The three sizable urban centers in the United States where the coronavirus is spreading fastest right now have something in common: They are major warm-weather tourist destinations.

Miami-Dade County, Fla., Honolulu County, Hawaii, and San Juan, P.R., are all averaging at least 85 new cases a day per 100,000 residents, with test positivity rates above 20 percent, according to a New York Times database. By contrast, the nation as a whole is averaging 34 newly reported cases a day per 100,000 residents, with a positivity rate of 13 percent.

As of Wednesday, new confirmed cases in the United States have been roughly flat at around 110,000 a day on average over the past two weeks, according to a New York Times database, after rising from lower than 30,000 a few months ago. And those are just the reported cases; widespread use of at-home testing means that many positive test results never make it into official tallies, experts say, and many people with mild or no symptoms may never be tested at all.

“Much of the U.S. is experiencing summer weather, yet Covid-19 cases are surging,” said Dr. Sandra Albrecht, an assistant professor of epidemiology at Columbia University. “So I wouldn’t expect to see this pattern look any different for warm weather destinations.”

The only places in the country with higher recent figures than those three urban centers are smaller communities in Puerto Rico or Hawaii and a few isolated rural counties elsewhere.

Some U.S. regions that were hit early by the latest surge, like the Northeast, have been showing signs of improvement lately. But Miami-Dade has gotten steadily worse since early April, with its daily new-case average rising more than tenfold, hospitalizations more than tripling and deaths ticking upward.

The C.D.C. now considers it, along with much of Florida, to be a high-virus-level area where extra precautions are recommended, including wearing masks on public transportation and in indoor public spaces.

Dr. Mary Jo Trepka, who heads the epidemiology department at Florida International University, pointed to several factors that could be driving the surge, including flocks of spring-break tourists, recent big events like the Miami Grand Prix race, and widening public apathy about the pandemic.

“I think people are no longer taking precautions as they did before,” Dr. Trepka said. “People were masking more here in the county, and we are seeing less of that. People are being less careful, because they are tired.”

Mayor Daniella Levine Cava dropped all of Miami-Dade’s pandemic safety mandates in February, around the time the C.D.C. shifted its strategy on measures such as masks and social distancing. At the time, the federal agency said, many such restrictions were no longer needed in most of the country, although counties should calculate their own risk as conditions change.

When the latest surge took hold in April, Ms. Levine Cava urged residents to get vaccinated, wear masks, disinfect surfaces and maintain social distance, but the county has not made any of those measures mandatory.

In a statement on Wednesday, Ms. Levine Cava once again called on residents to take precautions on their own: get vaccinated and boosted, get tested if they show symptoms, and stay home if they feel sick. “The best tools to fight the virus are the same ones we know and continue to use,” she wrote.

Ms. Levine Cava noted that Miami-Dade was “the most vaccinated county in Florida: and those efforts have paid off with fewer hospitalizations than in past surges. But caution was still warranted.

“We have not beaten this virus, but we know how to control it,” she wrote.

Mayor Rick Blangiardi of Honolulu County has taken a similar approach.

“Coronavirus is not going away,” he wrote in a statement on Wednesday. “I encourage everyone to continue to demonstrate personal responsibility and wear your masks when around others, get tested if you are not feeling well and please make sure to get your booster.”

Mr. Blangiardi said his administration was not considering reinstating mask mandates or other restrictions but that it would “consider all possible solutions to any situation that warrants a response.”

The county, which includes the islands of Oahu, Molokai and Lanai, has experienced a significant surge akin to Miami-Dade’s since early April, but in Honolulu’s case there are signs that it may have peaked. New virus cases have declined slightly over the past two weeks to 85 cases a day per 100,000 residents, and the positivity rate stopped climbing in mid-May.

Hawaii had some of the strictest travel restrictions in the country, requiring everyone arriving to the state to complete a 14-day quarantine. In March, it lifted its travel restrictions, allowing travelers from the continental United States to enter without testing and became the last state in the nation to remove its indoor masking requirement.

A month later, the state’s tourism industry recorded its highest traffic figures since the beginning of the pandemic, with more than 800,000 visitors arriving in the Hawaiian Islands, according to the state’s Department of Business, Economic Development and Tourism.

Mike McCarthy, the department’s director, said in a statement that the tourism sector was “showing strong recovery from the Covid-19 pandemic.” He said he expected a gradual resumption of international travel by Japanese citizens — typically a major share of visitors to Hawaii — to strengthen the rebound.

In Puerto Rico, Gov. Pedro Pierluisi lifted nearly all pandemic restrictions in March, and new confirmed cases soon started rising. But tourism to the island has bounced back: Though arrivals from cruise ships had not yet reached prepandemic levels, business travel for meetings and conventions was improving, Discover Puerto Rico, the island’s official tourism website, said in late April.

Kenira Thompson, president of the coalition of scientists and vice president for research at Ponce Health Sciences University in Puerto Rico, said that older and immunocompromised people there should consider continuing to wear masks in crowded places, and that those who are eligible for booster shots should seek them out.

Dr. Alain Labrique, the director of the Johns Hopkins University Global Health Initiative, said the summer tourism season meant large gatherings and increased contacts between people, a recipe for the easy spread of infection, even if fewer people are experiencing serious illness.

“Covid-19 hasn’t disappeared as much as our patience for precautions has,” he said.

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The COVID-19 pandemic sparked people’s interest in disinfecting products. In the battle to beat the outbreak into submission, everyone bought germ-killing products, including disinfecting wipes, like they were going out of style.

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But as the pandemic has stretched on, we’ve learned more about how we should clean our homes and businesses to prevent the spread of COVID-19. And while the Center for Disease Control and Prevention (CDC) says disinfecting surfaces isn’t always necessary, the wipes can still come in handy. 

But you’ll want to make sure the wipes you buy can actually kill viruses and germs and that you’re using them the right way. Infectious disease specialist Carla McWilliams, MD explains what you should know about disinfecting wipes, including how to use them safely and effectively.

What are disinfecting wipes?

These disposable cleaning wipes have a germ-killing solution on them. “They’re designed to kill viruses and bacteria on hard surfaces like doorknobs, counters, TV remotes and even phones,” says Dr. McWilliams. They don’t work on soft surfaces like clothing or upholstery.

The germ-killing ingredient on disinfecting wipes is a chemical pesticide, so you shouldn’t use them on your skin. You also shouldn’t use them on food (for example, don’t clean an apple with one before you eat it). The word “pesticide” may be concerning, but don’t panic. As long as your disinfecting wipes are registered with the Environmental Protection Agency (EPA), they’re safe to use as directed.

Do disinfecting wipes kill the coronavirus?

Many wipes do, but just because they say “disinfecting” don’t assume they will kill the COVID-19 virus. So how can you know for sure?

“The label will tell you what germs the wipes can kill, so look for the COVID-19 virus on the label,” says Dr. McWilliams. “There are hundreds of EPA-registered disinfectants that can kill the COVID-19 virus. Don’t worry about one particular ingredient or brand. Just read the label.”

To find out which wipes kill the COVID-19 virus, check the EPA’s running list of disinfectants for the COVID-19 virus.

Disinfecting wipes vs. antibacterial or sanitizing wipes

Disinfecting wipes are for hard surfaces in your home. If your wipes say “sanitizing” or “antibacterial,” they’re probably for your hands.

“Antibacterial wipes kill bacteria, not viruses,” says Dr. McWilliams. “They’re usually for your hands, but read the directions to be sure. And COVID-19 is a virus, not bacteria, so antibacterial wipes may not kill it. That’s why reading the label is so important.”

Sanitizing wipes may be alcohol-based wipes for your hands, or they could be disinfecting wipes for surfaces. Read the label so you know what you’re getting.

How to use disinfecting wipes the right way

Disinfecting wipes contain chemicals, so they have safety steps to follow. Use them as directed to make sure those unwelcome germs are gone for good.

