Robotic surgery for cancer; Zika, dengue update; quelling workplace violence: Upstate's HealthLink on Air for Sunday, April 21, 2024

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a chest surgeon explains why minimally invasive surgery is best for early-stage lung cancers. ...

Jason Wallen, MD: The incisions are smaller, which generally means that they hurt less. There's less damage to bones, so less cracking or cutting of bone involved. In fact, in most minimally invasive surgeries, there's none of that. And so you see faster recoveries. ...

Host Amber Smith: We'll get an update on efforts to prevent tropical diseases that are showing up in the U.S.

Stephen Thomas, MD: ... They're transmitted by mosquitoes. So Zika is transmitted by the Aedes aegypti mosquito, and that's the primary mosquito that transmits the dengue viruses. ...

Host Amber Smith: And we'll learn how hospital and health care groups are joining forces to support health care workers.

Jerry Santoferrara: ... The support from our district attorney really does represent a monumental step toward raising awareness and implementing essential changes to really enhance the safety of staff and everyone involved. ...

Host Amber Smith: All that, and a visit from The Healing Muse, right 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 explore the work underway for dengue and Zika virus vaccines. Then we will learn about a campaign to support health care workers. But first, 100% of surgery for early stage lung cancer at Upstate is minimally invasive, and we'll hear why this is good news for patients.

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

Cancer centers across the country do minimally invasive surgical procedures for people with early-stage lung cancers almost 89% of the time, but in Syracuse at the Upstate Cancer Center. It's 100% of the time.

Today I'll talk with Dr. Jason Wallen about why this is good news for patients. He's the medical director of the Lung Cancer and Thoracic Oncology Program at Upstate.

Host Amber Smith: Welcome back to "HealthLink on Air," Dr. Wallen.

Jason Wallen, MD: Thanks, Amber.

Host Amber Smith: Lung cancer accounts for about one in five cancer deaths, making it the deadliest cancer.

Is it true that if it's caught early, it can be cured?

Jason Wallen, MD: It's absolutely true. In fact, we utilize our lung cancer screening program, so we can catch more of these cancers earlier, so we can cure more people.

Host Amber Smith: Can you tell us about the various stages and what they mean?

Jason Wallen, MD: All cancers are staged with similar characteristics. Usually, a Stage 1 cancer is a small tumor, and it's only where it began. A Stage 4 cancer tends to have spread to other parts of the body. Stage 2 and 3 cancers usually are bigger tumors, or maybe lymph nodes are involved, or, maybe even both of those things.

And we use those stages to determine what are the appropriate treatments for any given patient.

Host Amber Smith: Now, there's different types of lung cancers, but the majority are the non-small cell. Is that right?

Jason Wallen, MD: That's right. About 70% of lung cancers are qualified as a non-small cell lung carcinoma. And those are the ones that usually people are talking about when they say, "I have lung cancer," or "I know somebody who has lung cancer."

Host Amber Smith: And what percent of those are smokers or former smokers?

Jason Wallen, MD: The vast majority are patients who have smoked at least some point in their life.

Host Amber Smith: So can you explain what happens when someone is first diagnosed with non-small cell lung cancer?

Jason Wallen, MD: The most important thing to figure out after somebody is diagnosed with any kind of a cancer is to figure out the stage number, because, like I said, it's very important to understand what the stage is so that we can figure out what are the reasonable treatment options for somebody.

And so that can mean additional X-rays, sometimes it might mean additional biopsies or procedures to firm up, as much as possible, what that stage number is.

Host Amber Smith: So is this a fast-moving cancer, where things are going to happen very quickly, the treatment ideas, and making a decision on what to do? Or do you have some time to kind of plan things out more?

Jason Wallen, MD: It's an interesting question. I always tell patients that if you had to pick a cancer to get, this is probably not one of the ones that you would choose. But that being said, there are varieties that can be quite aggressive, and there are other varieties that are much less aggressive and can take very long periods of time to progress.

But the most important thing to remember is cancer is never an emergency. Whenever we diagnose cancer, even the aggressive ones take several months to get to the point where we can even see them, and maybe even years. And so, what generally happens over the next few weeks as we're trying to understand somebody's diagnosis and stage is probably not what's having the most impact on how they're eventually going to do.

Host Amber Smith: So if someone is recommended for surgery, and that's usually what's recommended, right?

Jason Wallen, MD: For an early-stage lung cancer, you definitely want to be in the group of folks who's going to be offered an operation. That doesn't mean it's the only way to cure somebody, and it's not necessarily the best treatment for everybody, but if there are multiple options for a given patient, and surgery is included in one of those options, you probably want to be in the group that gets the surgery.

Host Amber Smith: So why is minimally invasive surgery preferred for someone with Stage 1 lung cancer over ... did it used to be an open surgery?

Jason Wallen, MD: Yeah, over the last 20 years or so, there's been a transition from patients getting, as you mentioned, quote-unquote open surgery.

People have lots of words for this. I hear people talking about cracking the chest or cracking the ribs or other, sort of brutal, terms, which we certainly try to avoid. And, happily, over these last 20 years, the number of surgeries that are done in that way have decreased dramatically. And that's come through the advancement in minimally invasive techniques, and, more recently, robotic surgery, which is a form of minimally invasive surgery.

