Deficiency Syndrome was accurate and also had an acronym which might live a while and would be something that could be used. So there was a meeting in Washington of blood banking officials. It was kind of a semi public meeting that Jeff Copeland chaired. And we arranged for Don Armstrong, who was the head of ID at Memorial Sloan Kettering, to make a suggestion to the PHS that the term AIDS be used. So there was a guy, it wasn’t this guy, it wasn’t at that meeting, and it was kind of prearranged by CDC to use the term AIDS. What else can I say about this meeting? That’s about it. I think what we were nervous about mostly is there wasn’t any consensus at this meeting. And it was a highly public meeting quoted in the press and everywhere else. And it was quite clear that the blood banks and the CDC were at odds. The National Heart and Lung Blood Institute was also at odds and basically what do a bunch of infectious disease epidemiologists know about blood banking anyway. Harold Jaffe: Well, fortunately, discussions that were held more in private over the next few months were more productive. And just three months later, in March of 1983, the U.S. Public Health Service issued the first guidelines for prevention of the disease that was known as AIDS at that time. But, first of all, the guidelines said that persons at increased risk of the disease those were signs and symptoms, their sex partners, sexually active gay and bisexual men with multiple partners, Haitian entrance into the U.S. which was contentious at the time, all we knew was that Haitians living in Miami and New York City were getting the disease. We knew that the disease was occurring in Haiti itself. We actually did a case controlled study trying to figure out what the risk factors were and we didn’t come up with anything. So we said for public health purpose we’re going to say that Haitians should not donate blood. Now, this clearly led to a lot of discrimination in the Haitian American community, which was undoubtedly not what we wanted. But at the time we didn’t really have a choice, or at least I didn’t think we did. Intravenous drug users were getting the disease, patients with hemophilia. And then the recommendations went on to say to avoid getting the disease, avoid sexual contact with persons known or suspected to have it. But having multiple partners increases the risk. In here it says it’s a temporary measure, but many of you know it’s still a requirement in the United States that blood bankers not accept donations from homosexual men. So despite the denial that went on at that meeting, these guidelines came out, which I think even in retrospect were essentially correct. Jim, can you tell us anything what went on between that meeting and the formulation of the guidelines? Jim Curran: There was increasing consensus that this was likely to be caused by infectious agent. And increasing concern that it was present in the blood supply. So that drove the consensus recommendations, and we were able to have these recommendations come from all public health service agencies, but also be endorsed simultaneously by the American Association of Blood Banks, American Red Cross, National Gay Task Force and many — American Association of Physicians for Human Rights. So we had AMA, lots of groups like this. So I think there was in general quite a proud moment for CDC that these recommendations could be promulgated well before the cause of the syndrome was discovered. Harold Jaffe: In fact, the first publication describing what we now know as HIV was made in May of 1983 by Luc Montagnier and his colleagues in Paris, that was recognized by the 2008 Nobel Prize in medicine. And it was another year before Robert Gallo and his colleagues at the NCI really established that the virus was the cause of AIDS. And as I mentioned, I think this is rally an important illustration of the power of the epidemiologic method to understand a new disease. Now, I’d like to say that the story of AIDS ended in 1983, but if it had, you wouldn’t be here. So let me just give you a snapshot of the next few years. So here’s May of 1985, the first 10,000 cases mainly in New York, San Francisco, Los Angeles, Miami. 1989, here’s the first 100,000 cases, large numbers in places like Puerto Rico, Houston, Dallas, Seattle, Chicago, Atlanta. And then by the end of 1995, the first half million cases. So at this point really every major metropolitan area in the United States was reporting cases. And finally, our most recent data, from June of 2010, with more than a million reported cases and more than half a million deaths. These numbers are important. But I don’t think they give you maybe the most important part which is the human face of the epidemic. To do this I’m going to show you the very last clip of the film, which includes a number of people who had the disease or were advocates for the cause. I know who a lot of them are but not all of them. But I’ll say the ones I know anyway. [Video] Yesterday you came to lift me up as light as straw and brittle as a bird. Today I weigh less than a shadow on the wall, just one more whisper of a voice unheard. Tomorrow leave the windows open as fear grows please hold me in your