1. Check for EPA approval. Look at the fine print on the package. EPA-approved products have a long EPA registration number on them.
2. Read the directions and warnings. With all the different disinfectants out there, it helps to know what you’re working with. In most cases, you need to wear gloves to protect your skin. The directions also tell you what to do if you accidentally get some of the cleaning solutions in your eyes.
3. Remove visible gunk or dirt first. Use a rag with soap and water or paper towels. You may want your gloves for this step.
4. Scrub with the wipe and let the disinfectant do its job. The entire surface should be wet with the disinfectant. But keep in mind that the solution needs time to work. The directions should indicate the contact time, which is the amount of time that you should leave the disinfectant on the surface without drying or rinsing it. Don’t touch it until that contact time is up.
5. Toss disposable gloves or wash reusable ones. Wash your hands with soap and water after removing them.
6.  Put the wipes away. Keep them out of reach of children and pets.

After the contact time is up, you can rinse off the disinfectant if you wish. “Definitely rinse it off if the surface will come into contact with food,” Dr. McWilliams says. “You don’t want to accidentally ingest the disinfectant.”

Are disinfecting wipes safe?

If you follow the steps above, they are. But stick with one product. Mixing two different household cleaners — even so-called natural cleaners — can create toxic fumes. These fumes can cause:

• Wheezing.
• Coughing.
• Trouble breathing.
• Eye, nose, throat and lung irritation.
• Nausea.
• Pneumonia.

If you’re exposed to cleaning fumes from mixing chemicals, get everyone out of the house. If anyone feels unwell, get them medical care or call 911.

Can I just use soap and water?

Maybe you want to clean the old-fashioned way. Do you really have to use a disinfectant, or will a rag and some soapy water be enough?

According to new guidance from the CDC, as long as no one with COVID-19 is in your home, washing surfaces with water and soap or detergent once a day is sufficient. 

But there are still reasons to use disinfectant wipes, the CDC says, including:

• Someone in your home may have been exposed to COVID-19 or has tested positive for COVID-19.
• If there’s a high COVID-19 case rate in your community.
• Members of your household belong to groups at high risk of contracting COVID-19.

“Using disinfectant ingredients is important in protecting your home if someone brings COVID-19 into your home,” Dr. McWilliams says. “There’s nothing wrong with soap and water for everyday cleaning. But in certain cases, disinfectant is better at killing all the germs than when you clean with soap and water alone.”

What about bleach?

Bleach is a notorious germ-killing machine. But it’s also very harsh.

“Bleach is effective if you dilute it correctly,” says Dr. McWilliams. “Don’t use it full strength. But even diluted, it can ruin surfaces and fabrics, so it’s not practical in many cases.”

Some disinfecting wipes contain bleach as their active ingredient. Check the label. Never mix bleach with other cleaners or chemicals, including natural cleaning products.

Cleaning is good, but it’s not a cure-all

COVID-19 has made us hyperaware of germs. Cleaning once a day with soap and water is a good approach and wipe your household surfaces with EPA-approved disinfecting wipes as needed. But cleaning alone can’t keep COVID-19 away.

“Wear a mask, wash your hands and practice social distancing to help prevent the spread,” Dr. McWilliams says. “That’s more important than your cleaning products.”

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For some reason, everybody seems to have got interested in keeping things clean lately. The COVID-19 pandemic saw antiviral hand gels sold out across the world while news reports circulated of people drinking bleach or bathing in disinfectant in an effort to keep the virus at bay.

The problem with all that – apart from the massive uptick in calls to poison control (seriously people, don’t drink bleach) – is that these disinfectant measures all come with a cost. Bleach, for instance, is one of the most hazardous compounds out there in terms of environmental effects, and without careful management can wipe out whole populations of aquatic life. Other sanitizers rely on isopropyl alcohol, which is only produced in a handful of places and has an outsized carbon footprint. There’s another kind of disinfectant, called phenolics, which may have better environmental credentials than the others, but are expensive and energy-intensive to produce.

That’s one motivation behind a new study, published this week in the journal PNAS, which aimed to find an alternative, sustainable disinfectant. The answer: sawdust.

“Biomass is widely available and renewable, and has typical multi-antibacterial structures, such as phenols and ketones,” the study points out. “In this study, a renewable disinfectant was developed from biomass and its effectiveness against highly pathogenic microorganisms was examined. The study demonstrates that effective use of biomass has the potential to support the biosafety of human environments with greater sustainability.”

Basically, the researchers noticed, phenolic structures already exist in nature – specifically, in the molecules of plant cell walls. By mixing sawdust with water under high pressure, the team created a liquid which they tested against viruses including E. coli, Staphylococcus epidermis, anthrax, and influenza A – all of which fell to the sawdust mixture.

“The inactivation rates of H1N1 (mask and quartz sand as carriers), H5N1, and H7N9 [flu viruses] were all 99.99% … and that of B. anthracis (quartz sand as carrier) was 99.49%,” the paper reports. “In addition, the inactivation rate of Bacillus subtilis var. niger spores (a typical challenge bacterium used to evaluate the disinfection effect) was 99.99%, indicating that the disinfection function of bioliquid had a broad spectrum.”

What’s more, the liquid was “safe in case people or animals unwittingly touch it,” the researchers noted, and cheap as well, costing less than 5 cents per kilogram to produce – that’s two hundred times less expensive than even some of the most economical hand sanitizers. And since the team found that many different types of sawdust can be used to create the liquid, they estimate a production capacity of a massive 113.02 million tons, which they point out is “beneficial for large-scale production, due to the abundance and low cost of renewable materials compared to those of the currently available commercial disinfectants.”

As the world continues to urbanize, industrialize, and hurtle towards a climate apocalypse, the need for biosafety – that is, keeping our environments relatively free from pathogens – is only getting more important. But with this new study, it is clear that the development and production of disinfecting agents doesn’t need to come with the high price we’re used to paying right now.

“Overall, the developed bioliquid is a good candidate for the prevention of an outbreak and for establishing better biosafety of human environments,” the authors write. “In addition, this bioliquid has a broad spectrum of action and a low cost, as it is obtained from renewable biomass, which is advantageous for large-scale applications.”

“Given the potential demonstrated in this study, the separation method for the enrichment of low-molecular-weight and low-polarity compounds should be more broadly studied to promote the commercial application of bioliquid,” they conclude.

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An increase in cases of meningococcal disease across Florida has prompted state health officials to urge residents – especially college students and people living with HIV – to familiarize themselves with its symptoms and to take simple precautions to keep from contracting or spreading the disease. The Florida Department of Health reports that the number of cases of meningitis in the state so far this year have surpassed the five-year average.

Jose Vazquez, M.D., chief of primary care at Baptist Health Medical Group

Meningococcal disease is rare but can be deadly, according to Jose Vazquez, M.D., chief of primary care at Baptist Health Medical Group. “The two most common types of meningococcal disease are meningitis, which is an infection of the meninges, or the membrane lining the brain and spinal cord, and septicemia, or sepsis, which is an infection of the bloodstream,” Dr. Vazquez explains. “Sepsis can very quickly lead to tissue damage, organ failure and death.”

Viral meningitis is the most common type of meningitis, Dr. Vazquez says. It is caused by viral pathogens such as enteroviruses, mumps, measles or influenza. “It can even be spread by mosquitos and ticks,” he adds. Viral meningitis is often much less serious than bacterial meningitis, which he says is caused by bacterial pathogens such as strep pneumonia, haemophilus influenza, and neisseria meningitidis.

Fortunately, Dr. Vazquez says, these bacteria are not as contagious as germs that cause the common cold or flu, and people don’t catch the bacteria through casual contact or by breathing air where someone with meningococcal disease has been. “Transmission typically occurs through saliva and from close contact over a period of time or through direct contact such as kissing or sharing drinks,” he explains.

Enteroviruses, spread via an infected person’s stool, are the most common cause of viral meningitis, according to Dr. Vazquez. “This can be seen in small children who are not yet toilet trained, or even adults who frequently change diapers of infected infants,” he says.

Although people in close contact with someone who has viral meningitis can themselves become infected with the virus that made that person sick, they are unlikely to contract meningitis, according to Dr. Vazquez. “Only a small number of people who get infected with the viruses that cause meningitis will actually develop viral meningitis,” he says.