And it's better for patients because the The incisions are smaller, which generally means that they hurt less. There's less damage to bones, so less cracking or cutting of bone involved. In fact, in most minimally invasive surgeries, there's none of that.

And so you see faster recoveries, less use of narcotics, which many people are concerned about these days. You see shorter hospital stays and, even more importantly, fewer complications. So we definitely want to be doing as much minimally invasive surgery as possible.

Host Amber Smith: Does surgery sometimes replace chemotherapy or radiation?

Can lung cancer be treated with just surgery sometimes?

Jason Wallen, MD: Absolutely. In fact, in Stage 1 lung cancer, generally speaking, surgery is the mainstay of treatment. There are different types of treatments, as you mentioned, and oftentimes we use surgery and radiation somewhat interchangeably. Those are both what we call local therapies, and what I mean by that is those are treatments that only work at what you point them at. Radiation is somewhat like a ray gun. If you point the radiation at a target, then it hits the target.

Surgery doesn't have a ray gun, but it does have a scalpel, and so surgery only works at where you cut. Other treatments, like chemotherapy, are what we call systemic. They go everywhere. And so you don't point them at anything. You hope they find the cancer, wherever it's hiding. And so those are better when you might not know where the cancer is.

And so sometimes radiation can be exchanged for surgery, and there can be various reasons to do that.

Host Amber Smith: When you're doing a minimally invasive surgery, are those done with robotic assistance?

Jason Wallen, MD: At Upstate, all of the lung cancer surgeries are done minimally invasively, with robotic assistance.

Certainly you can do them without that, and years ago, we did many surgeries in that way, but the current standard at University Hospital is 100% robotics.

Host Amber Smith: Do you know if cancer centers across the country, are they all moving toward this? Is this a goal?

Jason Wallen, MD: Definitely minimally invasive surgery is the goal.

And I think most cancer centers across the country are adopting minimally invasive surgery. There certainly are places where open surgery is still done. And there are certain places where open surgery sometimes is the preferred option if people have particularly advanced cancers or cancers in difficult locations.

But as we get better at robotic surgery and minimally invasive surgery, some of those complex surgeries, fewer and fewer of them are done open. But there still are certain things that have to be done that way. But every day, there seems to be fewer and fewer of those as the technology improves.

Host Amber Smith: So for the more advanced cancer, say Stage 2 or 3, if surgery's offered, it might not be minimally invasive. Is that right?

Jason Wallen, MD: That is more possible. At Upstate, the vast majority of lung lobectomies that are done for lung cancers in Stage 2 and Stage 3 are also done minimally invasively.

Host Amber Smith: You used the term "lobectomy." Can you define that?

Jason Wallen, MD: Most people know that we have two lungs. You have a right and the left.

Less people know that the lungs are divided into lobes. And we have five of those. You've got three on the right and two on the left. And they're all different sizes, and lung cancers can end up in any of the five lobes. And so sometimes we remove an entire lobe, and sometimes we do other operations to remove the lung cancers.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking about minimally invasive surgery for lung cancer with Dr. Jason Wallen.

As the surgeon, is your goal to remove just the tumor or an entire lobe of the lung?

Jason Wallen, MD: So that depends on the situation. We generally don't remove only the tumor, and up until recently, the standard was to always remove the entire lobe of the lung where the cancer was.

Now we're doing increasing amounts of what we call sublobar resections, or less than a lobe. And so there are multiple other operations where we can do that and take out a little bit less lung and try to save some breathing capacity, and whether or not we can do that depends on the size and location of the tumor.

And sometimes it also depends on how much breathing capacity a patient has. For example, some patients have limited breathing capacity, and even though they might have a bigger tumor, we might still take out less than the lobe to try to save them that lung capacity.

Host Amber Smith: So if you're going to take out the entire lobe, how big is a lobe?

Jason Wallen, MD: They're all different.

Host Amber Smith: But they're not small. I mean, I'm just wondering, how do they fit through? If it's minimally invasive, how does a lobe fit through that little hole?

Jason Wallen, MD: It's a great question. We almost always have to make one of the incisions a little bit bigger to pull out the piece of lung with the tumor that we are removing. And the nice thing about lungs, though, is they're mostly filled with air, and so you can squeeze them down quite a bit to get them through a smaller incision.

Host Amber Smith: So what is the recovery like for the patient? Are they hospitalized afterward?

Jason Wallen, MD: Yeah, these are still inpatient surgeries, and so, in most cases, patients spend at least two or three days in hospital after a surgery like this. They can spend up to four or five days in hospital, in certain situations, and every once in a while people go home the next day, but there's no outpatient lung cancer surgery at Upstate right now.

Host Amber Smith: Is the patient's breathing noticeably different? Do they have trouble taking a deep breath after they've had a lobe of their lung removed?

Jason Wallen, MD: How much you notice what we remove really depends on how much you use what you've got. And that's something that's difficult to measure. So, it's a factor of how much lung capacity somebody has. But, if patients are very active, for example, if they're CrossFit instructors, then they're most likely to recognize that we removed something.

If they have more of a sedate lifestyle, like me, then they're less likely to notice the lung that we removed.

Host Amber Smith: How soon do they get back to that CrossFit training and the regular activity?

Jason Wallen, MD: People are up and around right away after surgery, but they're definitely not up for CrossFit for the first few weeks.

I would say for really vigorous physical activity, you're looking at least a month. We usually ask people not to drive for about two weeks. It's not because you can't get a car around the block, but because you might react a little differently if somebody pulled out suddenly in front of you.

