Michael DeWitt

Brinkley Bellotti

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Collabathon on Estimating Real-Time Epidemic Growth Rates

Antimicrobial Awareness Week 2024   U.S. Antibiotic Awareness Week (AAW) is observed each year from November 18-24. The purpose of AAW is to raise awareness of the importance of appropriate antibiotic and antifungal use and the threat antimicrobial resistance poses to people, animals, plants and in our environment. See the CDC for more at here.

Antimicrobial Awareness Week 2024

Dr Brinkley Bellotti was recently interviewed by the MIT Technology Review on the topic of H5N1 and its continued spread in dairy cows and poultry. In her interview, Dr Bellotti mentions that unmitigated spread of H5N1 in animals could lead to recombination events of the influenza virus which could allow for strains that could more easily infect humans.

In the news: Wake Forest faculty discusses H5N1 and ongoing research

Erin Barnes

Infectious diseases and addiction   One of the most frequent questions I am asked is, “What does infectious diseases have to do with addiction!? How did you get into this?” I began my fellowship in infectious diseases at AHWFB in Winston Salem, NC in 2014. At this time prescription opioid prescribing was still near its peak.

An Introduction to the Intersection of Infectious Diseases and Addiction

Michael E. DeWitt

The Section on Infectious Diseases and the Atrium Health Division of Infectious Diseases attended IDWeek 2024 in Los Angeles, CA and made a strong showing. Presentations and posters were presented by a variety of members including infectious diseases pharmacists, pharmacy residents, medical residents,infectious disease fellows, and infectious disease physicians.

IDWeek 2024

Michael DeWitt attended the 2024 International Field Epidemiology and Tropical Medicine course in Peru hosted by the Universidad Peruana Cayetano Heredia and the EMERGE group(Unidad de Investigación en Enfermedades Emergentes y Cambio Climático) along with students and faculty from the University of Texas Medical Branch.

International Field Epidemiology and Tropical Medicine in Peru

Medical Student 2024

Estimated Monkeypox Susceptible MSM Population in North Carolina Review

.wrappingr {   float: right;   shape-margin: 50px;   width: 40%; } .wrappingl {   float: left;   shape-margin: 50px;   width: 40%; } #fig-structure &gt; figure &gt; figcaption {   float: left;   clear: both; } Part 1: Defining Addiction   A 22 year old male is sitting in bed, pale and mildly short of breath. He is recovering from a surgery on his heart valve which was badly damaged by infection he developed from injecting drugs intravenously.

Why Medication for Opioid Use Disorder Is Not “Trading One Drug For Another”

There are many arguments in academic circles about how to frame and think about addiction. In my personal experience, I find one of the most helpful ways to think of addiction is the classic framework that views addiction as a ‘biopsychosocial’ disease. I like this framework because it helps us identify and then examine all of the key ingredients that go into forming and maintaining a substance use disorder.

Addiction As a Biopsychosocial Disease

.wrappingr {   float: right; shape-margin: 50px; width: 40%; } .wrappingl {   float: left; shape-margin: 50px; width: 40%; } #fig-structure &gt; figure &gt; figcaption {   float: left; clear: both; }
<strong>
 What is happening when an addictive substance is used in the brain?
</strong>
Every addictive substance acts on a chemical in the brain called dopamine.

Why Medication for Opioid Use Disorder Is Not “Trading One Drug For Another: Part 2”

Our second year Infectious Diseases fellow Dr. Cook presented this work on serratia endocarditis at 2022 IDWeek in Washington DC! Here at AHWFB Health we have been seeing an increasing number of infections of the heart due to the bacteria Serratia marcescens in persons who inject drugs. This is a reddish-orange bacteria commonly found in soil and water that is not a usual cause of serious infections.

A Case Series of Serratia Marcescens in Persons Who Inject Drugs

Tracking the Outbreak   Learning lessons from the emergence of SARS-CoV-2 and the COVID-19 pandemic, we have launched a new website tracking the reported number of Monkeypox cases in North Carolina using data reported by the North Carolina Department of Health and Human Services (NCDHHS) as well as across the United States using data provided by the Centers for Disease Control and Prevention (CDC). Monkeypox virus (MPX), a double stranded DNA

Tracking Monkeypox Cases in North Carolina

.wrappingr {   float: right; shape-margin: 50px; width: 40%; } .wrappingl {   float: left; shape-margin: 50px; width: 40%; } #fig-structure &gt; figure &gt; figcaption {   float: left; clear: both; } Truly Trading One Drug for Another   ‘You are just trading one drug for another’ is a common refrain in the world of substance use disorders.