Early diagnosis key to avoiding long-term health issues

Without treatment, most simple viral meningitis cases will improve on their own within seven  to 10 days, Dr. Vazquez says, but it’s important to establish a diagnosis as soon as symptoms occur. “Some viral meningitis cases – particularly those caused by the herpes virus – need to be treated with antiviral drugs to avoid permanent neurological damage,” he says. “And bacterial meningitis needs to be treated aggressively with antibiotics, as it can lead to serious long-term complications including brain damage, hearing loss, learning disabilities and even death.”

College students have higher risk of contracting meningitis

According to the U.S. Centers for Disease Control & Prevention (CDC), the main outbreak in Florida this year has occurred among gay and bisexual men and men who have sex with men.  While the current outbreak is mostly contained to people who live in the state, it has also affected some people who have traveled to Florida, the CDC says.

Other smaller outbreaks of meningitis have also been reported across the state in recent months. These include multiple cases among college students, who tend to live in close proximity in dormitories and share beverages and other things. While these are not related to the larger outbreak, the CDC says, they are still concerning.

Symptoms of meningitis to watch for

Initial symptoms of viral meningitis are similar to those for bacterial meningitis, according to Dr. Vazquez. “Symptoms can include fever, headache, stiff neck, muscle aches, nausea, vomiting, light sensitivity, vision changes, confusion, and sometimes a rash,” he says. Bacterial meningitis, however, has a more sudden onset. “The symptoms can come on quickly, literally from one hour to the next, and it’s a more severe illness,” says Dr. Vazquez.

A meningitis diagnosis is confirmed by analyzing lab specimens collected from the patient. Occasionally, some people may have no symptoms at first. Some children, for example, may be asymptomatic but carry the organism in their nose or throat, according to Dr. Vazquez, who says that if you think you or your child might have meningitis, you should see a doctor right away. “A doctor can determine if you have the disease, what is causing it and what the best course of treatment is,” he says.

Treatment depends on type of meningitis

Ladan Pourmasiha, D.O.,is a family medicine physician with Baptist Health and medical director for the health system’s Urgent Care centers in Broward County. She says that despite its seriousness, viral meningitis is rarely deadly in people with normal immune systems. Babies younger than one month old and people with weakened immune systems are more likely to develop severe illness from the disease, she says.

While there is no specific treatment for viral meningitis, it usually resolves on its own within two weeks and the symptoms can be easily managed, Dr. Pourmasiha says. “Antibiotics are of no help against a virus so once a diagnosis is established the only thing we can do as doctors is to recommend bed rest, plenty of fluids, and medicine to relieve fever and headache.” Symptoms of viral meningitis typically last a week or two, she says, and most patients experience complete recovery.

While antibiotics are powerless to fight viruses, they do fight bacteria and are very important when treating bacterial meningitis, Dr. Pourmasiha says. “Bacterial meningitis can not only be extremely serious, it can result in disability or death if not treated promptly,” she says. “The earlier you begin treatment, the better your chance of survival.”

Take these steps to keep from getting meningitis

Although no measures are 100 percent effective in preventing viral meningitis, Dr. Pourmasiha says that certain habits and practices we can easily incorporate into our daily lives – or have already done so because of COVID-19 – can help decrease our risk of contracting the disease.

“This includes washing our hands, avoiding close contact with people who are sick, cleaning and disinfecting frequently touched surfaces, as well as staying home when sick to avoid any transmission,” Dr. Pourmasiha says. “However, the best way to prevent viral meningitis is to get vaccinated.”

The Florida Department of Health recommends the MenACWY vaccine for people in high-risk populations such as college students, people living with HIV or other immunodeficiencies, and anyone in a high-risk group whose last meningitis vaccination was more than five years ago. Vaccines can be found by contacting your doctor, county health department or pharmacy. 

Dr. Vazquez with Baptist Health Medical Group says that other ways viral meningitis can be prevented are by doing some of the same things we’ve become accustomed to with the coronavirus pandemic over the past two years.

“Avoid contact with anyone who has either been exposed to or is known to have meningitis and wear a mask, if possible,” Dr. Vazquez advises. “Also, try to avoid gatherings. This is a disease that commonly occurs in university dormitories, because people are in such close proximity to each other.” And, he adds, use common sense. “Don’t share drinks, don’t share toothpaste or toothbrushes, and avoid very close contact.”

Tags: Bacterial Meningitis, Baptist Health Medical Group, Baptist Health Urgent Care, Jose Vazquez M.D., Ladan Pourmasiha D.O., MenACWY vaccine, meningitis, viral meningitis

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What Is Xofluza?

Xofluza (baloxavir marboxil) is an oral prescription drug used to prevent or treat influenza A or B (the seasonal flu). It is available as a tablet or suspension that is taken by mouth.

Xofluza is in a drug class called antivirals, or more specifically, polymerase acidic endonuclease inhibitors. It works by preventing the flu virus from growing and spreading in the body.

Drug Facts

Generic Name: Baloxavir marboxil

Brand Name(s): Xofluza

Drug Availability: Prescription

Administration Route: Oral

Therapeutic Classification: Antiviral; Polymerase acidic endonuclease inhibitor

Available Generically: No

Controlled Substance: N/A

Active Ingredient: Baloxavir marboxil

Dosage Form(s): Tablet, suspension

What Is Xofluza Used For?

The Food and Drug Administration (FDA) approved Xofluza for use in adults and adolescents 12 and older (weighing at least 88 pounds) to:

• Treat uncomplicated flu with symptoms occurring for 48 hours (two days) or less in otherwise healthy people or those at high risk of developing flu-related complications.
• Prevent flu after being in contact with someone who has the flu.

Xofluza does not treat bacterial infections (such as pneumonia) that may occur as a complication of the flu. It also does not treat other viral infections, such as the common cold or COVID-19.

How to Take Xofluza

If you are prescribed Xofluza, make sure to read the prescription label and the information leaflet that comes with your prescription. Consult your healthcare provider if you have any questions.

Use Xofluza exactly as directed by your healthcare provider. Xofluza is usually taken as one dose, with or without food. The dose will be based on your weight. Your healthcare provider will either prescribe Xofluza’s tablet form or oral suspension formulation.

If you are taking the Xofluza suspension:

• Take it as soon as possible after mixing it. Do not take the mixture if more than 10 hours have passed.
• Use a measuring device, such as an oral syringe or measuring cup, to ensure accurate dosing.

Do not take Xofluza with dairy products, such as milk, yogurt, cheese, or calcium-fortified foods or drinks. Also, avoid taking Xofluza with medications that contain aluminum, calcium, magnesium, iron, selenium, or zinc. These ingredients are commonly found in antacids, vitamins, and laxatives.

Follow your healthcare provider’s instructions on how to take Xofluza:

• If you are taking Xofluza to treat your flu, take it at the first sign of symptoms (e.g., fever, chills, sore throat, muscle pain, and nasal symptoms). Xofluza is effective when taken in the first 48 hours (two days) of symptoms.
• If you are taking Xofluza to prevent the flu, take it as soon as possible after you have been in contact with someone who has it.

Contact your healthcare provider if your symptoms worsen or do not improve.

Storage

You can store Xofluza tablets and suspension at room temperature (68 to 77 degrees F). However, the suspension should not be kept at room temperature for more than 10 hours. If you don’t take it within 10 hours of mixing, discard the medication. Keep Xofluza out of sight and out of the reach of children and pets.

How Long Does Xofluza Take to Work?

In clinical trials, people who took Xofluza felt better after about two days compared with people who took a placebo.

What Are the Side Effects of Xofluza?

This is not a complete list of side effects and others may occur. A healthcare provider can advise you on side effects. If you experience other effects, contact your healthcare provider. You may report side effects to the FDA at fda.gov/medwatch or 1-800-FDA-1088.

Like other medications, Xofluza can cause side effects. Tell your healthcare provider about any side effects you experience while taking this medication.

Common Side Effects

The most common side effects of Xofluza are:

• Bronchitis: Symptoms may include cough and shortness of breath.
• Diarrhea
• Headache
• Nausea
• Sinusitis: Symptoms may include headache, facial pain, and runny or stuffy nose.