Most people, it's better to avoid heavy lifting right away, because we've punched some holes through some important muscles that are used in lifting. You're not going to do any damage, but you'll probably regret it, so it's better to take it easy for about a month.

Host Amber Smith: Can you tell us about the most common complications and the rate of complications at Upstate?

Jason Wallen, MD: So the most common complications are pneumonia and air leaks, and every once in a while, people get irregular heartbeats after surgery. Those are all relatively easy to take care of, and Upstate has one of the lower complication rates in the country for all of these complications.

Host Amber Smith: How is overall quality measured for lung cancer treatment at a cancer center? And how does Upstate fare?

Jason Wallen, MD: We submit data to the Society of Thoracic Surgeons' national database, which is a database that collects data across all the major thoracic surgical centers in the United States.

And, we are above average for our complication rates. We are amongst the top for our rates of minimally invasive surgery, and we have one of the lowest mortality rates in the country.

Host Amber Smith: So if someone had an early-stage lung cancer that was successfully treated, are they at risk for additional cancers?

Jason Wallen, MD: We really worry about subsequent lung cancers. Sometimes I think we worry more about subsequent lung cancers than we do about the original one coming back. And so it's very important to keep track of folks after they undergo surgery for lung cancer, with regular doctor's visits and often additional CT scans.

Host Amber Smith: So you're more concerned about another lung cancer, or you're also concerned about skin cancers and breast cancers and colon cancers? Is it both?

Jason Wallen, MD: It's very important for patients to do all of their recommended cancer screenings. For women, obviously, continuing to get their mammograms for breast cancer; for everybody, continuing to get their colonoscopies and evaluations for colon cancers and whatever other screenings are recommended by their doctors, based on their age and risk factors.

Lung cancer doesn't necessarily predispose people to that, but it's also very important not to lose sight of your other health maintenance just because you were treated for lung cancer and are going through that evaluation.

The surveillance for recurrent lung cancers is not good enough to pick up any of these other cancers. For example, just because you got a CT scan for your lung cancer doesn't mean you can skip your mammogram, even though they were in the same area of the body.

Host Amber Smith: So you have to be vigilant. So when you have a new patient with early-stage lung cancer, do they see an oncologist as well as a surgeon?

Jason Wallen, MD: Not typically. The oncologist is the doctor, most practically, who would administer things like chemotherapy or immunotherapy if that was indicated. But like we said, for a Stage 1 lung cancer, that usually is not indicated, and so you might end up only seeing your surgeon or radiation oncologist or whoever ends up being your treating doctor.

Host Amber Smith: So if you had the lung cancer treated surgically and then years later or months later, if it came back, if another lung cancer appeared, would surgery still be an option for that person a second time?

Jason Wallen, MD: It certainly can be. We have many patients who we've removed multiple lung cancers on. We've even had patients where we've diagnosed two simultaneous lung cancers and had to make complicated plans based on that.

But again, it really depends on how much lung you have to spare, because every time we remove a lung cancer, we have to remove some lung. And your breathing capacity is important enough that sometimes we will decide not to do surgery, because we can't spare the breathing.

Host Amber Smith: Well, I appreciate you making time for this interview, Dr. Wallen.

Jason Wallen, MD: Thanks for having me, Amber. It's been wonderful.

Host Amber Smith: My guest has been Dr. Jason Wallen. He's the medical director of the Lung Cancer and Thoracic Oncology Program at the Upstate Cancer Center. I'm Amber Smith for Upstate's "HealthLink on Air."

Tropical diseases are showing up in the U.S. --next, on Upstate's "HealthLink on Air."

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

It's important to be aware that some traditionally tropical diseases are being transmitted in the United States. Today we'll talk about the Zika and dengue viruses with Dr. Stephen Thomas. He's professor and chair of microbiology and immunology at Upstate, and also the director of the Upstate Global Health Institute.

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

Stephen Thomas, MD: Thank you, Amber. It's great to be back.

Host Amber Smith: Listeners may remember hearing from you frequently during the COVID pandemic, but you've worked extensively on vaccine development for other viruses, including Ebola and Zika. And before you came to Upstate, you spent 20 years in the U.S. Army Medical Corps at the Walter Reed Army Institute of Research.

Before we get into the dengue virus, let me ask you where things stand with a vaccine for Zika. And can you first remind us what the Zika virus is?

Stephen Thomas, MD: Sure. The dengue viruses and Zika virus are in the same family, so they're called flaviviruses, and yellow fever is in that family, and West Nile virus, which we've had a history of in New York, is also in that family, as is Japanese encephalitis virus.

And so, as you mentioned, most of these are located in tropical and subtropical climates. They're transmitted by mosquitoes. So Zika is transmitted by the Aedes aegypti mosquito, and that's the primary mosquito that transmits the dengue viruses.

Most people who get infected with Zika, they don't know it. Like a lot of viruses, people get infected, and they either don't get sick at all, or they get so mildly ill that it doesn't really interrupt their lives in any way.

But then there can be a percentage of people that, they get infected, and they do get sick. They get fever and headache and muscle pain, and they get fatigue. They can have a rash, or they can get these kind of red, inflamed eyes, bloodshot eyes. In a very small percentage of people, they can have some pretty significant neurologic problems that can result from infection, and this was one of the first signals that we saw back in the outbreaks in Latin America, back in, 2015, 2016. They can get something calledGuillain-Barré, which can be fatal. It can prevent you from being able to breathe on your own.

