Explaining melanoma; how germy are ATMs? -- Upstate Medical University's HealthLink on Air for Sunday, July 2, 2023

[00:00:00] Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a surgical oncologist explains how melanoma is diagnosed and treated and offers tips about prevention.

[00:00:12] Daniel Thomas, MD: "...Even as few as two or three sunburns, blistering sunburns, in childhood or adolescence can increase your risk of having a melanoma later in life. It's something that we think of as a cumulative sun exposure..."

[00:00:28] Host Amber Smith: And a scientist in infectious disease explores which germs lurk on ATM machines.

[00:00:34] Joe Domachowske, MD: "...We collected 234 samples from the same ATM keypad. And it was collecting them over the course of the year so that we could look over the full year, not just during cold and flu season..."

[00:00:46] Host Amber Smith: All that, followed by a visit from The Healing Muse coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, we'll learn about research into the type and amount of pathogens found on ATM machines. But first, melanoma skin cancer is diagnosed in a growing number of women in their 20s.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." It's less common than other skin cancers, but melanoma is more likely to grow and spread. Today I'm talking about melanoma with Dr. Daniel Thomas. He's an assistant professor of surgery at Upstate who specializes in complex general surgical oncology. Welcome to "HealthLink on Air," Dr. Thomas.

[00:01:48] Daniel Thomas, MD: Thank you for having me.

[00:01:50] Host Amber Smith: Can you describe what melanoma skin cancer is?

[00:01:54] Daniel Thomas, MD: Melanoma is a type of cancer that starts in certain cells in a patient's skin. It's the cells called melanocytes, which are the cells in our skin that produce the pigmentation or the color. And sometimes these cells can grow out of control, which is when it becomes a tumor, or when it becomes cancerous.

The majority of melanomas that are found occur in sun-exposed areas. And we know that in men that is usually on the upper back, certainly on the head and the neck. And in women, it's those same areas, but also they're more likely to have a melanoma diagnosed on their lower extremities, or their legs, also.

[00:02:46] Host Amber Smith: Are all races affected by melanoma, or do darker skinned people, are they protected from melanoma?

[00:02:54] Daniel Thomas, MD: We've shown that by looking back throughout history, that the highest risk of having a melanoma are lighter skinned patients, usually, most commonly of northern European descent that are then exposed to a lot of sunlight.

So we know that the, for example, people in Australia, in New Zealand have one of the highest incidents of melanoma, because much of the population is of northern European descent and then moved to an area with a lot of sun that they're exposed to. So that's, kind of a good instance of the risk of melanoma from sunlight, or UV rays. And so it does affect all races. However, lighter skin, fair hair are more prone to having a melanoma from sun exposure.

[00:03:54] Host Amber Smith: Are there any other risk factors, besides being fair-skinned, that put a person at risk for melanoma?

[00:04:00] Daniel Thomas, MD: Well, we know that it's things like having a family history of melanoma in your first degree relatives. Other things like having a lot of moles on your body. And that's just because many melanomas first were moles that developed into a melanoma. So just having more moles increases your risk of having it. But the, like I said, the main risk factor is the UV rays, causing damage to these melanocytes, which eventually develop into melanoma.

[00:04:38] Host Amber Smith: Sun protection includes the best way that we would recommend is covering up, clothing, which can be difficult at times, certainly in recreation during the summer months. So we do certainly recommend using hats and shirts when able, however, sunscreen when you can't do that. We generally recommend an SPF (sun protection factor) of 50, however, some people are OK recommending an SPF of 30. It's important to make sure you have it on you reapply. It's not a perfect prevention. So even with sunscreen, your skin is exposed to those UV rays, but it is definitely something that is very helpful.

[00:05:27] Daniel Thomas, MD: We know -- going back to the risk factors -- with sun exposure, we have shown through some good data that even as few as two or three sunburns, blistering sunburns, in childhood or adolescence can increase your risk of having a melanoma later in life. It's something that we call, or we think of as a cumulative sun exposure. So even exposure early in life, decades down the line, can increase the risk of all skin cancers, which are squamous cell carcinoma, basal cell carcinoma and melanoma, melanoma being the most worrisome and most difficult to treat.

So even children who get sunburned can have an increased risk. So that's why early in life, protection from the sun is also important.

[00:06:27] Host Amber Smith: So it sounds like most melanomas appear in older adults, not children, and because it's a cumulative thing, right?