Severe Side Effects

Call your healthcare provider right away if you have serious side effects. Call 911 if your symptoms feel life-threatening or if you think you’re having a medical emergency.

Hypersensitivity reaction or anaphylaxis can occur with Xofluza. Symptoms may include:

Any symptom of an allergic reaction requires emergency medical attention.

Long-Term Side Effects

For the most part, many people tolerate Xofluza well, especially since it is only one dose. However, delayed side effects have been noted on rare occasions. These include:

Report Side Effects

Xofluza may cause other side effects. Call your healthcare provider if you have any unusual problems while taking this medication.

If you experience a serious side effect, you or your healthcare provider may send a report to the FDA’s MedWatch Adverse Event Reporting Program or by phone (800-332-1088).

Dosage: How Much Xofluza Should I Take?

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The dose of this medicine will be different for different patients. Follow your doctor’s orders or the directions on the label. The following information includes only the average doses of this medicine. If your dose is different, do not change it unless your doctor tells you to do so.

The amount of medicine that you take depends on the strength of the medicine. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are using the medicine.

• For oral dosage form (tablets):
  • For the flu:
    • Adults and children 12 years of age and older weighing 80 kilograms (kg) or more—2 tablets of 40 milligrams (mg) taken as a single dose for a total of 80 mg per day.
    • Children 12 years of age and older weighing 40 kg to 79 kg—2 tablets of 20 milligrams (mg) taken as a single dose for a total of 40 mg per day.
    • Children younger than 12 years of age or weighing less than 40 kg—Use and dose must be determined by your doctor.

Modifications

Although Xofluza is safe for older adults (65 and older) to take, nausea may occur more often in this age group. Be aware that if you are older you might be more likely to experience the side effects of this medication.

Sometimes, kidney or liver impairment can affect what dose of medication you should take. In this case, people with mild or moderate kidney or liver problems can usually take Xofluza at the normal dose. If you have severe kidney or liver problems, consult your healthcare provider.

Xofluza comes in both tablet form and as an oral suspension. It may also be given through a feeding tube.

Missed Dose

Xofluza is taken as one dose and does not have a regular dosing schedule.

Overdose: What Happens If I Take Too Much Xofluza?

There is no specific antidote or treatment for overdosing on Xofluza.

What Happens If I Overdose on Xofluza?

If you think you or someone else may have overdosed on Xofluza, call a healthcare provider or the Poison Control Center (800-222-1222).

If someone collapses or isn’t breathing after taking Xofluza, call 911 immediately.

Precautions

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It is very important that your doctor check your or your child’s progress after treatment to make sure that the infection is cleared up completely, and to allow your doctor to check for any unwanted effects.

If your or your child’s symptoms do not improve or if they become worse, check with your doctor.

This medicine may cause serious allergic reactions, including anaphylaxis, angioedema, or certain skin conditions. These reactions can be life-threatening and require immediate medical attention. Call your doctor right away if you or your child have a rash, itching, blistering, peeling, or loosening of the skin, fever or chills, trouble breathing or swallowing, or any swelling of your hands, face, mouth, or throat while you are using this medicine.

This medicine is not a substitute for an annual flu shot. It also will not keep you or your child from getting a bacterial infection that starts with flu-like symptoms.

What Are Reasons I Shouldn’t Take Xofluza?

Xofluza is not appropriate for everyone.

Do not take Xofluza if you:

• Are allergic to baloxavir marboxil or any of the inactive ingredients in Xofluza
• Are pregnant or breastfeeding
• Have complicated illness, a severely compromised immune system, or are hospitalized

What Other Medications May Interact With Xofluza?

Tell your healthcare provider about all of your medications, including prescription and over-the-counter drugs, vitamins, or herbal supplements. 

Because these products may interfere with how well Xofluza works, Xofluza should not be taken with:

• Dairy products (e.g., milk, cheese, yogurt, or calcium-fortified drinks or foods)
• Laxatives, antacids, or vitamin/mineral supplements that contain calcium, iron, magnesium, selenium, or zinc

Do not take Xofluza within several weeks of the intranasal live attenuated influenza vaccine (LAIV). Taking Xofluza within this timeframe of receiving an intranasal LAIV has not been evaluated, but concurrent use may decrease the vaccine’s effectiveness.

Other drug interactions may occur with Xofluza. Consult your healthcare provider for a complete list of drug interactions.

What Medications Are Similar?

Xofluza is a prescription antiviral drug used to prevent or treat seasonal flu in adults and adolescents 12 and older.

Other antivirals used for this indication include:

• Rapivab (peramivir); Rapivab is given as an injection into the vein for adults and children 2 years and older. It is used for treatment only, not for prevention.
• Relenza (zanamivir): Relenza is administered as an inhaler for adults and children 7 years and older.
• Tamiflu (oseltamivir phosphate): Tamiflu is given as an oral capsule or suspension for adults, children, and infants 14 days and older.

The Centers for Disease Control and Prevention (CDC) recommends that everyone 6 months or older (with rare exceptions) get a flu vaccine yearly to help prevent seasonal flu. Xofluza does not take the place of a flu vaccine.

This list is a list of drugs also prescribed for the flu. It is NOT a list of drugs recommended to take with Xofluza. Ask your pharmacist or a healthcare provider if you have questions.

Frequently Asked Questions

• What is Xofluza used for?

  Xofluza is a prescription medication used to prevent or treat seasonal flu in adults and adolescents ages 12 and older.

• How does Xofluza work?

  Xofluza prevents the flu virus from spreading in the body and shortens the length of time that your symptoms last.

• What drugs should not be taken with Xofluza?

  Xofluza should not be taken with medications (such as vitamin/mineral supplements, laxatives, or antacids) containing calcium, iron, magnesium, selenium, or zinc. Xofluza should not be taken with dairy products, such as milk, cheese, yogurt, or foods or drinks fortified with calcium. Xofluza should not be given within several weeks of the intranasal live attenuated influenza vaccine.

• How long does it take for Xofluza to work?

  People who take Xofluza usually feel better in about two days. If symptoms worsen or do not improve, contact your healthcare provider.

• What are the side effects of Xofluza?

  The most common side effects are nausea, headache, and diarrhea. Serious side effects include allergic reactions. Symptoms of hives, shortness of breath, swelling, or skin lesions can indicate an allergic reaction and require emergency medical attention.

How Can I Stay Healthy While Taking Xofluza?

Before taking Xofluza, discuss your medical history and all medications you take with your healthcare provider. 

Here are some measures you can take every day to help reduce the spread of flu:

• Cover your nose and mouth with a tissue when you cough or sneeze, then discard the tissue and wash your hands.
• Avoid touching your face; germs can enter through the eyes, nose, and mouth.
• Avoid people who are sick. If you are sick, stay separated from others as much as possible.
• Wash hands often and thoroughly with soap and water. If soap is not available, use a hand sanitizer with at least 60% alcohol.
• Clean and disinfect contaminated objects and surfaces in the home.
• Stay home for at least one day (24 hours) after the fever is gone (without the need for medication to lower the fever).

If you have the flu, symptoms may include:

• Fever
• Cough
• Sore throat
• Body aches
• Headache
• Nasal symptoms

Ask your healthcare provider or pharmacist for advice on methods to help improve your symptoms in addition to taking Xofluza. Rest and drink plenty of fluids.

Medical Disclaimer

Verywell Health’s drug information is meant for educational purposes only and is not intended to replace medical advice, diagnosis, or treatment from a healthcare provider. Consult your healthcare provider before taking any new medication(s). IBM Watson Micromedex provides some of the drug content, as indicated on the page.

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New York State Agriculture Commissioner Richard A. Ball today announced the end of the bans on live poultry shows, exhibitions, auctions, sales, meets, and swaps in New York State. The Department had previously issued the bans on March 25 and April 14 as highly pathogenic avian influenza (HPAI) spread across the United States, including detections in New York State. The decision to lift the bans comes as cases decrease nationwide, including in New York State, which has not had a detection of HPAI in nearly two months. Additionally, as the state enters agricultural fair season, phylogenetic studies have shown that the majority of flocks affected in the current outbreak were infected by introductions from wild birds, rather than by farm-to-farm transmission, lending additional confidence to the decision to allow comingling of poultry again.