But the real public health burden of Zika were the infections that occurred in pregnant women who, they might not have become ill, but there was a relatively high rate of the fetus becoming infected and significantly damaged with -- it's a syndrome, so you can have multiple different types of findings, but they call it -- congenital Zika syndrome, one of which was microcephaly. And people may remember seeing these pictures of children from Brazil with very, very small heads and deformed heads and, of course, brains that had significant problems as a result. So that's Zika, and that's why it's really so important to us.

Host Amber Smith: We still don't have a vaccine, right, for Zika?

Stephen Thomas, MD: You are correct. So, like many things, when there's a problem, and it's right in your face, and when there's a fire going on, everyone scrambles, and everyone starts looking for water and sand and things of that nature. And then, when the raging fire becomes a small, little thing, they all forget and move on to the next problem.

Stephen Thomas, MD: The global scientific community and the global medical countermeasure development community, they were all rallied at one point, when this was all going on. I was still in the Department of Defense at that time, and we were very concerned because we have service members who deploy or are stationed all over the tropical and subtropical world, to include tens of thousands of women of childbearing age. And so we were very concerned and wanted to try to develop a vaccine, as did the U.S. NIH (National Institutes of Health), as did a number of pharmaceutical companies. And we advanced very fast, and we went very fast and got into human testing quickly. And it was because we had a lot of experience, similar experience, with other viruses that were like Zika. And we had technologies that were on the shelf that we could pull off those playbooks and modify them to meet the Zika need. But when things started to calm down, and the problems started to dissipate, then attentions went to other problems, and resources dried up, and things kind of paused.

Host Amber Smith: So is the work still being done to help pregnant women?

Stephen Thomas, MD: We had down in Brazil, in particular, thousands of children born to infected mothers and thousands of children who were affected either in very severe ways, like the way I mentioned, where it's clearly obvious, microcephaly is clearly obvious, but also in ways that were not obvious at the time of birth, but that have become obvious over time as the children have grown.

And so kids having significant neurologic problems or psychological problems, or they're having behavioral disorders or developmental delays or other issues that are not evident at the time, but they become evident over time. And so, the public health burden of Zika still very much exists in places that had large outbreaks. So they're still contending with that, with the issues from 2015, almost 10 years ago.

There is still, clearly, in places where Zika is possible, there's educational campaigns that go on, that talk to the risks of getting infected, especially if you're, pregnant.

I just came back from Thailand. I was in Thailand last week, up north, where they've had Zika before, and big, huge posters saying, "Look out for these mosquitoes and look out for Zika, especially if you're a woman of childbearing potential or pregnant."

And I have been to some meetings recently that have focused on Zika. So there is clearly attention coming back to Zika, that it is still a problem, it's still a problem that could explode at any moment, and we could run into the same issues we had a couple years ago, because we still don't have a specific treatment for Zika, and we still don't have a vaccine that can protect people, so the work that's being done is, some of the work, that is occurring in the laboratory and animal studies and things of that nature.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking with Dr. Stephen Thomas. We talked about efforts to protect people from the Zika virus, and now we're going to look at another mosquito-borne virus, dengue.

So let's talk about the efforts to create a dengue vaccine. You wrote about this recently for Forbes magazine. Can you remind us about what the dengue virus is?

Stephen Thomas, MD: Sure. There are four different dengue viruses, dengue 1, 2, 3 and 4. They're similar in many ways, but they're distinct enough that they get a different name for each of them. And they kind of behave differently. They behave differently in nature. They behave differently in mosquitoes. They behave differently in people.

And so, we need to develop treatments and prophylactics, like vaccines, for example, that can address each of the four different types of dengue virus.

We have been trying to work on developing a dengue vaccine for almost a century. This started in the early 1900s, people understanding that dengue was a problem. We had had very large outbreaks of dengue in the United States. Back in the late 1700s, we had tens of thousands of people along the Delaware River and Philadelphia get infected. It was a known entity.

And groups, especially the Department of Defense, because we had such a bad experience during World War II in the Pacific, the Department of Defense has been working on trying to create a dengue vaccine since the '50s.

Matter of fact, Albert Sabin, who became very famous because of the oral polio vaccine, he was a young officer in the Army working on dengue long before he worked on polio, which is interesting.

But there are three vaccines that really in the last 10 to 15 years have either been licensed for use, or they are in advanced clinical development.

Sanofi Pasteur licensed the first vaccine, but the vaccine had a safety signal, especially in young children. The safety signal was in people that had never been infected with dengue before. When they got vaccinated, they had an increased risk of having a severe outcome if they did get infected after vaccination. And so it has a very limited indication, in terms of who can get it and under what circumstances. And so, as I wrote in the piece, it's kind of died of market neglect. It just has not been picked up quite a bit.

And then the most recent vaccine to be licensed was made by a Japanese pharmaceutical company called Takeda. And that does not have the same issues as Sanofi, in terms of safety, but it does have issues of its own in that it works against dengue 1 and 2, it does not work against dengue 3, and we really don't know if it works against dengue 4. So even though I think, my personal opinion is, it can deliver a public health benefit, it's not going to be all things to all people.