[00:06:35] Daniel Thomas, MD: Right. Yes, exactly. And even saying older adults ... we're seeing it now in younger adults, women in their late 20s. It's the most common cancer of women in their late 20s, 25 to 29. It's the second most common cancer in women -- this is in the United States -- of women age 30 to 35 after breast cancer being the most prevalent. And melanoma comes in No. 2.

And so yes, it increases later in life. But, even for patients that I don't consider too much older, in their 20s and 30s, have a significant risk. It's something certainly to look out for.

[00:07:24] Host Amber Smith: Is that tied to tanning salons?

[00:07:28] Daniel Thomas, MD: We think it is. You know, the data that showed that are in the last decade or so, and we know that tanning beds really hit their height in the 90s and 2000s. And so what I think we're seeing, certainly in the United States, is some of that now coming into play and not just tanning beds, but just the predilection for younger women to sunbathe, as well. So yes, I think that is what we're seeing there.

[00:07:55] Host Amber Smith: So do we know what makes melanoma develop? Why does it choose someone at age 20 and another person at age 70? Is there something else intrinsic in the body that makes it go into melanoma?

[00:08:10] Daniel Thomas, MD: We don't know. We don't have a great grasp on why somebody in their 20s with only a decade's worth of sun exposure would get a melanoma when somebody who lived into their 80s with lots of sun exposure, never had a melanoma.

I like to think of it as a similar situation where somebody who never smoked in their life gets a lung cancer at age 40, but then there's somebody who's in their 80s and smoked their entire life and never had a lung cancer. We don't have a perfect prediction tool of who's going to get it.

Like I said, having more moles and having fairer skin, that is more likely, the UVA rays are more likely to damage these melanocytes and cause a melanoma.

[00:09:02] Host Amber Smith: So let's talk about how melanomas are diagnosed. What do they usually look like?

[00:09:07] Daniel Thomas, MD: Most melanomas are diagnosed either by primary care doctors or dermatologists. And really what they are looking for are what we call the A B C D E rule. And so that's looking at a specific pigmented or dark mole and assessing the characteristics of how it works.

And our A B C D E rule is that the mole is Asymmetrical, or it's not a perfect circle or oval. And B is the Border; if it has what we call irregular borders, and that's if the edges of it aren't kind of confined, it can jut out and have kind of finger-like projections on it. The C is Color; if a mole has more than one different color, often if it's a melanoma it will be a light brown or maybe a medium brown mole that has an area or two within the mole itself that is much darker, darker brown, or even black. And then the D is for Diameter; most moles are within the size of about the end of an eraser tip on a pencil, which is about five to six millimeters, and so when they get larger than that, even in the absence of some of the other characteristics, it's something that many primary care doctors or dermatologists will just keep a close eye on, if not biopsy. And then the E is Evolution, which means that you had this mole, you know it was there, it's been there for years, or maybe just a few months, but then you start to notice it changes, or evolves. And really any change over the course of months to a year or two is something that should probably be brought to attention, because most moles don't change over the course of that short time period. People can have moles their entire life that change over many years or decades, but when they change in a shorter interval, it's something to bring up.

And then the last one, and this one is important for people who have many moles, is what we call the "ugly duckling" sign. It's you have a lot of moles and this one that you just noticed doesn't look quite like the others, for one reason or another. People who have a lot of moles, they tend to all look similar and scattered throughout whichever part of their body. But if there's one that just doesn't look like the other, the ugly duckling sign, that's something you should probably bring up as well.

And so these are usually, like I mentioned, diagnosed by primary care doctors or dermatologists who are performing thorough skin exams and really keeping track of a patient's moles and skin lesions over the course of, many visits so that we can get a good idea of what is changing and what's just staying the same.

[00:12:11] Host Amber Smith: So if there's a suspicious mole and it gets biopsied and it's found to be a melanoma, can you tell from that biopsy whether the cancer has spread?

[00:12:23] Daniel Thomas, MD: The main treatment for melanoma and the prognosis of a melanoma is determined primarily by the depth of the melanoma. It starts on the skin. And most melanomas spread what we call laterally, or on the surface of the skin. And the majority of melanomas don't penetrate deeply down into the skin. And it's the deep penetration into the skin layers, through what we call the superficial is the epidermis, and followed by the dermis underneath it. It's when melanomas grow downward, or vertically, that we become more concerned.

And so we look at the depth of invasion in the number of millimeters. And we classify them as what we call a thin melanoma, which is less than one millimeter, and then an intermediate melanoma, which is two to four millimeters, and then a thick melanoma, which is greater than four millimeters. And that really determines how worried we are, and it determines the aggressiveness of the surgery that we're going to do.