arms. Won’t you help me if you can to shake this anger. I need your gentle hands to keep me calm, ’cause I never thought I’d lose. I only thought I’d win. And never dreamed I’d feel this fire beneath my skin. I can’t believe you love me. I never thought you’d come. I guess I misjudged love between a father and his son. Things we never said come together. The hidden truth no longer haunting me. Tonight we touched on the things that were never spoken. That kind of understanding sets me free. Because I never thought I’d lose. Only thought I’d win. I never dreamed I’d feel this fire beneath my skin. I can’t believe you love me. I never thought you’d come. I guess I misjudged love between a father and his son. Things we never said come together. The hidden truth no longer haunting me. Tonight we touched on things that were never spoken. That kind of understanding sets me free. ‘Cause I never thought I’d lose. Only thought I’d win. I never dreamed I’d feel this fire beneath my skin. I can’t believe you love me. Never thought it would come. I guess I misjudged love between a father and his son. Harold Jaffe: Thank you. [Applause] Booker Daniels: I’ll try to keep my composure. We have ten minutes for questions for the panelists. If you would, form a line in the center of the aisle and we’ll direct some questions. Member from the Audience: Since the theme of this involves a little bit of Hollywood, if you could write the end of the script, what would it look like? Jim Curran: As a result of a safe and effective vaccine and curative therapy, in the year 2000 and blank, HIV was eliminated from 90 percent of the countries on earth with the promise of eradication not too far behind. [Applause] Member from the Audience: Thank you for the presentation. I actually was one of those people who — I’m not that young. But I do — I was young enough not to pay that much attention in the early ’80s. You mentioned a little bit about once or twice about the movie “Contagion” that is coming out. We know that Hollywood dramatizes things for effect as we saw in this presentation. How can we as public health workers, not just in respect to HIV, but in respect to any type of infectious disease, how can we then communicate with communities who are going to be going to see this motion picture to help them understand what it is that we do and what they can do? Harold Jaffe: I haven’t seen the film myself. Although, several people from our office have. And I think it’s some horrible disease that kills just about everybody. I think the message from public health is that’s why we’re here. I mean, there is no such disease. Thank goodness. But if there ever were, that’s why we’re here. So I think that’s the message that CDC would want to get across. Jim Curran: It’s hard — the problem with this movie for Harold and I and other people who are at CDC we’re actually real people. And we have real names and then we see ourselves and we see all the changes and all this sort of thing. And so it’s hard for us and our friends and family to look at this and get beyond the personal part of it. But if you step back from this, if you look at And The Band Played On as a movie, in general I think you see in CDC and parts of the country reacting quite positively and doing the best we could under the circumstances to combat the epidemic. And this was occurring in somewhat of a sea of denial and there was some neglect. Probably wasn’t quite as blatant as Randy Schultz in the movie portrayed it. But it certainly was there. There was a lot of denial and neglect on the part of many, many people. I think in general, names aside and who did what aside, the CDC, staff and faculty and people we worked with and the people we worked with in the gay community, and the people we worked with who are HIV positive, were extremely courageous and worked very well together to get to the bottom of the problem. So if the public sees this and all they see is CDC working hard with the gay community about a disease which was a really, really horrible disease, with an unknown cause, people getting needle sticks when they were investigating cases, not knowing what it meant, not knowing what their future was, but still having the courage to go do it, I think in a sense it’s public health at its best. They could have used somebody more handsome, though. Member from the Audience: Just one question. You remarked about perhaps being more a pathogenic virus early on. Couldn’t it also be the phenomenon of a lot of acute infection going around where the guys were very recently infected and still very sexually active in those houses as opposed to it being more pathogenic? Jim Curran: I think the fact that you could link up a number of cases to somebody who had sexual contact, all of whom had sexual contact with somebody reasonably recently. In a lot of these cases that had contact with Gatan Dugas, just like the dentist case, people were getting sick and getting AIDS within a couple of years, within three years. So you had to have a cluster of people with a rapid infection. That’s one of the things that I think stopped a lot of the demonstration of healthcare workers associated cases because most of them would be in isolation