And then the third vaccine, which is in advanced development right now, was developed by the U.S. NIH, and then it was licensed to a Brazilian company called Butantan. And it was also licensed to Merck, which is now (called) MSD. And the company in Brazil, they're in the middle of a five year, very, very large trial, over 16,000 people. And the initial results from that are also positive in that it seems very safe. It seems to work against dengue 1 and 2, but we do not know if it works against dengue 3 or dengue 4, because there have not been enough dengue 3 or dengue 4 cases. So the study continues, and hopefully we'll have that information at some point.

But I think this is going to be one of those things where these vaccines are going to be able to deliver clinical benefit, but it's not going to be all things to all people. We're going to have to manage our expectations, and we're going to have to not let great be the enemy of good, and figure out how to best utilize these tools.

Host Amber Smith: So it sounds like as much as it would be ideal to have one vaccine that covered all four types of dengue, we may get four separate vaccines or fewer.

Stephen Thomas, MD: Yes. There are ministries of health and other public health authorities and regulatory authorities that make decisions of whether or not they're going to allow a country to license the vaccine and allow it to be marketed in that country.

They're going to have to make risk-benefit determinations, as long as they're safe, right? As long as they have proven that they can be safe, then they're going to have to think about, well, what viruses are most commonly being circulated in our community, or at least recently in our community, and which vaccine maybe is a better match for that.

And then there's also going to be practical considerations of how many doses of the vaccine is there? What kind of vaccine construct is it? Can it be used in pregnant people? Can it be used in immunocompromised people? What's the cost of the vaccine?

Like, all these kinds of things are going to play into it. The only vaccine that's been licensed in the United States is Sanofi's vaccine. But it can be used in very, very limited people; 9 to 16 years of age was the original approval, and you've got to be tested before you can use it.

The Takeda vaccine, was under consideration by the FDA (Food and Drug Administration), but they pulled it from consideration after long discussions with the FDA and at least what the company had in the lay press, that they were being asked for information that they weren't asked for previously. And so they didn't have that information, so they stopped pursuing a license in the U.S. They may come back; who knows?

But we now have dengue, and we've had, sporadically over the years, dengue in the United States. So we've had outbreaks, which have sickened hundreds of people, in Key West (Florida) and Hawaii. We've had sporadic cases in Southern California, Arizona, Texas. Last year alone, we had almost 180 cases of locally transmitted dengue in Florida. So, if the susceptible people are there, if the mosquitoes are there, all you need is for the virus to be introduced, and the fire can start, and things can take off.

So dengue countermeasures really need to be on the forefront of public health officials' mind for the United States because it's not a matter of if, but when, and I can tell you, having seen firsthand Zika outbreaks and dengue outbreaks, they stress even the most advanced and well-resourced public health systems, and they can kill people. They kill about 40,000 people a year, mostly children. And so I think it's something we need to take seriously, now, at home.

Host Amber Smith: Is there more than one type of dengue circulating in Florida? Like the cases from last year, were they all one type of dengue?

Stephen Thomas, MD: Typically what you see is you either see a single type, which predominates, sometimes you see two types, which predominate. You also have to distinguish, as you did, what is local versus what is travel related. Because if you look at travel-related cases, from 2010 to 2023 in the United States, we had over 10,000 travel-related cases of dengue, in the United States, which means 10,000 opportunities for a virus to be introduced into a new place. At some point your number comes up, right? And it starts to be locally transmitted.

Host Amber Smith: So does this spread from person to person?

Stephen Thomas, MD: No, it requires a mosquito. That's what happens the vast majority of the time. So, for example, somebody goes on a cruise to the Caribbean, they go to Puerto Rico, they go wherever. They get infected, they come back home, the virus is replicating. They get off the plane, the mosquito feeds on them. Now the mosquito has virus in it, and then it goes to feed on another person. And as it's feeding on that person, the virus gets into that next person, and now that person's infected, and then another mosquito can come and feed. And that's kind of the way that it plays out.

There are some very, very rare circumstances -- blood donation, organ donation, laboratory accidents, things of that nature -- but it's most predominantly with mosquito to human to mosquito to human.

Host Amber Smith: Are people ever screened for dengue or Zika when they're traveling to or from the U.S.?

Stephen Thomas, MD: No. Ideally, if you were going somewhere that dengue has circulated, or Zika has circulated, or any of the other viruses that we talked about, you'd go get a pre-travel consultation from a clinician, and they would explain to you how to protect yourself and if there was a vaccine available or not, or if there were medications you could take, et cetera.

And, in the same way, if you came back and you were ill, I mean, I would highly encourage people, if you come back from a trip and you have a fever, if you come back from anywhere in the tropical or subtropical world and you have fever, you should go to see a physician, because it could be something serious.

And then, during times when there are outbreaks, even if it's not in the U.S., if there are regional epidemics going on, or certainly a pandemic going on, then the FDA or others may decide to screen the blood supply. They might do that at that time, if it makes sense to do that.

But no, it's not routine that people would be screened. It would just be part of whatever routine wellness checks they're doing at airports, then that's what they would do. And they don't do much of that now. They do it in other countries where they don't want these viruses to be introduced.

They may have thermal cameras set up and things of that nature, but not in this country right now that I'm aware of.

Host Amber Smith: Upstate's "HealthLink on Air" has to take a short break. Please stay tuned for more about tropical mosquito-borne diseases with Upstate Global Health Institute Director Dr. Stephen Thomas.