We know that once we have found a melanoma, and it's been biopsied, and that gives us the depth of the melanoma, and then we stratify it into those three thin, intermediate, and thick categories. We know that melanomas, when they spread, the most common place they spread is to the lymph nodes. We have clusters of lymph nodes underneath our armpits, in our groins, many other places, on the head and neck, along the neck and underneath your jaw. And so the first way that we look to see if there's any spread is by feeling those lymph nodes. If you have a melanoma on your arm, the first place I'm going to feel, or palpate, during a physical exam is underneath your armpit to see if there's any enlarged or firm lymph nodes. That's the first test to see if it has spread.

And like I mentioned, the majority of melanomas that we diagnose are early, or thin or intermediate melanomas, and those have a lower risk of going to the lymph nodes. And so most patients are treated for their melanoma with what we call a wide local excision, which is just taking the skin around the melanoma, cutting it out with the whole layer of skin and some of the tissue below. And then that is the only treatment that most patients get for their melanoma.

Now, of course, if there is concern for lymph nodes or we do a special test called sentinel lymph node biopsy on some patients, then once the lymph nodes are involved or concerned to be involved, then we start talking about bigger surgeries that involve the lymph nodes.

[00:15:42] Host Amber Smith: Upstate's "HealthLink on Air" has to take a short break, but please stay tuned for more about melanoma with Dr. Daniel Thomas, a surgical oncologist at Upstate.

Welcome back to Upstate's "HealthLink on Air." I'm your host, Amber Smith. I'm talking with Dr. Daniel Thomas. He's a surgical oncologist at Upstate, and we've been talking about melanoma.

I know a lot of dermatologists remove many skin cancers. Does a surgeon like yourself get involved when it's melanoma, or how do you determine who sees the patient, the dermatologist, or the surgeon?

[00:16:18] Daniel Thomas, MD: The answer would be both of us, both the surgical oncologists and the dermatologist, because most melanomas are thin, and dermatologists do a great job of removing those with that wide local excision we talked about. And when it's thin like that, there's less concern for lymph nodes being involved, and the primary treatment is to remove it, and dermatologists do a great job of that.

However, when it starts to get thicker into the intermediate area, we start to talk about having to do a biopsy of the lymph nodes to confirm that there is no melanoma in the lymph nodes, and at least in the United States, dermatologists don't routinely perform that. And so that's when dermatologists reach out to the surgical oncologists, and then we kind of take over the care of that melanoma by removing the primary melanoma and testing the lymph nodes.

And so that is usually done once you get to what we think of as the intermediate melanomas like we talked about, and certainly some thin melanomas.We have a really great dermatology community in Syracuse and the surrounding areas, which I've been fortunate to work with, and many of them send their melanoma patients to us here at the Upstate Cancer Center, just as routine so that we can have a multidisciplinary approach to these patients and get more than just one opinion on the next step in treatment.

It's also common to be referred to somebody like myself, a surgical oncologist, to talk about the melanoma, even once it's been completely dealt with by the dermatologists. It's just, it's part of what we do in surveying these patients going forward, to make sure that they're well taken care of and there is no concern for a recurrence of a melanoma.

[00:18:23] Host Amber Smith: What are survival rates like for melanoma?

[00:18:26] Daniel Thomas, MD: The survival rates for melanoma certainly vary. The majority of patients are diagnosed at stage one and stage two. Stage one and stage two melanomas are the thin and intermediate melanomas that have not spread to any lymph nodes. And those patients have what we call melanoma specific survival, which is the likelihood of them dying from their melanoma cancer. And so in patients with stage one and stage two cancers, it ranges from 85 to 99%. Of course the lower number there, and the 80 to 85%, are patients with thicker melanomas, and so into that intermediate zone.

And somebody who has a thin melanoma, under one millimeter, and we don't have any concern for lymph nodes, they have a very, very good prognosis. Those are the people that we look at and say, you have 10 years down the line, there's a 95 to 97, 98% chance that you're not dealing with this melanoma, and we're just keeping a close eye on you, and you don't have much to worry about.

It's when the melanoma spreads to the lymph nodesthat we really start to see the melanoma specific survival numbers go down, and that can be into the 50s to 60s. When we look 10 years down the line, of course those numbers are changing because we're getting better and better therapies for melanoma. But it is still something, like we talked about at the beginning, it is still the most aggressive form of the skin cancers and something that we need to keep a very close eye on.