Truly Trading One Drug for Another”

Wake Forest School of Medicine Section on Infectious Diseases

Our second year Infectious Diseases fellow Dr. Cook [presented this
work](https://zenodo.org/record/7277381#.Y2PFXnbMKUk) on serratia
endocarditis at 2022 IDWeek in Washington DC! Here at AHWFB Health we
have been seeing an increasing number of infections of the heart due to
the bacteria [Serratia
marcescens](https://en.wikipedia.org/wiki/Serratia_marcescens) in
persons who inject drugs. This is a reddish-orange bacteria commonly
found in soil and water that is not a usual cause of serious infections.
The biggest series of cases of heart infections caused by this organism
published in the literature in California in the 1970s but few reports
have followed since. This bacteria belongs to a family of bacteria (the
Gram Negative bacteria) that are less likely to cause heart infections
than bacteria such as Staphylococcus aureus or Streptococci (the Gram
Positive bacteria) which are skin and mouth. These latter bacteria are
still the most common cause of heart infections in both persons who do
and do not inject drugs. We do not know what has caused this increase in
Serratia heart infections but we believe that other centers in the
Southeast are seeing similar increases. We look forward to collaborating
with our infectious colleagues across the nation to unravel how and why
these infections are occurring and how best to treat them!

::: {.quarto-figure .quarto-figure-center}
<figure class="figure">
<p><img
src="https://wakeforestid.com/posts/2022-11-04-serratia/preview.jpg"
class="img-fluid figure-img" /></p>
<figcaption>Image credit:
https://en.wikipedia.org/wiki/Serratia_marcescens#/media/File:Serratia_marcescens.jpg</figcaption>
</figure>
:::

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::::: {#quarto-reuse .section .quarto-appendix-contents}
## Reuse {#reuse .anchored .quarto-appendix-heading}

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<div>

[CC BY 4.0](https://creativecommons.org/licenses/by/4.0/){rel="license"}

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::::::: {#quarto-citation .section .quarto-appendix-contents}
## Citation {#citation .anchored .quarto-appendix-heading}

<div>

::: {.quarto-appendix-secondary-label}
BibTeX citation:
:::

``` {.sourceCode .code-with-copy .quarto-appendix-bibtex}
@inproceedings{cook2022,
  author = {Cook, Julia and B. Anderson, Matthew and Barnes, Erin},
  title = {A {Case} {Series} of {Serratia} {Marcescens} in {Persons}
    {Who} {Inject} {Drugs}},
  booktitle = {IDWeek2022},
  date = {2022-11-04},
  url = {https://wakeforestid.com/posts/2022-11-04-serratia/},
  doi = {10.5281/zenodo.7277381},
  langid = {en}
}
```

::: {.quarto-appendix-secondary-label}
For attribution, please cite this work as:
:::

::: {#ref-cook2022 .csl-entry .quarto-appendix-citeas}
Cook, Julia, Matthew B. Anderson, and Erin Barnes. 2022. "A Case Series
of Serratia Marcescens in Persons Who Inject Drugs." In *IDWeek2022*.
<https://doi.org/10.5281/zenodo.7277381>.
:::

</div>
:::::::
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:::::::::::: {#infectious-diseases-and-addiction .section .level2 .page-columns .page-full}
## Infectious diseases and addiction {.anchored anchor-id="infectious-diseases-and-addiction"}

One of the most frequent questions I am asked is, "What does infectious
diseases have to do with addiction!? How did you get into this?" I began
my fellowship in infectious diseases at AHWFB in Winston Salem, NC in
2014. At this time prescription opioid prescribing was still near its
peak. The first person I saw was a 22 year old male who died of
injection drug use associated infection of the heart (endocarditis). And
from that day on my service was FULL of very young people suffering from
infections of the heart and bones due to injection drug use. I had just
completed my internal medicine training in Richmond VA only 4 hours
away, but I had never seen anything like this. At this time, the
majority were injecting a substance called oxymorphone, which was also
new to me- this prescription opioid was not as widely prescribed as some
comparators and its illicit use was much more regionally variable. That
is a good thing because it was found that an ingredient in the 2012
tamper-resistant version of oxymorphone resulted in Very Bad Things if
injected. It caused a condition that destroyed the kidneys and the
platelets that help blood to clot in addition to the person being sick
from the infection.