Host Amber Smith: Welcome back to Upstate's "HealthLink on Air." This is your host, Amber Smith, continuing our conversation with Upstate's Dr. Stephen Thomas about mosquito-borne tropical diseases, specifically the dengue virus.

So if somebody had dengue and survived and got well, are they protected from getting dengue again or any of the other types of dengue?

Stephen Thomas, MD: The good news is that the vast, vast majority of people who get infected, they're going to have a mild to moderate form of the disease.

They're going to recover in about a week. They might have some prolonged period of fatigue and kind of the doldrums and not feel well for multiple weeks after that. But ultimately, everybody recovers, the vast majority of people recover. There are a small percentage of people who, if they have significant preexisting medical problems, that they can do poorly, and they can end up developing severe complications and die.

What's interesting with dengue, though, is, and it's something unique about dengue, is the people who end up doing poorly are most of the time people who are getting infected a second time with a different virus than they got infected with the first time. And it's usually when the time span between that first infection and second infection is 18 months or more. They call these secondary infections.

And so in people that have secondary infections, about 5% of them will develop severe disease. And severe disease is your blood vessels become leaky, and fluid that's in the blood vessels leaks out of the blood vessels. You can have problems with coagulation, so you can start to hemorrhage internally, like in the GI (gastrointestinal, or digestive) tract, for example. You can get buildup of fluid in your chest or in your abdomen. And all of this can contribute to developing shock. And what shock is, is when your organs are not getting enough blood, they're not getting enough oxygen, and then they start to shut down, and you go into something called multi-system organ failure, and that's what kills people. And that happens in about 5% of people that get these secondary infections; 5% doesn't sound like a lot, but they think on average, they estimate, there's about 400 million people a year who get infected and about a hundred million people a year who get sick.

It's the denominator that matters when you're talking about the percentages. And so, it does create, especially in low- and middle-income countries where dengue is endemic, it creates a huge resource issue, and it can create a huge public health issue, with hospitals just overflowing with patients during an epidemic. But in places that they know how to take care of dengue, the mortality rates can be less than 1%, well below 1%, but in places where they don't know how to take care of dengue, it can be as high as 20%, meaning one in five people will die.

And unfortunately, in 2023, there were thousands and thousands of deaths. And in 2024, we're also seeing deaths already. A young person in the place I was in Thailand last week, a very young person had died of dengue. So, it's a problem.

Host Amber Smith: It sounds like you definitely don't want to get it if you can avoid it or try to avoid it.

Stephen Thomas, MD: You absolutely do.

And to your question, once you get infected with -- this is what we believe to be the case, based on decades of, research -- once you get infected with one dengue type, you should be immune to that dengue type, at least for decades. The dogma is for the rest of your life, but at least for decades, you should not be able to get infected with that type again.

And so in places where there is a lot of dengue, and where there are multiple types of dengue circulating over time, most people, by the time they're 20, 25, they've already been infected twice. And we don't really see third infections or fourth infections that cause a problem, which kind of gives you targets, in terms of a vaccine, of the bar you need to exceed to be able to protect somebody through their life, and, through vaccination, advance them beyond that window of risk.

Host Amber Smith: So a vaccine would be one way to get at this. Is there any effort going into getting rid of the mosquitoes or making them where they can't transmit this?

Stephen Thomas, MD: They've tried a bunch of different ways to control the mosquitoes, to control how they breed. They've actually become quite well domesticated. They like to live in people's closets and in the houses and these kinds of things, because they like to be near their food source. Spraying and all these other things, they just really haven't worked well, and they're really expensive, and you need a lot of expertise, and you need just tons of people to be able to consistently do this.

And so even in places that are highly well resourced and highly controlled, like Singapore, for example, where they can show that they actually make a dent in the mosquito population, it doesn't necessarily translate into less human disease. What has happened now, and there's a couple of groups that are taking different approaches, I'll just mention one of them, but there are these new, innovative ways of trying to address mosquito populations.

One of those ways is there is a bacteria that can infect mosquitoes. It's called Wolbachia. It can infect lots of different things, but it infects mosquitoes. It infects the mosquito that transmits dengue. And what they observed was that when the mosquito is infected with this bacteria, it cannot get infected with dengue virus. And these infected mosquitoes can overpopulate and push out uninfected mosquitoes.

So what they have done is they have manufactured, in these farms, millions of infected mosquitoes that they can release, then, into these areas. They will outcompete the uninfected mosquitoes, and now the predominant mosquito species is unable to get infected and unable to transmit. And they've started doing those experiments and releases in different parts of the world over the last five years or so. The data's coming out, and it's pretty compelling, and I think it could definitely be one of the tools, along with vaccination, for example, one of the tools in the toolbox to try to do something about this.

I think there's other genetically modified mosquitoes, and other approaches, but what I would say is, they're innovative, there's potential there, and I'm very interested in seeing the information because it really seems like there's something there.

Host Amber Smith: Well, considering climate change, do you think that there'll be any sort of a vaccine available before dengue becomes more of a problem in the United States than it is already?

Stephen Thomas, MD: Well, I think it already is a problem, to be honest with you. You don't even have to talk about climate change, necessarily, because just think of the ingredients. What do you need? You need mosquitoes, you need a virus, and you need susceptible people. So the, vast majority of the population is susceptible because they've never been infected before. There are billions of travelers around the globe every single year, including the United States, so there's billions of opportunities to introduce viruses into the country.