[00:20:14] Host Amber Smith: What about recurrence rates?

[00:20:16] Daniel Thomas, MD: The recurrence rates for melanoma are not very high when we talk about the thin and intermediate melanomas. Similar to the overall survival, you have a higher recurrence rate when you have it in your lymph nodes.

And so when we do a risk / benefit conversation with the patient. If we know that it's in your lymph nodes, through that biopsy that we sometimes do, the sentinel lymph node biopsy, If it's in your lymph nodes, we have a conversation about using what we call adjuvant treatment, or follow up treatment. We've done the surgery and we've removed all the visible melanoma that we can, but we know that you still have a higher than average risk for that to return. An adjuvant therapy helps to reduce that risk. And in melanoma, that is the mainstay of treatment, which has been groundbreaking in the last decade or so, is the use of immunotherapy.

And so that has been a huge help in helping those numbers that I talked about before in patients with spread to the lymph nodes, that has been a huge help in helping those patients overcome their melanoma and continue to have a great overall prognosis after they've been fully treated with surgery and the immunotherapy.

[00:21:48] Host Amber Smith: I imagine the thinner melanomas can be removed in an outpatient procedure or in a doctor's office, but do you ever have the more extensive cases that have to be done in the hospital where the patient ends up staying overnight?

[00:22:05] Daniel Thomas, MD: Yes. Most melanomas if they're removed in the office are done under local anesthesia, just numbing up the area nicely and removing it.

If the patient's referred to me, most of my operations I do in the operating room. And that's because I have to take for even some of the thin melanomas and certainly anything thicker than that, we have to remove the skin for several centimeters below the superficial skin. And so we've found two things. One, the patient is certainly more comfortable. We use some anesthesia with our anesthesia colleagues, not to the point where you're completely asleep or having to have the anesthesiologist breathe for you with any tube in your lungs. But, it's just kind of like you go to sleep and wake up within a few minutes after we're done. And so it's more comfortable for the patient.

And secondly, some of these are in sensitive areas, so on the head, the neck, certainly on the arms and legs, it can be a little more tricky to do those operations. In order to do the full surgery and remove the melanoma and close the skin so that it heals nicely, it takes a little bit more surgery. And so we found that that works better in the operating room. And certainly if we have to do any procedures like the sentinel lymph node biopsy on the lymph nodes or a complete lymph node surgery, that should be done in the operating room.

Now that being said, the majority of patients that we see and do these operations go home the same day. This is usually a same-day surgery.

[00:23:57] Host Amber Smith: Are your patients concerned about scars?

[00:23:59] Daniel Thomas, MD: I certainly have patients who are concerned about scars. The main issue that we run into is melanomas on the head and neck. When you think about having the margin around the melanoma, or the area of healthy skin that we have to take around to make sure we get all the melanoma cancer cells, can be one to two centimeters. And that doesn't sound like a lot, but when it's in a sensitive area on the head, on the neck, or sometimes when it's on the arms or legs near the joints, that can be a little more difficult to remove that amount of skin and have it heal nicely. And so we certainly have patients who are concerned about their scars, and we work closely with our plastic surgery colleagues.

We have a specialized team here of head and neck surgeons, or ear, nose and throat surgeons who specialize in melanoma of the head and neck and do different types of what we call reconstructions or moving skin around, doing what we call flaps to improve the cosmetic outcome of these after surgery. So most patients I talk to say, "I, you know, I don't care what it looks like. I just want this gone." We want that as well, but we know that we can do both. We can reduce the cosmetic issues after surgery when it's carefully planned out and you have the right team involved.

[00:25:36] Host Amber Smith: Well, before we wrap up, I wanted to ask you about medical care and what that's like after melanoma treatment. Is there anything that you do or advise patients to do to reduce the risk of recurrence?

[00:25:50] Daniel Thomas, MD: When I think about follow up after melanoma, I think of things in two different buckets. The first would be we've completely removed the melanoma that we can see with a surgery. And the next step is to do two things.

One, talk about lowering the risk of this coming back. And that's done with usually immunotherapy, which is given by our medical oncology colleagues. And immunotherapy is a medical treatment that goes throughout your whole body. So it has similarities to chemotherapy in that it can treat a cancer cell wherever it is in your body but is much better tolerated than chemotherapy. It uses your body's own immune system to fight cancer cells wherever they are in your body. And so it ramps up your immune system to fight those cancer cells. And Melanoma has been one of the types of cancer that. Immunotherapy has taken the forefront of treatment because it works so well in melanoma, compared to some other cancers where it doesn't work as well.