and also would be long, long incubation periods. So I think it’s probably potentially a combination of both. But I think there had to be — in order to have the detection with people with end stage disease linked to individuals who were still alive, you had to have some kind of epidemic situation. If I were the movie character I would say: Think, can’t prove. [Laughter] Although I never said that until now. Member from the Audience: Took us, what, about four years before we actually had a test for HLB 3 LAV and 1985 we introduced that test. Yet it wasn’t universally accepted. Can you kind of talk a little bit about that? Some of the issues that we dealt with back then. Jim Curran: I have a cartoon I showed. One of the things that our laboratories did when the virus was isolated, we got a lot of reagent from the National Cancer Institute. Our jobs, John Ward, Charlie Schaible, Paul Feorino, Tom Peterman, a lot of people worked with the American Red Cross to demonstrate the sensitivity and specificity of the blood test and blood banking situation because it was about to be rolled out in blood banks nationwide. Unfortunately, the study that Harold did, he had several thousand gay men who were tested from a San Francisco hepatitis cohort, and demonstrated that the longer people were infected, not only were they infected a long time earlier, but the longer they infected, if they had positive antibody, the longer they were infected, the more sick they were to be. And Dr. Feorino tested specimens we had from blood donors and found out that essentially having a positive antibody was equivalent to being infected unlike a lot of other viruses. So it was a dangerous virus and having the antibody meant you had the virus and there was no treatment. So what came from a real need and urgency to get the infection led to a lot of distrust, particularly in the gay community about what would happen to the test results, who would know, who would tell whom, what would happen to my insurance status, what would happen to my identity? Because, after all, if you were a man with a positive antibody test, you were probably gay, at least that’s what people thought. And to this day, when we see somebody with HIV, our own brains always say to us I wonder how she got it or I wonder how he got it. So that was the thing that led to the concern. There was essentially nothing that could be done for these people. But we were promoting the test and people were not always happy about that. Harold. Harold Jaffe: I think the other thing to say is the test really was first rolled out for the blood banks, because there were at that point hundreds of transfusion cases, and we had no way to prevent them other than voluntary disclosure of a man being homosexual or injection drug user. So really the point of the test initially was to screen donated blood because of a concern that people would go to blood banks to get the test because there was no other place to go led to CDC setting up a series of alternative test sites where people could go if they wanted to be tested but not be blood donors. Member from the Audience: First, thank you for the session. Thank you both for your service. Two simple questions: First, how do you think the AIDS epidemic has changed the thinking and practice of public health today? And the second is what do you think, the second simple question, what do you think is the perception in the general population in the U.S., I’ll keep it to the U.S., the current thinking about AIDS and in that regard what is our biggest challenge going forward in that regard? Harold Jaffe: I’ll do the first one because I think it’s easier. It was interesting. Gary Nobel is sitting in the audience. I think he would confirm this. The thinking at the CDC in the early ’90s was that the year of infectious diseases was over. We had vaccines. Small pox had been eliminated eradicated. We had antibiotics. And CDC’s mission was changing. So we started growing in areas of chronic disease and environmental health. And there was really no expectation that suddenly we would have to sort of say, wait a minute, there’s more out there than we knew about. But there was. And HIV became the prototype of the emerging infection, and now we’re aware of dozens, if not more than that, of infections that we had no idea would infect humans that we thought were only in animals or didn’t know about it at all that suddenly popped up. So I think it told us that we weren’t as smart as we thought we were, and infectious disease era was far from over. Jim Curran: I’d rather answer that one again, so I’ll try. Couple things in CDC that were going on. Harold and I worked in STD research before AIDS came along, and people used to say to us, when they thought there ought to be more contact tracing, how come you don’t treat AIDS like any other STD? And my comment usually was: What do you mean, just ignore it? Because that’s really what people did with STDs. They essentially ignored them as public health problems, for the most part. What made AIDS different was of course that it was fatal. And the fatality and the activists who were dying people themselves called attention to something that was so important that it