Commissioner Ball said, “New York has taken an aggressive approach to slowing the spread of avian influenza and it has paid off. With cases decreasing in our state and throughout the country, as well as new data showing very low rates of farm-to-farm transmission of HPAI during the current outbreak, I am confident that it is time to lift the bans on live poultry shows and sales. I thank all of our farmers, suppliers, distributors, and live bird markets for employing excellent biosecurity practices as we continue to monitor the HPAI situation closely, and I commend the Department’s Division of Animal Industry staff, who have worked so hard to keep the cases here in New York State under control.”

To date, eight flocks in New York have tested positive for HPAI, with the last detection in a Fulton County flock on April 6. The Department continues to work closely with the United States Department of Agriculture (USDA) Animal and Plant Health Inspection Service (APHIS) on a joint incident response and is also collaborating with partners at the Department of Health and Department of Environmental Conservation. Additionally, Department officials are conducting extensive outreach to poultry and egg farms across the state to ensure best practices are being implemented.

Commercial and hobby poultry farmers should continue practicing good biosecurity measures to help prevent the spread of the disease. The Department encourages all poultry producers, from small backyard to large commercial operations, to review their biosecurity plans and take precautions to protect their birds. Poultry biosecurity materials and checklists can be found on the USDA’s “Defend the Flock” website.

Best practices to prevent transmission of disease at poultry shows or swaps include:

• Always transport birds in crates that have been cleaned and disinfected between uses.
• Do not share equipment or supplies with other exhibitors. Always clean and disinfect any equipment between uses, and especially upon return from a fair, swap, or show.
• If you take some of your birds to a fair or exhibition, be sure to keep them separated from the rest of your flock for at least 21 days upon return and observe for signs of illness.
• Keep new additions to your flock separated for at least 30 days before comingling them with the rest of your flock. Be sure to monitor them for any signs of disease.
• Only purchase birds from reputable sellers and inspect birds thoroughly before purchase. Consider only buying from flocks that participate in the National Poultry Improvement Plan.
• Always wear clean clothes and footwear when entering areas where poultry are housed.
• Be sure to wash your hands with soap and water before and after handling or caring for your birds.
• If there are any signs of illness or abnormalities in your flock, leave your birds home. Do not bring them to fairs, shows, or other events where they will come into contact with other birds.
• Know the signs of HPAI: sudden death of birds, drop in egg production or misshapen eggs, lack of energy or reduced appetite, respiratory signs including nasal discharge or difficulty breathing, swelling of the eyes and head, or purplish discoloration of combs, wattles, or legs.
• Report sick or dying poultry to the Department at (518) 457-3502 or [email protected].

According to the U.S. Centers for Disease Control and Prevention, the public health risk associated with these avian influenza detections remains low. 

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Bird flu virus detected in ducklings at Lincoln Memorial in DC

FOX 5’s Perris Jones reports that officials are warning residents in D.C. about coming in contact with wild birds after two ducklings at the Lincoln Memorial Reflecting Pool tested positive for the avian flu.

WASHINGTON – The virus that causes the avian flu, a contagious disease affecting wild and domestic birds, has been found in mallard ducklings at the Lincoln Memorial Reflecting Pool, according to authorities.

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The National Park Service (NPS) announced Wednesday that two ducklings tested positive for the virus recently, marking the first confirmation of the “highly pathogenic” flu in the District. The virus had previously been detected in domestic and wild birds in Delaware, Virginia, and Maryland, but officials are unsure where the virus detected in D.C. spread from.

According to the Centers for Disease Control and Prevention (CDC), the currently circulating version of the virus poses a low risk to humans. To date, there has only been one documented human case of the virus in the U.S. 

READ MORE: First wild case of bird flu detected in US in 5 years

Despite the low risk, CDC and NPS officials are warning visitors to the Lincoln Memorial Reflecting Pool to avoid touching live or dead birds. They also warned people to avoid coming into contact with bird droppings, as they can help the virus easily spread through a person’s shoes.

Officials say the same warnings also apply to your household pets.

“For visitors to the National Mall who may have poultry or pet birds at home, they want to especially make sure that, if they think they’ve come in contact with a dead bird or droppings from that bird, you’ll want to make sure to disinfect their shoes since it’s the primary way it can be transmitted from bird to bird.”

Visitors at the Lincoln Memorial Reflecting Pool are encouraged to report sick or dead birds to NPS staff.

The avian flu is spread through respiratory and fecal secretions, contact with contaminated environments, or direct bird to bird interactions, particularly among waterfowl like ducks and geese. The virus is highly contagious among some wild birds and can be deadly for some avian species, such as bald eagles or vultures.

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The U.S. Department of Agriculture offers several resources to help people learn about the virus, including how to keep poultry and pet birds safe, advice on what to do if you find a dead wild bird, and national reporting on virus detections in poultry and wild birds.

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A panel of experts advising the health ministry on COVID-19 procedures recommended looser controls on medical and elderly care facilities to ease their daily workloads now that the worst of the crisis seems to be abating.

Noting that patient numbers have dropped sharply in recent weeks, coupled with past findings about how the novel coronavirus spreads, the panel called June 8 for doing away with excessive disinfecting measures, such as frequently wiping handrails and doorknobs, or covering elevator buttons.

COVID-19 does not present a high risk of being spread through contact with objects that patients may have touched, according to one finding.

The panel said regular medical face masks were up to the task of keeping medical staff safe from infection, rather than the highly efficient N95 version that some wearers complain makes it harder for them to breathe.

It also said medical and care staff did not need to wear aprons and gowns if they were only asking patients about their condition or taking their temperatures and not coming in physical contact.

While many medical facilities have set up special zones for COVID-19 patients in different wings, the panel said it was now possible to move to a more flexible approach that would allow separation in hospital rooms.

The panel also suggested loosening conditions for allowing visitors at medical and elderly care facilities.

Visitors to elderly care facilities would be allowed as long as they wore face masks, came in small groups and stayed for only a short time.

Likewise, hospitals will be allowed to let in visitors for certain patients, such as those in the pediatric ward or expectant mothers.

According to sources, the panel initially wanted to extend the relaxed measures to those in close contact with COVID-19 patients.

One proposal was to do away with current close contact protocols. Such individuals are required to self-isolate at home, but the panel suggested lifting the self-quarantine requirement for those who had received booster shots.

Another proposal was to allow those confirmed with COVID-19 to leave home for short periods while wearing face masks if they showed no symptoms after five days.

But health ministry officials urged further discussions on the topic rather than include those proposals in the recommendations released June 8.

The panel, a high-ranking ministry official noted, was set up to base its discussions on accumulated scientific knowledge rather than make decisions about the extent to which new COVID-19 cases should be allowed in exchange for allowing greater economic activity and pedestrian traffic.

While the ministry panel came up with its recommendations, another body of experts advising the government, including those knowledgeable about economic issues, has not met since May and vast differences in opinion remain among the panel members. That has delayed discussions about further relaxing various infection-prevention measures.

(This article was written by Yuki Edamatsu and Kai Ichino.)

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Introduction

The new SARS-CoV-2 Virus first appeared in China in December 2019 as a result of the coronavirus disease 2019 (COVID-19) which has turned out to be a highly contagious virus. Ultimately, this virus can lead to a respiratory infection with a potentially fatal outcome and has caused a global pandemic.1,2 A Chinese ophthalmologist based in Wuhan – Dr. Li Wenliang – became known for warning the public of this emerging disease, as he was supposedly the first documented patient-to-ophthalmologist fatality contracting the virus from an asymptomatic patient.3

Respiratory aerosols, contact or fomites can transfer the COVID-19 virus and thus the ocular surface is believed to also play a part in passing on the disease. According to a study by the Johns Hopkins University, “there is not only a risk of contamination from aerosols in the air, but also a possible, potential risk from the surface of the patient’s eye”.4,5

However, the majority of the available data regarding SARS-CoV-2 colonization of ocular and periocular tissues have to be considered controversial, it cannot be excluded that SARS-CoV-2 could both infect the eye and the surrounding structures. SARS-CoV-2 may use ocular structure as an additional transmission route, as demonstrated by the COVID-19 patients’ conjunctival secretion and tears positivity to reverse transcriptase-PCR SARS-CoV-2-RNA assay.6–9

The growing number of cases and the rapid geographic spread of the disease has raised great concerns and in consequence has led to the implementation of extraordinary public health measures to reduce the spread of the virus.