And then the second thing, after you've had your treatment for your primary melanoma is to keep a close eye on you. And that is truly where it becomes a multidisciplinary approach because we follow patients every three to four months. And I follow the patients every three to four months to check up on the area where they had their surgery. Because one of the areas you can have a recurrence is in the scar around where we did surgery. And then I also keep a close eye on those lymph node basins that we talked about before by doing ultrasounds and palpating, or feeling, those lymph nodes for any concerning new lumps or bumps. And so that's my part of it.

And then we know, one thing I didn't quite say before, we know that if you have one melanoma, you are at an increased risk to have another one in your life. And so that's where our dermatology and primary care colleagues come in with thorough skin exams. Some people use different protocols, every three to six months after you've been diagnosed with melanoma. And it's very important to keep up with those because of that increased risk of having another melanoma. And so that's where I am in constant contact with our dermatology colleagues and primary care doctors to make sure we're all coordinated in keeping a close eye. And we do that for five years, where you get those really close examinations, and then we recommend after five years after your diagnosis, we keep a close eye on you yearly, and of course you have any new concerning moles, lumps or bumps that you feel, it's important to reach out to us.

We always want to hear from a patient with any concerns because they know their body best. They know when something changes better than us checking in every three to six months. They're usually the first person to truly pick it up, or a loved one.

[00:29:08] Host Amber Smith: Well, Dr. Thomas, thank you so much for making time to explain so much about melanoma.

[00:29:13] Daniel Thomas, MD: Great. Thank you so much. It's been wonderful. Thank you for having me.

[00:29:16] Host Amber Smith: My guest has been Dr. Daniel Thomas. He's an assistant professor of surgery at Upstate who specializes in complex general surgical oncology. I'm Amber Smith for Upstate's "HealthLink on Air."

How germy are ATM machines? Next on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Have you ever wondered about how many germs live on surfaces like countertops, shopping cart handles, TV remote controls? My guest today took a scientific look at the presence of pathogens (disease-causing agents) on ATM machines.

Dr. Joe Domachowske is a professor of pediatrics and also of microbiology and immunology at Upstate, and he specializes in pediatric infectious disease.

Welcome back to "HealthLink on Air," Dr. Domachowske.

[00:30:09] Joe Domachowske, MD: Thanks very much.

[00:30:10] Host Amber Smith: Where did the idea come from to examine ATM machine keypads for germs?

[00:30:16] Joe Domachowske, MD: It's not unusual for medical students or other trainees to come to me and say, "Do you have a project that I can help out with?"

This was one of those projects that I had in the back of my mind for a couple years, even before COVID, and I thought, we have the machinery now to do this instrumentation, and we should really go for it. So the collection of students and trainees got together and made a plan, and that's how it all happened.

[00:30:40] Host Amber Smith: What did you think you might find?

[00:30:41] Joe Domachowske, MD: I was very skeptical, mostly because we started in January of last year, and we wanted to go a full calendar year. And of course it's not that long ago that all of us remember that that was sort of the peak of the Omicron wave coming through Central New York of COVID.

And so, given how careful everyone was being about cleaning and disinfecting and sanitizing, I really thought we'd be hard pressed to find a lot. But I figured we'd find something.

[00:31:11] Host Amber Smith: Interesting. So how did you go about collecting samples?

[00:31:17] Joe Domachowske, MD: The students and the other trainees got together and made a schedule of sorts, and they would be assigned certain days of the week to go to the ATMs and do the swabs.

They would take the swabs, and they would wet them with the transport media for the pathogens, for the organisms, and just have them damp, and then they would just rub it across the keypad of the ATM, put it back into the tube containing the rest of the solution, and then they would bring it back to the lab, and we'd do the PCR testing, the molecular testing, on the sample.

[00:31:51] Host Amber Smith: So, was this more than one ATM machine, and where was it located? Indoors or out?

[00:31:57] Joe Domachowske, MD: This was an indoor ATM machine that was a convenient location for us to access. The bank itself asked us to not disclose where it was, because we could do this anywhere and probably find the same thing, but they don't want to be identified specifically.

[00:32:10] Host Amber Smith: Well, let me ask you a little bit more about, you said PCR. Can you explain the difference between traditional culture techniques and the molecular type of testing that you did and the relevance of using the molecular test for this study?

[00:32:24] Joe Domachowske, MD: Molecular testing is done much more commonly now, even for human diagnostic testing.