And the mosquito is here. And what makes the mosquito be able to be here is, it's the right temperature, the right amount of moisture and the right duration of the right temperature. And so if the temperature's going up, and if weather patterns are changing for whatever reason you believe they're changing, which we know that they are, then yeah, it creates this opportunity to establish dengue in the United States as an endemic disease, like it was at one point in time. So I think the vaccine and the treatment discussion is now, it's not when the fire has gotten so far out of control.

But again, maybe Takeda will come back to the FDA. I have no idea. And maybe Merck's development of the NIH vaccine, which I think all indicators are that it has the potential to be a very good vaccine, maybe they'll pursue licensure in the United States, and we'll have an option, even if it's not just here, it's an option for when you want to travel, when you want to go somewhere warm during the long Syracuse winters, because more than one traveler has come back to Syracuse with more than just a souvenir and a T-shirt. They've come back sick and end up needing to see the doctor, and it turns out that they have dengue. That is not a rare event. It happens all the time.

Host Amber Smith: Will the cold winters that we have in Central New York, will that protect us from getting these mosquitoes that are carrying dengue?

Stephen Thomas, MD: Well, it doesn't get cold enough in many parts of the Southern part of the country, where the mosquitoes would dissipate.

We do not have that mosquito up here. Different groups debate whether we do or we do not. I think the surveillance that the county has done over the last 10, 15, 20 years has shown that or has failed to show that that mosquito is up here. We've got ticks, we've got other problems of our own, but again, as it gets warmer, as the winters get warmer, as the winters get shorter, then there is the possibility for these mosquitoes to persist for longer durations of time and for their offspring to survive the winter. But the ecology plays a lot into this, and as that changes, then the calculus for human disease changes as well.

Host Amber Smith: Well, Dr. Thomas, once again, I appreciate you making time for this interview.

Thank you.

Stephen Thomas, MD: Thank you very much.

Host Amber Smith: My guest has been Dr. Stephen Thomas. He's professor and chair of microbiology and immunology at Upstate, and also the director of the Upstate Global Health Institute.

I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air," a campaign that supports health care workers.

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

We've seen news coverage of airline passengers flipping out on flight attendants, teachers who are assaulted in the classroom, health care workers who are attacked in the course of caring for patients. With incidents of violent, disrespectful, and disruptive behavior on the rise, Upstate leaders are responding.

Here to explain how are Frank Ferrante and Jerry Santoferrara. They're both workplace violence coordinators at Upstate.

Welcome to "HealthLink on Air," both of you.

Frank Ferrante: Thank you for having us.

Jerry Santoferrara: Yes, thank you.

Host Amber Smith: Let's talk about what "Respect and Heal" is. Mr. Santoferrara, can you explain how it came together?

Jerry Santoferrara: Sure. "Respect and Heal" is a collaborative effort of leaders from the hospitals and health systems across Central New York. Its aim is ensuring the safe and respectful treatment of health care workers, including support from the Onondaga County District Attorney Wiliam Fitzpatrick. Part of the platform actually addresses federal and state legislation that provides more penalties for those who knowingly and intentionally assault or intimidate hospital employees.

And then in the words of Dr. Corona himself, regarding the major themes, "All staff will be treated with respect. There will be zero-tolerance policy of any threat, and that any violence against frontline staff will be met with the full enforcement of the law."

Host Amber Smith: The Dr. Corona that you've mentioned is Dr. Robert Corona. He's the chief executive officer for Upstate University Hospital.

So when we say zero tolerance, what does that mean? What happens to a patient or their family member if they start getting pushy with staff?

Frank Ferrante: Well, you know, it's most important that our first intervention would always be to attempt to de-escalate, but to echo what Jerry was referring to with Dr. Corona's statement is that the violence is still not going to be tolerated. That we encourage our staff to, if they feel that they're unsafe, or if they are in danger, we are fortunate, we have our UPD (University Police Department) and public safety, and you leverage their resources from there.

There can be police reports filed, charges pressed -- that applies to both patients and visitors. Workplace violence is a significant issue in health care which refers right back to "Respect and Heal," and the involvement of the DA and addressing federal and state legislation to levy more penalties.

Our staff do not come to work to get hurt. They're here to provide high level patient quality care, and it's not going to be tolerated to be assaulted.

Host Amber Smith: Do you think the fact that multiple health organizations are banding together for a "Respect and Heal" campaign -- when these are normally competitors -- do you think that that signals this is a really important issue?

Jerry Santoferrara: Yes, absolutely. The situation you described is truly not limited to Upstate. It's a nationwide crisis. The collaboration of other organizations and the support from our district attorney really does represent a monumental step toward raising awareness and implementing essential changes to really enhance the safety of staff and everyone involved within the institution.

Host Amber Smith: Do you have a feel for how many health care workers have been harmed on the job recently, or how severe the injuries have been?

Jerry Santoferrara: Upstate does closely monitor the data to identify high risk areas. So far, we've been able to suss out the emergency department and psych(iatric) units where violence is most prevalent. Notably, nurses bear the brunt of these incidents, with a wide range of severity.