deserved more attention. But there was no magic bullet. And so Bill Darrow was either the only doctorally trained behavioral scientist or one of two or three at the CDC in 1981. Now there are hundreds and hundreds and hundreds. And so I think that changed. I think the recognition and respect of behavioral and social scientists and social determinants of health occurred in parallel with the beginning of the AIDS epidemic. I’m not saying it wouldn’t have occurred anyway. But it was certainly stimulated by AIDS and a lot of behavioral scientists at CDC kind of cut their teeth on AIDS. And it was okay to talk about sexual behavior. The other thing that happened was a new relationship with nongovernmental organizations occurred with direct funding and partnership with state and local health departments, because of the general horrible distrust of government at all levels by many people in the communities. And that’s something which I think is renewed public health. I forgot your last question, Paul, but it was something about — Member from the Audience: Perception. Jim Curran: I think people think it’s pretty much over and not paying too much attention to it, largely because it hasn’t been in the press very much. It’s not publicized very much, because not as many people are dying. And you know every year four million plus people have sex for the first time in the United States. So since HARK, there’s been 60 million new Americans having sex for the first time in an era where there hasn’t been as much publicity. That’s sort of the way I would summarize it. It’s not over. And more people are infected than ever and they’re going to be really crunched by the economic crush in the United States and the impossibility of healthcare reform. I think we’re going to see more and more people lined up to get treatment in the future. Booker Daniels: With that, we’ll have to conclude our panel session. Our time is up. Let’s give a round of applause to our panelists one more time. [Applause]

Can Somebody Have A Yeast Infection And Have No Symptoms?

Can Somebody Have A Yeast Infection And Have No Symptoms?


Good day, Eric Bakker, naturopath with another
frequently asked question regarding yeast infections. Can somebody have a yeast infection with no
symptoms? Well, they can, but it’s highly unlikely,
more likely that they are experience symptoms but not really noticing that they actually
have the symptom themselves. The symptoms may be noticed by those around them. It could
be digestive noises or it could be body odor. And it could be likely that this person has
had these symptoms for so long that they’ve actually grown used to them, which is quite
common. Many people are used to having odd bowel motions,
lots of gas and burping, particularly men will find this most amusing and a normal part
of being a male. And some women may experience recurring vaginal infections and find this
a normal part of being a woman. It’s not until they talk to friends or family or their doctor
that they realize that these are not a normal part of being male or female. In fact, they
are symptoms of an underlying yeast infection. Yes, somebody usually has got a symptom or
a sign with having a yeast infection that will be apparent, maybe not to them, but may
be to other people. If you’ve got family or friends and you’re concerned about something
that you think could be Candida, perhaps talk to your health care professional or a trusted
friend, and they may be able to tell you whether they believe it’s a normal occurring thing
or not. So I hope that answers your question.

WARNING Nasty Infected Wounds (Thailand)

WARNING Nasty Infected Wounds (Thailand)


It is approximately two weeks after I got
these wounds. And they are still, they are getting better
now. And this is from my mosquito bite. Mosquito bite here. Doesn’t look good. But it is getting better. I think you just need to wash these things,
and just put some coconut oil on or aloe vera or something like that. This is also getting better, from the mosquito
bite (sting). And this is my trench foot, from the doi inthanon
ride approximately two weeks earlier. And this is… also I have not been treating
myself very well. I have been hiking in Sweden. This is also getting better. I don’t know really why these are getting
like white, from stuff that needs to get out. Here too, really weird. I didn’t use any plasters when I was in Sweden. That might also been like doing some… But it was nice to have foot out in the open,
not in like wet sweaty socks. Don’t have your feet in a wet environment
for a long time. Just for the record, I just want to show the
wounds after I have been in the shower. The thing will like go off and, it is an open
wound now, so it’s like a hole in my leg. And I have it on the other side also. Some say it is a parasite thing. Some say it is just an infection but… Pretty nasty, it has been around for a while,
but it feels like it is getting better. Well I am getting better myself. Here too. Doesn’t look very good. And my trench foot. Here it is just like very random, but on the
sides it is almost healed. That is pretty good. And this one is also almost healed. And the thing I had on my finger is also almost