For example, COVID PCR from a nasal swab, that's PCR, that's a molecular test. It's not a specific test that takes the sample from the person and tries to culture the virus itself in the laboratory.

And the reasons that things have swung toward molecular testing include that it's much more efficient. It's much more sensitive because what we're looking for with molecular testing is fragments, or pieces, of the germs' DNA or genetics in general. We can find even one copy of a piece of DNA or RNA that's been pretty much chopped up, but we amplify it artificially with these instruments in the laboratory.

If we're looking for culture, things get really complicated, especially with trying to do cultures of viruses. Every virus prefers a different type of cell to replicate in and get growing, so we'd have to have all sorts of different cell types. These are cancer cells that generally support different viruses to grow. They've been used in classic virology for a long time, but then some also like the cells to be supplemented with other types of very expensive supplements, essentially. And so we'd have to design a study that was really extremely expensive and time consuming to pick up all of the possible viruses and bacteria that we were looking for.

[00:33:55] Host Amber Smith: If this molecular testing gives you, like, remnants of the pathogens or whatever, say you go in, and you take a sample at noon, are you looking at all of the germs that joined that ATM machine in the last 10 hours or last 12 hours, or how far back would it go?

[00:34:12] Joe Domachowske, MD: Well, theoretically it would go back really as far as the detection of those genetic fragments could exist. That really goes back to the previous time there was really pretty rough sanitization of the instrument, or the "fomite," itself. Bleach, in particular, is really good at degrading RNA and DNA and getting rid of it. And we were at a period of time when that was being done, extremely carefully, on a regular basis.

And so I was wondering, are we going to really find much? And we did, as you know.

[00:34:45] Host Amber Smith: Well, in the 12-month period that you studied, January 2022 to 2023, how many samples were collected?

[00:34:53] Joe Domachowske, MD: We collected 234 samples from the same ATM keypad. And it was collecting them over the course of the year so that we could look over the full year, not just during cold and flu season, because one of the limitations of similar types of studies looking at different fomites were that they were only done during the outbreak of influenza or during a wave of COVID, for example.

And so they were sort of designed specifically to find a certain pathogen based on what was going on in the community, but we wanted to do it year-round, for a full calendar year. Of those 234 swabs that were taken, 36 of them, about 15%, were positive for either a bacterium or one of several different viruses.

[00:35:38] Host Amber Smith: What were the most prevalent germs or viruses or bacteria that you found?

[00:35:44] Joe Domachowske, MD: Well, not unexpectedly, the single most commonly detected pathogen was SARS-CoV-2, which is the agent of COVID-19. Nine of our positive samples were that agent itself, but it's not well appreciated that there are several other coronaviruses that are common causes of just mild upper respiratory infections, like a common cold. We found five of those, four of one kind and one of another. So as a group, that was the most common pathogen group that we detected.

The second biggest group detected were the adenoviruses. These viruses predominantly cause respiratory illnesses, but in young children, they can cause prolonged high fevers without much in the way of other symptoms.

They're very, very common, and they're also very stable in the environment because a characteristic of their virology is they don't have this envelope, sort of, around them. They have this sturdy "capsid" (a protein shell) that's kind of hard to get rid of. They're fairly stubborn in the environment, so it wasn't a big surprise. We found 13 of those.

And then the biggest surprise was we had five positive molecular tests, which were backed up with cultures. So all five of them also grew in culture for a bacterium called Bordetella parapertussis. This is a cousin of the bacterium that causes whooping cough. And it can cause a nasty cough illness in anyone at any age. We don't have a vaccine for it. But that was a surprise. It hasn't been described before from a fomite, so we were interested in that finding. And we did have a couple RSVs (respiratory syncytial viruses) that we picked up, and then a smattering of one or two of several other common viruses that cause respiratory illnesses.

[00:37:29] Host Amber Smith: The word "Bordetella": I hear that when I go to the veterinarian's office. Is that the same disease that dogs might get when they're put in, like, doggy day care with other dogs?

[00:37:38] Joe Domachowske, MD: Very close. Bordetella bronchiceptica is the cause of kennel cough, which is a veterinary pathogen infecting largely the dogs.

We even have a vaccine that's given to dogs to prevent it because it can cause such serious illness in the canines. Bordetella parapertussis is a human pathogen, but it's sort of a "pathogen lite" compared to its more famous cousin, Bordetella pertussis, which is the cause of whooping cough.

[00:38:07] Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Joe Domachowske about a study he oversaw looking at the germs on ATM machines.

Now, I learned a new word: "fomite." So that's something that's likely to carry infection? Is that how you would define it?