Not only was the number of these cases shockingly higher than they had
been in my previous location, these patients were SICK. What I had
generally been taught in my medical training could be distilled as 'this
type of endocarditis is not nearly as bad as 'regular' endocarditis and
they should mostly do fine'. The medical reports and studies of previous
cases also taught that racial minorities, males, and urban settings
would have the highest rates of this otherwise rare infection.

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So I was confused. None of this matched what I was seeing. My patients
were predominately White and I had as many females as males. Winston
Salem was more rural than my previous center but I saw much more
injection drug use here. And these patients were definitely NOT fine.
Many of them died. Many of them stayed in the hospital for weeks at a
time receiving intravenous antibiotics but we had no addiction medicine
care. We then sent them back to rural and under-resourced areas where
relapse to substance use and subsequent infection were common. And then
I watched more of them die.

::::: {.columns}
::: {.column style="width:40%;"}
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width="250"}
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::: {.column style="width:60%;"}
These experiences changed the direction of my vocation and life. I
became interested in learning more. What had changed that this disease
was now so much more common and looked so very different? At this time
the reports on the rising rates of substance use disorder associated
were just beginning to be published so for all I knew this was unique to
my location or maybe even the oxymorphone. I pursued additional training
in research methods to better understand how to ask and answer questions
about this population. But even more than curiosity I felt frustration.
I was spending weeks treating an infection while doing nothing to impact
the root cause. The number one rule of infectious diseases treatment is
that source control is the most important thing!
:::
:::::

This population tends to be uninsured, have limited access to
transportation, and has multiple socioeconomic barriers. This limited
their ability to enter substance use treatment even before they became
sick. And now that they had such severe physical illnesses, many
existing substance use treatment programs were not equipped to handle
their complex needs. Some of these patients had not wanted to stop their
use until this happened. I now had persons in a unique window of time
where someone was vulnerable and truly seeking help...and I did not know
how to give it!

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</div>
::::

And so...I decided to try. Despite being afraid to do something I had
not been systematically taught in medical school or seen other
physicians model first, I embraced the thought that surely I couldn't be
worse than nothing and became waivered to prescribe buprenorphine. At
this same time [Dr. Ernesto
Aranda](https://www.wakehealth.edu/providers/a/ernesto-luis-aranda-aguirre)
completed his infectious diseases fellowship and became the first
addiction medicine fellow at AHWFB. Together we began a combined clinic
which sought to capitalize on this time of crisis and potential change.
Our goal was to catch these patients on discharge from the hospital to
continue care for their infectious diseases, provide basic primary care
services, and administer medication assisted treatment with
buprenorphine for opioid use disorder. We were joined by [Dr. Kelsie
Pierre](https://atriumhealth.org/provider-profile/kelsie-pierre-1801271556)
2 years later who did an additional year of addiction medicine training
following completion of her infectious disease fellowship.

:::: {.no-row-height .column-margin .column-container}
<div>

![](https://wakeforestid.com/assets/helping-hand.jpg){.img-fluid}

</div>
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We screen for sexually transmitted infections, hepatitis, and HIV. We
treat sexually transmitted infections and hepatitis C. We vaccinate
against hepatitis A and B and more. We provide care for members of our
HIV clinic population who also suffer from opioid use disorder. Since
this clinic endeavor started we have suffered heartbreak, self-doubt,
innumerable logistical challenges, ethical and moral dilemmas, and
joyful celebration of victories large and small. It is the most
simultaneously challenging and rewarding aspect of medicine I have ever
experienced.