healed. And on my left leg. This is also looking pretty nice. Does not hurt at all at the moment, but you
will never know. Seems like that they get better, and they
just like, get bad again, I don’t know why. I also had something on my back. I used different things in the beginning I
used like…. In the beginning I just used soap I guess. Soap and water. And then when I came back to Denmark at some
point after a while, I thought OK, I need to do something else. I used…. First I just made a foot bath for my feet,
with camomile. And then I used a bit of camomile with ginger
and stuff. And then I went to the doctor, and he said
it was a bad idea to use camomile and ginger because you never know what is in it. And you can do more harm than good. He said he would either give me a hormonal
solution on these wounds, but I told him that I prefer not to use medicine….. His advice was to use only water. I am currently only using water. And I think it will just disappear, when my
immune system will get better. Exercise in Thailand with the Doi Inthanon
together with the flies and stuff, and insect bites, or insect stings. And afterwards like pretty much stress with
getting around in Sweden and also pretty hard exercise. The thing that my ex girlfriend and I like
went… Split up, like split things up totally in
the house, also was pretty stressful i guess. I also got bit in Danish nature, or stung
by insects also, like mosquito bites. And I got a wound here, but it is getting
good now. After I just used water. And also the lack of sleep and maybe eating
a bit too much of salt. The salt thing can tip your hormone balance
completely off actually also destroy your immune system. I had a little dip, and now I am pretty good
again. I am trying to get rid of some of my wounds
from the insects probably a bad mix of parasites, and infection, and stuff. I am not really sure what it is. It looks pretty nasty as you can see. This is almost good. So this healed. This is not from insects, or maybe it is. Maybe it is the flies, but… This is the most nasty one. And this one is also seems to be healing more
nicely than this one, just went crazy tonight. I have not tried this before, but people say
that salt water is good. Let’s try to get in there. I don’t have my towel, so I will not go totally
in there, just covering up the wounds. Don’t go near here because… Don’t go swimming here because there will
be filled…. The ocean will be filled with parasites now. We have the end of December (September…). And we can see that the wounds have almost
healed here. And the worst one I have here is also almost
healed. It’s like som old skin now. It is not a crater anymore, it’s not a hole. So it is pretty clean. And it will heal up pretty nice soon now. The same with the other wounds. My toe is almost also ready. Everything looks smooth and clean. What I want to talk about is that if you get
these type of wounds, and there will be an infection. What I would recommend is to clean it in the
morning and then put a plaster on, or cover it up in some way. And then change the plaster, or the cover,
or the bandage, or whatever in the evening. And just wash it up, put a new one on before
you sleep. A wet wound… not a wet, but like a wound
that is covered up is in a moist environment. And that heals up apparently much better if
you ask around. I would…. I haven’t found any studies, recent studies,
on that, but I might do that. I should actually because I went to two doctors. One said that I should just leave it in the
open, and the other one said that it should be covered up. And I trust the doctor who said that I should
cover it up. I also read some time ago that you should
cover up, and the thing that you need to have it in the open is just old school thing. And yeah, I think that it’s…you can use
aloe vera or whatever, just to also clean it, but otherwise just clean it with water
or soap water. But water should be fine, and I… I would use soap water, just to clean out
the bacteria if it is really nasty. And if you can push out the pus or the bacteria,
it’s a good idea to push it out, help the body to get rid of the bacteria and the nasty
stuff in there. But otherwise it should also have some time
to rest and heal. And get your… Drink water. Get your early nights. And just relax, don’t do… I went for… I did a lot of crazy stuff-
I just pushed my body too hard. And I think it is therefore that it took so
long time for it to heal up. Rest – don’t go Doi Inthanon. Don’t go do crazy stuff. Don’t go hiking in Sweden. In a “dirty” environment. Like hiking with a lot of things, it’s not
a good idea to stress the body. Just relax. Eat whole foods vegan. And if you are like in an environment where
you are, where you have access to a lot of organic and raw fruits and vegetables that
is great – eat a lot of that (raw fruits and veggies). Some say even that if you go fully raw, you
will heal up even faster, and I actually think that is true. If you are able to get enough calories in,
then it is a good idea to make the body heal up faster. But you will heal anyway. I didn’t go raw, and I pushed my body anyway… I didn’t take any medication…. Yeah, it is just about the time and how much
you stress the body.