[00:38:25] Joe Domachowske, MD: Any fomite certainly could carry infection, but fomites in general are any inanimate objects that are found in the environment, so doorknobs, ATM keypads, books, pencils, bedding, clothing, really anything that's inanimate that potentially could get exposed to or contaminated with human secretions of any kind. And if those secretions have pathogens or germs on them, they can kind of hang out for a while and someone else comes along and is unaware, happens to touch it and then touch their eyes or their nose or their mouth, they could potentially inoculate themselves.

[00:39:05] Host Amber Smith: Do you think there are people in our community who were exposed to germs or got sick from those germs after using the ATM machine after someone who was infected?

[00:39:16] Joe Domachowske, MD: This is the controversial part of the description of the science that we laid out.

And that's because it's hard to prove something like that. But the part of our study that differed from most other research done on fomites is that we backed up every single positive PCR molecular test with culture.We did not do cultures on everything, because it would've been very time consuming and probably too expensive to afford.

But any positives that we had, we picked the culture techniques that would optimize recovery of that particular agent, and we were able to recover 75% of those 36 positives that we had. So, this suggests to me that there's replication-competent, viable pathogen on many of these swabs, and it wasn't just remnants of DNA or RNA that was already rendered non-infectious, either through drying or through alcohol wipes or whatever they're doing to sort of sanitize the keypads.

[00:40:21] Host Amber Smith: Assuming that some fomite or some kitchen counter or ATM surface is not sanitized, how easy is it for germs from a cough or a sneeze to live there and then transfer onto the hands of another person or into the eyes or mouth? Is it an easy task for that pathogen to live?

[00:40:43] Joe Domachowske, MD: It's not. It's actually quite stressful, and most agents won't survive in the environment at those temperatures lower than body temperature in a replication-capable manner for more than a couple of hours, with some exceptions. And it also depends on how much, let's call it "juice," comes with it. If it's a cough or a sneeze from really microscopic aerosols, then it's probably not going to hang around long. They'll evaporate and dry, and these agents do not like to be dry. They die very quickly.

But if the contamination happens where there's some mucus involved, or it's from the hands after touching the nose or the mouth or the eyes, and they get contaminated with some mucus and some body fluid, even though you can't see it anymore, if it's still there, can sort of protect those agents from environmental factors that will inactivate it.

So not more than a few hours for most of these things, but something like adenovirus can persist on surfaces even up to two or three days.

[00:41:45] Host Amber Smith: I'm assuming we know this because there's other similar studies that have been done about pathogens living on inanimate objects.

Is that right?

[00:41:54] Joe Domachowske, MD: That's true. And most of that work has been done in hospital settings or long-term care facility settings, some of it artificially, where countertops are exposed to known amounts of certain pathogens, and then recovery at different time periods after that are attempted.

But sometimes the studies involve similar methods that we used, where the countertops or the higher-risk, frequently touched areas are checked for these agents. And if they are found to be present by molecular methods, there may be an attempt to see if it's viable agents that are there, and this really has changed the way we disinfect things in places like hospitals, where there is very, very aggressive disinfection, especially when something like COVID is going through the community. I kind of read through some of the COVID experiments where in hospital settings, scientists were looking for SARS-COV-2 in patients' rooms or nearby their rooms.

And when they could detect it by molecular methods, but they could not get it to grow in culture, they argued that we don't have to worry about fomites transmitting SARS-CoV-2, but the part that I think they missed was that it's an artificial setting because it's so intensely cleaned all the time, repeatedly, and so there may be residual bleach or other sanitizing agents on the counter.

And yeah, we can detect some of the RNA from the COVID that the patient has and has contaminated their

So, that's very different than if we talk about an elementary school countertop next to a sink or an elementary school bathroom or ATM machine that's just getting a lot of traffic all day long without being cleaned every time, in between every use.

[00:43:44] Host Amber Smith: Well, what do you think is the takeaway from your study?

[00:43:47] Joe Domachowske, MD: I think we have to be careful about fomite transmission in our community, not just for SARS-CoV-2. That was obviously the top one on our list, but we did this study during the Omicron surge, so just by definition, we'd expect it to be the most common one we detected.

It was the most common thing going around in the general community in adults at the time. So we have to be careful, and I looked to some of these studies done in elementary schools looking for influenza or looking for pathogens that intend to target the young children even more, like RSV, as far as that age group goes, and we would find it.