The overlap between the care of infectious diseases and addiction
medicine is startling large and is expanding all the time. The same work
force of physicians who rallied to treat the disease of HIV when it was
complex, ostracized, and misunderstood is uniquely placed to join the
fight against substance use disorder. I look forward to exploring these
intersections, challenges, and unresolved questions with you in coming
posts.
::::::::::::

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::::: {#quarto-reuse .section .quarto-appendix-contents}
## Reuse {#reuse .anchored .quarto-appendix-heading}

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::::::: {#quarto-citation .section .quarto-appendix-contents}
## Citation {#citation .anchored .quarto-appendix-heading}

<div>

::: {.quarto-appendix-secondary-label}
BibTeX citation:
:::

``` {.sourceCode .code-with-copy .quarto-appendix-bibtex}
@online{barnes2022,
  author = {Barnes, Erin},
  title = {An {Introduction} to the {Intersection} of {Infectious}
    {Diseases} and {Addiction}},
  date = {2022-08-12},
  url = {https://wakeforestid.com/posts/2022-08-11-an-introduction-to-the-intersection-of-infectious-diseases-and-addiction/},
  langid = {en}
}
```

::: {.quarto-appendix-secondary-label}
For attribution, please cite this work as:
:::

::: {#ref-barnes2022 .csl-entry .quarto-appendix-citeas}
Barnes, Erin. 2022. "An Introduction to the Intersection of Infectious
Diseases and Addiction." August 12, 2022.
<https://wakeforestid.com/posts/2022-08-11-an-introduction-to-the-intersection-of-infectious-diseases-and-addiction/>.
:::

</div>
:::::::
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::: {#how-many-vaccines-do-we-need .section .level2}
## How many vaccines do we need? {.anchored anchor-id="how-many-vaccines-do-we-need"}

The 2022 global outbreak of monkeypox virus has been predominantly in
gay, bisexual, and other men who have sex with men (MSM). A group of
researchers in the Section on Infectious Diseases and the Division of
Infectious diseases sought to answer the question of how many MSM could
be in the state of North Carolina as well as estimate the proportion of
those who had more than one sexual partner in the last year, individuals
who represent the highest risk for infection and onward transmission of
monkeypox. Understanding these figures will aid in the public
understanding of how many vaccines are needed and how to prioritize the
limited supply of vaccines.
:::

::: {#key-findings .section .level2}
## Key findings {.anchored anchor-id="key-findings"}

Researchers found that at a minimum roughly 15,700 sexually active MSM
in North Carolina should be offered vaccines to reduce the risk of
monkeypox infection and to blunt transmission chains, which is
unfortunately far greater than the current vaccine supply in North
Carolina. Additionally, about 49,400 vaccines should be offered to other
members of the MSM community in North Carolina to reduce their risk of
infection. These estimates do not include other occupations where there
is a high risk for monkeypox exposure including laboratory personnel and
front-line healthcare workers with dedicated public health response
roles where exposure could rapidly increase with increasing prevalence.
Monkeypox is an infectious disease and can infect anyone.
:::

::: {#study-limitations .section .level2}
## Study limitations {.anchored anchor-id="study-limitations"}

- The basis for estimating sexual activity and practice relies on the
  accuracy of responses to the NHANES survey. Because of violence and
  stigma against MSM, respondents may not be inclined to answer
  questions about sexual practices, thus these estimates could
  underestimate the true number of MSM or the number of persons exposed
  to monkeypox.
- The NHANES survey is a national level so inferences at the subnational
  level may have much larger error due. These limitations are more
  likely to underestimate the eligible population for vaccination,
  suggesting significant expansion of vaccine supply will be needed in
  order to contain the current monkeypox outbreak.
:::

::: {#read-the-full-report .section .level2}
## Read the full report {.anchored anchor-id="read-the-full-report"}

The full [pre-print is available on
medRxiv](https://www.medrxiv.org/content/10.1101/2022.07.21.22277860v1.full-text).
:::

::::::::::: {#quarto-appendix .default}
::::: {#quarto-reuse .section .quarto-appendix-contents}
## Reuse {#reuse .anchored .quarto-appendix-heading}

:::: {.quarto-appendix-contents}
<div>

[CC BY 4.0](https://creativecommons.org/licenses/by/4.0/){rel="license"}

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::::::: {#quarto-citation .section .quarto-appendix-contents}
## Citation {#citation .anchored .quarto-appendix-heading}

<div>

::: {.quarto-appendix-secondary-label}
BibTeX citation:
:::

``` {.sourceCode .code-with-copy .quarto-appendix-bibtex}
@online{dewitt2022,
  author = {DeWitt, Michael},
  title = {Estimated {Monkeypox} {Susceptible} {MSM} {Population} in
    {North} {Carolina} {Review}},
  date = {2022-08-11},
  url = {https://wakeforestid.com/posts/2022-08-11-estimated-monkeypox-susceptible-msm-population-in-north-carolina/},
  langid = {en}
}
```