Countries tried to stem the spread of the infection by means of social distancing and stay-at-home orders. As a result, routine outpatient visits and elective procedures had been postponed.10–13

All hospitals and clinics in Germany, including ophthalmologists, were recommended to limit visits to emergencies only and to postpone all elective surgeries as well as examinations and treatments, which were not absolutely necessary, starting from the lockdown in Germany in mid-March for a maximum of three months.

In our Department a wide spectrum of hygiene measures had been introduced very soon after the outbreak of the pandemic: The entire staff as well as every patient have been required to wear facemasks during all encounters. Slit lamps have been equipped with a transparent protective filter separating the patient and the doctor. In order to promote social distancing, the chairs were arranged approximately 2 meters away in all waiting rooms. Visits and accompanying persons of patients in the outpatient sector were prohibited except in cases of high necessity or only under special circumstances.

After every use, the equipment is disinfected and additionally hand hygiene is necessary, as usual, prior to entering or exiting the examination room. Furthermore, we have taken all the necessary precautions to ensure that our medical care can continue to be available reliably and completely safe. Protective masks and disinfectant are available for patients.

At the entrance to the hospital, a registration desk has been set up with a hospital porter who explains patients the required hygiene measures and fills in a questionnaire to check whether the patient belongs to a risk group and whether he/she is vaccinated/ boostered. Firstly, the patient is asked whether he/she has been infected with the COVID-19 virus in the last 14 days, or has recently been in contact with a person who has been tested positive for Covid-19 in the last 2 weeks. The patient also has to state whether he/she has any of the following symptoms: sore throat, runny nose, diarrhea, fever, pain in the limbs, cough or other acute respiratory symptoms, loss of smell or loss of taste. If there is no suspicion of an infection with the Coronavirus, the patient may go to the appropriate sector in compliance with all hygiene regulations. If an emergency patient has had contact with an infected person and/or shows corresponding symptoms, he/she has to go to a separate waiting room or an isolation area to receive a COVID-19 test via nasopharyngeal swab and is examined with appropriate protective equipment.

Registration for the outpatient consultation takes place with the necessary safety distance. A large protective glass protects the patient and the employee. In addition, each of our diagnostic devices has a sneeze and spit shield, which protects patients and staff. During the medical examination, strict hygiene requirements are also observed. As usual, hand and device disinfection before and after each patient is mandatory. All slit lamps in all examination rooms have a sneeze and spit protection, too.

In addition, we carry out a PCR based test prior to any inpatient procedure.14 Only after receipt of the negative result, the patient is operated on. Until then, the patient remains isolated in the floating area of the ward or in domestic quarantine.15

Bearing all these precautions in mind, the purpose of this study was to assess the impact of the COVID-19 pandemic on the in- and outpatients as well as surgical and diagnostic procedures at a southwestern German university hospital with corneal subspecialization comparing the first “COVID-19 lockdown” period from 18 March until 8 May 2020 with the same period in 2019.

Materials and Methods

This retrospective study was carried out at the Department of Ophthalmology, Saarland University Medical Center in Homburg/Saar in order to study the impact of the Covid-19 pandemic on patient volume and turnover in the in- and outpatient unit of a German university hospital with corneal subspecialization between 18 March and 8 May 2020 compared to the same period in 2019.

Patient consent to review their medical records was not required, according to the Ethics Committee at the Saarland Medical Association in Saarbrücken, Saarland, Germany, because we did not refer to any confidential patient data, but only number of surgeries and consultations were counted by using the electronic patient administration systems of our Department. In addition, a patient informed consent statement was not required because of the retrospective nature of the study. Compliance with the Declaration of Helsinki was granted by the authors of this study.

The data of in- and outpatients, surgeries and diagnostic procedures required for the study were extracted from the SAP database used in the hospital and the electronic patient records FIDUS for the above-mentioned periods.16–19 All data were accumulated from cases which occurred on regular working days during regular working hours from 7:30 a.m. to 4:30 p.m. for the same periods in 2019 and 2020 (emergencies beyond these hours and on weekends were not recorded). Statistical analysis was done using the SPSS software (Version 27, 2020, IBM, USA).

In order to evaluate the difference between the two groups (2019 and 2020) in each category the following tests were used: Chi-Squared Test of Association and Fisher’s Exact Test.

By running the test two-tailed a P-value that describes the result was calculated. A P-value < 0.05 was considered to reject the null hypothesis (as there is no difference between the groups) and indicated a statistically significant difference.

Results

In total, 289 patients were admitted to our hospital in 2020 in contrast to 461 patients in 2019. These admissions included 80 emergencies in 2020 and 115 emergencies in 2019.

Regarding the number of inpatient surgeries in our department, we saw a similar number of patients for the following surgeries: PTK, DMEK, Cyclophotocoagulation and filtering bleb revisions when comparing 2020 and 2019. The number of patients with penetrating keratoplasty was significantly higher in 2020 compared to 2019 (60 vs 54, p=0.0089). On the other hand, we observed a significant drop in the number of the following operations: Eyelid, Strabismus, Pterygium, EDTA chelation, Amnion membrane transplantation (AMT), Crosslinking, Corneal suture removal, Pars plana vitrectomy and especially Cataract surgeries (phacoemulsification with IOL implantation 24 vs 51, and extracapsular cataract extraction with IOL implantation 2 vs 7). In fact, there was an overall significant decrease in the number of patients operated on in our Department as part of a hospitalization with a total number of 281 in 2020 vs 409 in 2019 (Table 1).

Table 1 Ophthalmic Surgeries of Patients, Who Attended the Inpatient Unit of the Department of Ophthalmology, Saarland University Medical Center Between 18 March and 8 May (2020 and 2019)

In the outpatient units of our department, we observed a decrease in the number of consultations with a total number of 1.711 in 2020 vs 3.194 in 2019 (Table 2). This includes a significant drop in patients coming in for cataract consultation (34 vs 137, p<0.001), contact lens consultation (56 vs 220, p<0.0001) and the general university outpatient clinic (1.121 vs 1.883, p<0.0001). In contrast, the decrease in the number of consultations of patients who attended the pediatric ophthalmology and orthoptic unit (458 in 2020 vs 841 in 2019) was not statistically significant (p=0.7408) (Table 2).

Table 2 The Number of Consultations of Patients, Who Attended the Various Outpatient Units at the Department of Ophthalmology, Saarland University Medical Center Between 18 March and 8 May (2020 and 2019)

From the first to the second analyzed period, we noted a significant decrease of IVIs (intravitreal injection) (577 vs 768, p<0.001) in our IVI center (intravitreal injection center). In addition, there was a significant number of patients who did not show up for their treatment at the IVI center (198 vs 68, p<0.0001) (Table 3), although it was still freely accessible during the lockdown period. In contrast, the number of follow-ups after the IVIs increased in 2020 compared to 2019 (76 vs 49, p=0.0036).

Table 3 The Number of Consultations, Intravitreal Injections and Diagnostic Procedure (M-OCT) of Patients, Who Attended the IVI-Center (Intravitreal Injections Center) of the Department of Ophthalmology, Saarland University Medical Center Between 18 March and 8 May (2020 and 2019)

In terms of outpatient operations, there was a significant decrease in patients with corneal suture removal (40 vs 70, p=0.0319), and especially in patients operated on for cataract with 64 vs 216 (p=0.0070) (Table 4).

Table 4 Ophthalmic Surgeries of Patients, Who Attended the Outpatient Operation Center at the Department of Ophthalmology, Saarland University Medical Center Between 18 March and 8 May (2020 and 2019)

Regarding the ophthalmologic diagnostic procedures performed in the outpatient unit at the Department of Ophthalmology, Saarland University Medical Centre, we also noted a significant drop (all p<0.02) in the number of most examinations (Visual field, Pentacam, endothelial cell specular microscopy, Anterior Segment-OCT, Corvis-ST (Corneal Visualisation Scheimpflug Technology), ORA (ocular response analyser), Fluorescein angiography (FA)) during the “Corona lockdown period”, with a total number of 7.653 in 2020 in contrast to 12.538 in 2019 (Table 5).