And we just have to be careful about maintaining some level of care in sanitizing these frequently used areas, especially if multiple people are going back and forth and touching it on a regular basis during the day. And that's common sense.

And to me, that's just like "wash your hands," right, as much as you can. but with the hospital-based studies coming out about COVID-19 not being able to be grown from these swabs that detect the RNA, there's now this cluster of scientists that think we're overemphasizing the risk of fomites, and I think that they're probably overstating the results that they found, forgetting the type of environment that they were trying to culture the agent from.

[00:45:11] Host Amber Smith: Well, before we wrap up, I'd like to talk about the sensible precautions we can take to reduce the chance, aside from washing our hands, are there best practices for using an ATM? If I go in there, and I know this is a fomite, and I want to keep myself safe, what should I do?

[00:45:31] Joe Domachowske, MD: Well, as far as I'm aware, there are not very many touch-free ATMs around. You still have to touch it. There's not the voice-activated kinds of things that we've switched to for other related kinds of tasks. But just be careful and wash your hands or use hand sanitizer before, do your thing, and then (use hand sanitizer again) after. You could even carry some gloves and put the gloves on and press the buttons with your gloved hand.

I remember coming back to work at the hospital when things were starting to open back up again (during the pandemic), and we were starting to see more and more sick patients in the hospital, just in general, after a long period of time where we didn't see a lot of sick kids, and just walking in and going into the elevator thinking, "OK, how do I do this without the possibility of touching something and not getting to clean my hands right away?" And I would just cover my hand with my sleeve of my coat and hit the button that way. So there there are ways to do it, but I think just having one of those tiny little pocket hand sanitizers handy is always a good idea.

[00:46:37] Host Amber Smith: So, I think a lot of people were introduced to hand sanitizers during the pandemic, but obviously they work against things other than the coronavirus.

[00:46:47] Joe Domachowske, MD: Yes, absolutely. And they're highly effective against most of those agents, but not all infecting agents are inactivated by alcohols or related substances. They really do have to have that envelope part if they're a virus in order to be inactivated. Those adenoviruses, they're so sturdy, they will resist standard concentrations of alcohol.

They are inactivated by bleach, but not by other cleaning agents that we typically would use.

[00:47:14] Host Amber Smith: So, I'm not going to be washing my hands in bleach. Does soap and water do the job or no?

[00:47:19] Joe Domachowske, MD: Absolutely. Soap and water is great for absolutely all of it. It not only eliminates most of the pathogens from your hands or bacteria from your hands, but even for the ones that can persist in the environment because they're not inactivated, just the physical action of washing and rinsing your hands off with the water reduces the amount that's on your hands already.

[00:47:42] Host Amber Smith: That's really good to know. Dr. Domachowske, thanks so much for making time to tell us about your work.

[00:47:47] Joe Domachowske, MD: It's my pleasure. Thanks.

[00:47:49] Amber Smith: My guest has been Upstate professor of pediatrics and microbiology and immunology Dr. Joe Domachowske. I'm Amber Smith for Upstate's "HealthLink on Air."

[00:47:57] Host Amber Smith: And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

[00:47:58] Deirdre Neilen, PhD: Marilyn McVicker has published several books of poetry and nonfiction. The poem she sent us deftlyseparates good doctors from poor doctors. She reminds patients to speak up and not settle for less than a caring professional. Here is "Doctors."

I breathe, review my notes,

while the clock ticks the minutes,

weeks, years of illness, decanted

into a 20-minute appointment.

I have driven so many miles.

Will she listen?

Will she walk in with a smile?

I have had so many doctors wear

their impertinence like stethoscopes.

"Well, you certainly don't look sick."

"Your diagnosis is too complicated."

"There's nothing I can do to help you."

This poem is not for all those smirking

frenzied physicians, who push judgment

and peddle fear.

This poem is for the doctor who pulled up

a chair, made eye contact, listened. This poem

is for the doctor who ventured from behind

the computer, listened, asked intelligent questions.

This poem is for the doctor who did not

reflexively grab the prescription pad,

realized I needed medical care, admitted

he couldn't help, found someone who could.

This poem is for the doctor who worked

to find the right diagnosis, taught me to give

my own injections, started home infusions,

called each week to check in.

This poem is for the doctor who understood

his partnership was more important than healing

that would never come.

[00:49:43] Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air," learn how the Upstate Cancer Center is set up to assist families. If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at HealthLinkonAir.Org. Upstate's "HealthLink on Air" is produced by Jim Howe with sound engineering by Bill Broeckel. This is your host, Amber Smith, thanking you for listening.