To provide comprehensive support, though, we do offer resources that address physical, emotional, and cognitive needs. The resources for these include, but are not limited to, our social worker, Lauren Angelone. She's a staff support social worker, specifically for instances of these sort of violent or aggressive approaches to assist with employee management and sort of being a liaison to other services, along with our employee assistance program, which aims to bridge the gap as well for necessary care.

Host Amber Smith: Well, Mr. Ferrante, looking beyond the person who gets injured on the job, let's lay out why this is a bigger issue than the threat of individual harm. Because I'm thinking about it is got to be really difficult for a doctor or a nurse or a technician to function, I mean, just even to think straight, if they're worried about being attacked.

Frank Ferrante: It's a justifiable right, when you're considering that this is a national issue. That's why one of the things we are emphasizing is really for staff, at this point, is that situational awareness. Upstate has made it the focus to ensure that the employees are provided a safe environment by addressing issues in real time and supporting staff. health care providers, they can be very, it can be task oriented, and it is essential that they take their time to familiarize themselves with their surroundings and positioning. This can sometimes be overlooked or challenging given the level of patient care required. But as health care workers, you know, our primary focus is providing care, but we should also remember to take those necessary measures, when appropriate, to keep themselves safe and as safe as possible. While we must always keep in mind that the only be behavior we can ever control is our own.

Host Amber Smith: That's true. So let me ask you if you can describe your role at Upstate. You're both, I know, workplace violence coordinators, but what do you do?

Jerry Santoferrara: So as workplace violence coordinators, we're responsible for running the data to identify trends in violent activity, along with developing interventions within interdisciplinary teams to reduce the risk of violence against staff. So basically, we review each reported assault. We meet with our mitigation committee weekly, comprised of providers, nursing leaders, nurse managers, ethics officials (and many others, to optimize care of the patient to assure that their needs are met, while also reducing the risk to the staff.

We also conduct rounds throughout the institution, assessing units for environmental risks, as well as getting essential feedback from the frontline staff regarding their concerns and perspectives.

So we try to make sure that we're a visible presence and as supportive as we can possibly be.

Host Amber Smith: Is there training, or lessons to be taught, that can help a health care provider, stay safe?

Frank Ferrante: Currently the hospital does offer, there is CPI, which is Crisis Prevention Intervention. There's CISM, which is Crisis Incident Stress Management. And they're all various levels of identifying risk and how do you manage them on a variety of different levels.

We are looking into whether there's other opportunities -- that's that feedback we're getting -- to see if there is additional training to be more specific to units, with the issues that they're actually encountering.

Host Amber Smith: Let me ask you -- because we know this is happening nationwide -- what is it that's making people more aggressive these days? Do you have some ideas?

Jerry Santoferrara: So as far as ideas are concerned about this, it's definitely challenging because people have speculated maybe some fatigue and challenges with longer wait times, short staffing, issues that maybe aren't necessarily a direct result of COVID, but things that have sort of contributed to bogging down of some of the systems.

And so being able to understand that -- however, at the same time firmly stand by our policy here, and not tolerate disrespect and unsafe behaviors -- we can have a sort of holistic approach. And as being able to validate and understand frustrations with some individuals and how care has maybe been impacted. But we really, we're struggling as far as the violence, right? Like we are, we're not condoning that, but understanding holistically that there are more things at play and frustrations, and it's just not easy.

Host Amber Smith: People maybe have complaints about having to wait a long time, because we're short staffed, or something along those lines. Do you find that explaining that to them helps, or not?

Jerry Santoferrara: Some people do understand, and they're very, very patient. And then others, not so much. It's a tough thing to kind of field, really. Because you do, you see people kind of feel bad for, and the patients will say, "Oh, you know, I didn't want to bother the nurses. I feel bad because I see how busy people are." And so it really just depends on the person and their level of awareness and their tolerance and their patience.

Host Amber Smith: Well, it didn't used to be this way, so it gives me hope that we'll get back to what it was like before, before people started sort of freaking out. So it's encouraging to know that you are working on "Respect and Heal," and we'll see what that does. Thank you both so much for making time for this interview.

Frank Ferrante: Thank you, Amber. Really appreciate it.

Jerry Santoferrara: Yes, no problem. We appreciate it.

Host Amber Smith: My guests have been Frank Ferrante and Jerry Santoferrara. They're both workplace violence coordinators at Upstate.

I'm Amber Smith for Upstate's "HealthLink on Air."

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Alice Irwin is a poet and a cancer survivor from Manlius, New York. Her poem "A Visit to the Emergency Room" gives a damning portrait of what it means to say our hospitals are understaffed and over-busy. We need to do better.

"A Visit to the Emergency Room"

I found my brother at the end of the corridor

on a gurney shoved up against the wall,

hooked up in a space with a number,

docile, dazed, pale and confused,

needing help to fill in the blanks.

I staked my claim on a folding chair

and a tiny patch of hallway,

prepared to stand guard for another siege:

the endless weight between tests and results

and the usual barrage of redundancies.

He struggled to rise from a seizure fog and

make sense of what was happening to him.

We waited for hours, overlooked and ignored

amidst the constant drone of buzzers and beepers,

also unheard and unnoticed.

I finally managed to corner a nurse who

tracked down the doctor in charge.

Discharge papers were stuffed in my hand with

"So sorry, so busy, go follow up elsewhere."

Beside me, my brother limped down the hall,

out into the dark, a forgotten phantom.

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," what impact does cannabis have on cognition?

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.