Table 5 The Number of Diagnostic Procedures Performed at the Outpatient Unit at the Department of Ophthalmology, Saarland University Medical Center Between 18 March and 8 May (2020 and 2019)

Discussion

COVID-19, which has turned out to be a highly contagious virus, can ultimately lead to a respiratory infection with a potentially fatal outcome and has caused a global pandemic. The current knowledge is that the virus can be transferred via aerosols. However, other ways of transmission are still unknown and it has been controversially discussed that transmission is possible through infected ocular tissue.20 Furthermore, it has been hypothesized that the nasolacrimal system can act as a conduit for viruses to travel from the upper respiratory tract to the eye. Hence, ocular tissue and fluid may represent a potential source of SARS-CoV-2.20,21

In March 2020, the American Academy of Ophthalmology (AAO) recommended limiting practice visits to emergencies and cancelling elective surgeries.22

A publication by the AAO from 18 March 2020 “New recommendations for urgent and non-urgent patient care”, advised ophthalmologists to stop providing any treatment that is not urgent.

The recommendations included the following:

• Re-schedule appointments for patients with non-urgent ophthalmic problems and only see patients with emergent needs or those requiring frequent management.
• Only patients are allowed inside the practice but in certain circumstances, one person may accompany the patient.
• Minimizing interaction between patients and staff by using online transfers for additional payments.
• Use slit lamp breath shields.
• While the slit lamp examination is in progress, patient and physician should keep conversations to a minimum.
• For patients with documented COVID-19, persons under investigation, or patients who are “potentially infected with COVID-19,” ophthalmologists should wear personal protective equipment (PPE) including an N95 mask, gown, gloves and eye protection.23,24

In Germany, the Federal Association of Ophthalmologists decided to postpone all examinations and treatments, which were not absolutely necessary – starting from the lockdown in Germany in mid-March – for a maximum of three months. This includes: routine checks, glaucoma controls, diabetic screening without known retinopathy, cataract surgery, cosmetic operations on the eyelids as well as surgical correction of ametropia (refractive surgery).

The recommendation of the German Ophthalmology Society (DOG) was that the patients should only consult an ophthalmologist in a clinic or practice if absolutely necessary and applied to checkups that could not be postponed as well as therapies such as IVIs or emergency interventions. New prescriptions for medication, which were required permanently, should be sent by post, as recommended by the Federal Association of Ophthalmologists. Emergency care had to be maintained. Likewise, care had of course to be maintained for patients whose treatments could not be postponed for several weeks or months without the risk of permanent loss of vision.25

During the initial phase of the pandemic, a contingency plan for non-selective basic eye care was developed at the initiative of the Association of German Chief Ophthalmic Physicians (DOCH) and in consultation with the boards of directors of the Retinological Society (RG), the Association of Ophthalmology Chairholders (VOL) and the German Ophthalmological Society (DOG). The indications and emergencies listed in Table 6 are understood as basic recommendations, which must be weighted in each individual case and according to available resources.26 It should be noted that “keratoplasty” was grouped with “surgical treatment within hours until the following day”.

Table 6 Contingency Plan for Non-Selective Basic Eye Care in Germany During the Corona Lockdown Period Developed at the Initiative of the Association of German Chief Ophthalmic Physicians (DOCH) and in Consultation with the Boards of Directors of the Retinological Society (RG), the Association of Ophthalmology Chairholders (VOL) and the German Ophthalmological Society (DOG)

During the COVID-19 outbreak, the majority of treatments in our department were especially threatening conditions, such as corneal ulcers, retinal detachment, angle-closure glaucoma attack and other ophthalmic emergencies.14,27,28

Due to the pronounced increasing number of Covid-19 cases in Germany starting with only one single case on 27 January 2020 to 262 confirmed cases on 04 March 2020 and following the instructions of the German Government and the German Ophthalmology Society, the Department of Ophthalmology at Saarland University Medical Center decided to cancel and postpone the majority of cataracts, eyelid, glaucoma and elective operations starting from 6 March 2020. Additionally, all appointments with the exception of emergencies were postponed for seven weeks to reduce the influx of patients to our clinic. As a result, we observed a significant decrease in the number of admissions to our hospital with a total number of 289 patients in 2020 compared to 461 patients in 2019, including 80 emergencies in 2020 and 115 emergencies in 2019. There was a significant decline in the number of the following outpatient and inpatient surgeries: Eyelid, Strabismus, Pterygium, EDTA, Crosslinking, Corneal Suture Removal, Pars plana vitrectomy (ppV) and especially Cataract surgeries. This has been reported for glaucoma surgeries in the literature.29 In comparison, we saw a similar number of patients for the following surgeries: PTK, DMEK, Cyclophotocoagulation and filtering bleb revisions when comparing 2020 and 2019.

A report from 39 academic ophthalmology centers in Italy, another country severely impacted by the pandemic, compared surgical interventions of the 2-month lockdown period (March 10 to May 9, 2020) to pre-lockdown months (January 10 to March 9, 2020) and the corresponding 2 months in 2019 (March 10 to May 9 2019). Overall, the number of surgeries decreased by 68.8% and 69.9%, respectively, with a reduction of 96.2% and 96.4% in the number of elective surgeries and 50.7% and 53.9% in the number of urgent surgeries.30

In the outpatient units of our department, we observed a significant decrease in the number of consultations with a total number of 1.711 in 2020 compared to 3.194 in 2019 (Table 3) which includes patients coming for cataract consultation (34 vs 137, p<0.001), contact lens consultation (56 vs 220, p<0.0001) and the general ophthalmic outpatient clinic (1.121 vs 1.883, p<0.0001).

In our center for intravitreal drug injections (IVI), established at our department in 2016 and separate from the other sections, we especially treat patients with macular diseases.31 During the “Corona lockdown period” we had given considerable attention to the importance of the therapy with IVIs for the treatment of choroidal neovascularization mainly secondary to age-related macular degeneration, diabetic macular edema, and also macular edema linked to retinal venous thrombosis. None of the treatments mentioned above were postponed within our IVI Center from our side due to the pandemic.

However, we could observe a significant decrease in the number of anti VEGF injections between 2020 and 2019 (577 vs 768). In addition, we were confronted with a significant increase in patients who just did not turn up for their appointment (198 vs 68). It should be noted that most of the patients who come in for treatment with anti VEGF injections are elderly, and some patients present with more advanced or severe systemic disease. This in turn suggests that patients were reluctant to present for treatment in our department to avoid the risk of eventual exposure to COVID-19, which could be potentially dangerous for them. Furthermore, we noted that the means of transport during the pandemic were restricted and diminished which was another disadvantage for patients to reach the clinic.