::: {.quarto-appendix-secondary-label}
For attribution, please cite this work as:
:::

::: {#ref-dewitt2022 .csl-entry .quarto-appendix-citeas}
DeWitt, Michael. 2022. "Estimated Monkeypox Susceptible MSM Population
in North Carolina Review." August 11, 2022.
<https://wakeforestid.com/posts/2022-08-11-estimated-monkeypox-susceptible-msm-population-in-north-carolina/>.
:::

</div>
:::::::
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::: {#tracking-the-outbreak .section .level2}
## Tracking the Outbreak {.anchored anchor-id="tracking-the-outbreak"}

Learning lessons from the emergence of SARS-CoV-2 and the COVID-19
pandemic, we have [launched a new
website](https://mpx.wakeforestid.com/) tracking the reported number of
[Monkeypox](https://www.cdc.gov/poxvirus/monkeypox/response/2022/index.html)
cases in North Carolina using data reported by the [North Carolina
Department of Health and Human
Services](https://epi.dph.ncdhhs.gov/cd/diseases/monkeypox.html)
(NCDHHS) as well as across the United States using data provided by the
[Centers for Disease Control and
Prevention](https://www.cdc.gov/poxvirus/monkeypox/response/2022/us-map.html)
(CDC). Monkeypox virus (MPX), a double stranded DNA virus belonging to
the orthopoxvirus genus,is endemic in West and Central Africa. In May
2022, reports emerged of growing cases of MPX in Europe and North
America with the World Health Organization declaring MPX a [*Public
Health Emergency of International
Concern*](https://www.npr.org/2022/07/23/1113183728/monkeypox-global-health-emergency-who)
on July 23, 2022.

You can visit the website at <https://mpx.wakeforestid.com>.
:::

::::: {#next-steps .section .level2}
## Next Steps {.anchored anchor-id="next-steps"}

We will be calculating relevant epidemiological metrics such as the
effective reproduction number and the doubling time of cases. We
anticipate that this website will continue to evolve as our
understanding of the current outbreak unfolds.

::: {.quarto-figure .quarto-figure-center}
<figure class="figure">
<p><img
src="https://wakeforestid.com/posts/2022-07-27-tracking-monkeypox-cases-in-north-carolina/preview.png"
class="img-fluid figure-img" /></p>
<figcaption>Reported MPX Cases in North Carolina</figcaption>
</figure>
:::

We provide an [interactive
longitudinal](https://mpx.wakeforestid.com/us.html) view of all states
using the CDC data.

::: {.quarto-figure .quarto-figure-center}
<figure class="figure">
<p><img
src="https://wakeforestid.com/posts/2022-07-27-tracking-monkeypox-cases-in-north-carolina/interactive-mpx.png"
class="img-fluid figure-img" /></p>
<figcaption>Interactive View of Reported MPX Cases by State</figcaption>
</figure>
:::
:::::

::: {#questions .section .level2}
## Questions? {.anchored anchor-id="questions"}

Please reach out to [your
provider](https://www.wakehealth.edu/specialty/i/infectious-diseases) if
you have any questions regarding monkeypox infections.
:::

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::::: {#quarto-reuse .section .quarto-appendix-contents}
## Reuse {#reuse .anchored .quarto-appendix-heading}

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::::::: {#quarto-citation .section .quarto-appendix-contents}
## Citation {#citation .anchored .quarto-appendix-heading}

<div>

::: {.quarto-appendix-secondary-label}
BibTeX citation:
:::

``` {.sourceCode .code-with-copy .quarto-appendix-bibtex}
@online{dewitt2022,
  author = {DeWitt, Michael},
  title = {Tracking {Monkeypox} {Cases} in {North} {Carolina}},
  date = {2022-07-27},
  url = {https://wakeforestid.com/posts/2022-07-27-tracking-monkeypox-cases-in-north-carolina/},
  langid = {en}
}
```

::: {.quarto-appendix-secondary-label}
For attribution, please cite this work as:
:::

::: {#ref-dewitt2022 .csl-entry .quarto-appendix-citeas}
DeWitt, Michael. 2022. "Tracking Monkeypox Cases in North Carolina."
July 27, 2022.
<https://wakeforestid.com/posts/2022-07-27-tracking-monkeypox-cases-in-north-carolina/>.
:::

</div>
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