The literature indicates that patients were afraid of contracting the virus leading to a lower request for healthcare services/hospitalizations – particularly during the period of hard lockdown (March – May 2020). This factor certainly contributed to a lower afflux of patients to hospital and to contentious relationship between patients and health care workers (HCWs). On the other hand, the hard lockdown led to a worsening of the conditions of non-autonomous patients.32–34 In a study performed in Italy only 70% of patients for whom an operation/intravitreal injection was recommended, finally underwent surgery. The remaining patients did not turn up because they were afraid of being infected at the hospital (23%), taking public transportation (6.5%), or unavailable swabs (0.5%).34

It is also worth noting that during lockdown, some models of working from home or home schooling were proposed to improve productivity, including online work and home schooling, based on the use of electronic equipment. There is no doubt that these smart work models with electronic equipment have given rise to new lifestyles, digital work and digital school, forcing people, both young and adult, into prolonged near visual work. Unfortunately, this can predispose to ocular surface disorders, such as dry eye disease (so-called “quarantine dry eye”).35

Despite the main streaming, in the present study we observed a significant increase on the number of corneal transplantations between 2020 and 2019 (60 vs 54). This may be due to the fact that we are one of the university departments performing most penetrating keratoplasties in Germany and there is a constant need for donor tissue. In addition, “keratoplasty” was classified under “emergencies” in Germany (Table 6). Thus, we decided not to interrupt our eye bank activities, since tissue was available and must not be discarded.36 We recommended continuing the collection of all available corneas, as long as the appropriate precautions were taken. Only tissue from donors with confirmed SARS-CoV-2 infection or with a high clinical suspicion of COVID-19 should not be selected for transplantation purposes.37

In other European countries, in Italy for example, corneal transplants were considered as an elective surgeries and during lockdown a dramatic reduction in the number of keratoplasties was observed there. The number of cancelled transplantations during the COVID-19 lockdown period in 2020 was 103. On the other hand, in the same timeframe of 2019, only 27 cancelled procedures were registered.38

The risk of transferring viral loads – through respiratory droplets or contact with surfaces – from the patient to the physician increases where a close proximity to the patient is required during the application of ophthalmic diagnostic equipment and procedures, for example slit lamp, ophthalmoscope or ocular manipulation. Furthermore, there are certain ophthalmic instruments, which are used frequently during single-patient visits and can become potential sources of transmission if they are not disinfected accordingly.39 In our Department, single-use instruments, for example a single-use tonometer, were used during the Corona lockdown period. Additionally, we decided to limit the use of certain diagnostics procedures that posed a high risk of transmitting infection through the air pulse such as Ocular Response-Analyzer (ORA) and Corvis-ST (evaluation of corneal biomechanical response, tonometry and pachymetry) as much as possible which resulted in a significant decrease in ophthalmologic diagnostic procedures performed in the outpatient unit during the lockdown with a total number of 7.653 in 2020 in contrast to 12.538 in 2019 (Table 5).

A paradigm shift for ocular surgery and preparatory examinations during the still ongoing COVID-19 era seems to be mandatory. While telemedicine may be able to solve some problems in clinical ophthalmology, the lack of adequate health and legal protections for surgeons and patients may result in an excessive reduction in the volume of surgical interventions, thus determining inability to ensure required health care to all patients.40

Conclusion

Despite taking all the necessary precautions to ensure that our medical care can continue to be available reliably and completely safe during the “Corona lockdown period”, the number of in- and outpatient surgeries and the number of outpatient consultations decreased significantly. However, the number of corneal transplantations still increased, as this procedure relies on donor tissue in demand and was thus classified as an emergency in Germany.

Disclosure

The authors report no conflicts of interest in this work.

References

1. Williams AM, Kalra G, Commiskey PW, et al. Ophthalmology Practice During the Coronavirus Disease 2019 Pandemic: the University of Pittsburgh Experience in Promoting Clinic Safety and Embracing Video Visits. Ophthalmol Ther. 2020;9:1–9.

2. Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health concern. Lancet. 2020;395(10223):470–473. doi:10.1016/S0140-6736(20)30185-9

3. Parrish RK. 2nd, Stewart MW, Duncan Powers SL. Ophthalmologists Are More Than Eye Doctors – In Memoriam Li Wenliang. Am J Ophthalmol. 2020;213:A1–A2. doi:10.1016/j.ajo.2020.02.014

4. Zhou L, Xu Z, Castiglione GM, Soiberman US, Eberhart CG, Duh EJ; Zhou L, Xu Z, Castiglione GM, Soiberman US, Eberhart CG, Duh EJ. ACE2 and TMPRSS2 are expressed on the human ocular surface, suggesting susceptibility to SARS-CoV-2 infection. Ocul Surf. 2020;18(4):537–544. doi:10.1016/j.jtos.2020.06.007

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Middle East Respiratory Syndrome, or MERS, is a respiratory disease caused by a coronavirus. It’s can be passed from camels to humans, and it can also be passed between people. Most cases of MERS have been identified in the Middle East, Africa, and South Asia.

While MERS is not common, it can be helpful to know more about symptoms and treatment, especially if you plan to travel to a country where MERS has been found.

Read on to learn more about this virus, including how to diagnose and treat it. Another common question may center on its connections to another coronavirus, SARS-CoV-2, which causes COVID-19.

MERS is a zoonotic virus, which means it can pass from humans to animals as well as from animals to humans.

Most of the original infections are passed from dromedary camels to humans. As for human-to-human infection, those take place in healthcare settings and in households where someone else already has the viral infection.

MERS is a respiratory disease, so it mostly affects the lungs and breathing passages. However, it can cause general flu-like symptoms. In severe cases, it may cause organ damage.

The World Health Organization (WHO) reports that approximately 35 percent of people diagnosed with MERS die, although most also have underlying conditions that weaken the immune system, such as cancer.

MERS was first identified in Saudi Arabia in 2012 and has since been diagnosed in 25 countries, mostly in the Middle East, Africa, and South Asia. All cases of MERS have been diagnosed in people who have a history of travel to the Arabian Peninsula or contact with someone who traveled there.

Only two confirmed cases of MERS have ever been diagnosed in the United States, both in 2014 in people who were from Saudi Arabia and visiting the United States.

Symptoms of MERS generally appear about 5 to 6 days after a person is exposed to the virus. However, symptoms can start anywhere from 2 to 14 days after exposure.

MERS primarily affects the lungs and airways. While some people don’t have any symptoms, most people with MERS have at least some of the following symptoms:

If left untreated, or in severe cases, MERS can cause complications like pneumonia and kidney failure.

COVID-19 and MERS are both caused by a coronavirus, which is a family of viruses that causes upper respiratory tract illness in humans.

• Specifically, MERS is caused by the MERS coronavirus (MERS-CoV).
• COVID-19 is caused by a coronavirus called SARS-CoV-2.

A third severe type of coronavirus is severe acute respiratory syndrome (SARS). Other types of coronaviruses can cause common colds and coughs.

When COVID-19 began being transmitted, scientists were able to use previous research on SARS and MERS. This allowed them to move more quickly in creating COVID-19 diagnostics, treatments, and vaccines.

If a doctor suspects you might have MERS, they’ll first ask you a series of questions about your:

• symptoms
• travel history, such as if you’ve been to the Middle East or any other country where MERS has recently been identified
• recent history of contact with people who are sick, including people diagnosed with MERS
• contact with camels recently

Depending on your answers, the doctor will then order a series of test to diagnose MERS, including:

• blood tests, such as a complete blood count, to look for certain chemicals that MERS makes in your blood and to look for other potential viruses
• chest X-ray
• PCR testing, which is done with a nasal or throat swab, mucus sample, stool sample, or some combination of samples and is the only way to officially confirm an active MERS infection

There’s no treatment specific to MERS, so care is focused on easing symptoms. This may include:

• intravenous (IV) fluids
• pain medications
• rest
• oxygen

In severe cases, supportive treatments like a ventilator or dialysis might be needed.

There are some experimental treatments that may be used for MERS, such as combination treatment with ribavirin and interferon (IFN) treatments. These have not been approved by the Food and Drug Administration (FDA) and have not been rigorously tested in humans, but they show some promise in animal trials.

In addition, researchers are testing other treatments in human clinical trials, including plasma from people who have recovered from MERS (convalescent plasma), monoclonal antibodies, and antivirals.

If you have contact with someone who has MERS or are in a country with confirmed cases of MERS-CoV transmission, there are steps you can take to lower your risk, like with other viruses:

• Wash your hands for at least 20 seconds with soap and water often.
• Cover your mouth and nose when you sneeze or cough.
• Avoid touching your face with unwashed hands.
• Avoid contact with people who are sick, especially if someone in your household has been diagnosed with or is being evaluated for MERS.
• Clean and disinfect frequently touched surfaces.

If you’re not traveling to the Middle East or in contact with someone who has traveled there recently, it’s extremely unlikely that you will be exposed to MERS-CoV, as all diagnosed cases of MERS have been linked to the Arabian Peninsula.

However, even if you are not likely to be exposed to MERS-CoV, this virus has likely impacted your life. Because it’s a coronavirus, previous research into MERS allowed scientists to develop tests and treatments for COVID-19 more quickly than they otherwise would have been able to.

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