As COVID-19 wanes, CHOC’s medical epidemiologist, Dr. Jasjit Singh, recalls 2016 dental clinic outbreak

As the grip of the COVID-19 pandemic continues to weaken, Dr. Jasjit Singh, CHOC’s medical epidemiologist and medical director of infection prevention and control, recalls a ghost of outbreaks past.

Nearly five years ago, a mysterious outbreak of oral infections that eventually was traced to a clinic in Anaheim alarmed parents and dominated the local news.

The health crisis spurred Dr. Singh and a multidisciplinary team at CHOC, working with several community partners, to search for answers – and to provide optimal care for the patients, whose median age was 6.

Over 100 children were admitted to CHOC for evaluation, of whom 70 were confirmed cases, hospitalized for an average of more than a week.

Some suffered permanent tooth loss – as many as six teeth.

The culprit: a Mycobacterial abscessus infection that was detected after each child underwent a pulpotomy procedure, or “baby root canal,” to remove or treat an infected tooth at the Anaheim clinic between Jan. 1 and Sept. 6, 2016.

The outbreak turned out to be the largest ever of invasive Mycobacterial abscessus infections associated with a dental practice. The commonly occurring M. abscessus bacteria is found in water, dust, and soil, but it’s an uncommon cause of healthcare-associated infection.

Between July and September 2016, three patients were admitted to CHOC with atypical infections. All had some combination of facial cellulitis, dental abscess, and/or cervical adenitis that had been present for weeks.

“We had our first child present with what appeared to be a really unusual infection,” Dr. Singh recalls. “Our first thought was, ‘What’s wrong with this child’s immune system?’

“When the second child came in, one of my very astute colleagues, Dr. Negar Ashouri, ascertained that the child had been treated at the same dental clinic. She alerted the OC Health Care Agency immediately, who soon found unexplained symptoms brewing in other kids.” 

A mobilized effort

The California Department of Public Health, the Centers for Disease Control and Prevention, and the Dental Board of California worked with the OC Health Care Agency (OCHCA) to investigate the infections.

The team at CHOC helped OCHCA with the epidemiologic and diagnostic probe. Of 1,081 at-risk patients, 71 case patients (22 confirmed; 49 probable) were identified.

Here at CHOC, 27 of the most severely affected children were treated with a complex regimen of antibiotics, including clofazimine, marking the largest number of children to ever receive that medication outside of treatment for leprosy.

Details of the work of Dr. Singh and many others recently was published by Oxford University Press on behalf of the Infectious Disease Society of America.

Publication of the paper, “Invasive Mycobacterium abscessus Outbreak at a Pediatric Dental Clinic,” was delayed a year and a half by the COVID-19 pandemic, Dr. Singh says.

The infections were caused by untreated municipal water the Anaheim clinic was using for drilling and irrigation during pulpotomy procedures. Because pulpotomies are not considered surgical procedure, sterile water is not required.

A change in state water standards

The work of Dr. Singh and an army of others led to a change in water standards for pediatric dental procedures in California.

In September 2018, the governor signed into law a bill that specified as unprofessional conduct the use of water that is not sterile or that does not contain recognized disinfecting or antibacterial properties when performing dental procedures on exposed dental pulp.

Dr. Singh is hopeful that the publication of the paper, whose listed authors include 11 CHOC physicians and three officials with the OC Health Care Agency, will lead to similar laws being enacted in other states.

As the paper puts it, “The authors believe the measure adopted in California for the use of sterile water for all pulpotomies is an appropriate standard which we would like to see embraced by the American Dental Association and state dental boards around the country.”

Dr. Singh credits the multi-disciplinary team for caring for the patients. The team included specialists in infectious disease, oral surgeons, ENT doctors, radiologists, dentists, pharmacists, and staff members of Providence Speech and Hearing, among others.

“These were normal, healthy children that were affected,” Dr. Singh says. “The multi-disciplinary coordination was a huge part of the success of this story. Still, many of the patients who lost permanent teeth will need dental rehabilitation in the future. It was a very difficult period for these families.

“We talked to national experts and really delved through whatever literature was out there,” Dr. Singh adds. “We all came together to get the kids and families through this with the least morbidity and the best long-term outcome possible.” 

Read about Dr. Jasjit Singh and Dr. Antonio Arrieta earning a global distinction for excellence.

CHOC telehealth visits continue at a rapid pace

As the world surpasses the one-year anniversary of the COVID-19 pandemic, the resulting rapid rise of telehealth continues to propel forward in 2021, with CHOC patients consistently reporting a 90-plus percent satisfaction rate in surveys, hospital officials say.

Virtual visits with a CHOC provider via a smart phone, tablet, or computer not only are here to stay, but are expected to continue growing at a rapid pace – not just in Orange and surrounding counties, but nationally and globally.

The rapid growth and acceptance of telehealth is a definite sign that consumers want easier access, convenience, and comfort as they seek medical care,” says Dr. Michael Weiss, vice president of population health. “CHOC is committed to providing the highest quality and service to fulfill these needs.”

Kathleen Lear’s son, Matthew, 18, was diagnosed with intractable epilepsy when he was 6 and the last 12 years have been a non-stop roller-coaster, she says.

In mid-February 2021, Matthew became the first epilepsy patient at CHOC to undergo a procedure called Deep Brain Stimulation (DBS), in which electrodes were placed in his brain to help reduce his seizures by sending electrical currents to jam his malfunctioning brain signals. In another first, CHOC recently conducted DBS on a patient with the movement order dystonia.

Kathleen and Matthew recently have had neurology and hematology telehealth visits with Dr. Joffre Olaya and Dr. Mary Zupanc, as well as a consultation with Dr. Antonio Arrieta and Dr. Loan Hsieh.

“I think it was amazing that we even could have a virtual neurology visit,” Kathleen says. “The doctors were able to assess a lot by watching Matthew walk and run and touch his finger to his nose.”

Kathleen says the telehealth session was especially helpful because her husband is working from home during the pandemic and he, too, could participate.

“It was really nice,” she says.

Growth projections

According to Fortune Business Insights, the global telehealth market size was valued at $61.4 billion in 2019 and is projected to reach $559.52 billion by 2027, exhibiting a compound annual growth rate (CAGR) of 25.5 percent during the forecast period.

The U.S. telehealth market size was valued at $9.5 billion in 2020, up a whopping 80 percent over 2019, and is expected to exhibit a CAGR of 29 percent between 2020 and 2025, according to market research firm Arizton.

Quick pivot

At CHOC, a lot of teamwork was necessary for the quick pivot that began in the early days of the pandemic, says Lisa Stofko, CHOC’s telehealth manager.

“There is a difference between a two-way video and telehealth,” Lisa says. “We are committed to making telehealth a seamless experience for both patients and providers, and ensuring that it replicates the safe, quality care patients are used to receiving in person.”

The information services department, Lisa says, worked feverishly to get technology set up so clinicians could use video conference software that came with extra layers of protection that allowed them to safely consult with patients virtually.

Training videos were delivered to more than 700 providers so they could replicate the in-person visit as closely as possible, Lisa says. And a 20-member steering committee was established from key stakeholders from across CHOC’s health system — including administrative executives and physicians — to further improve the telehealth experience and capabilities at CHOC.

In December 2020, Dr. Robert Hillyard, CHOC neonatologist, and Dr. Kenneth Grant, CHOC pediatric gastroenterologist, began serving as co-medical directors of CHOC’s telehealth program, while each retaining existing clinical responsibilities.

Some statistics

Dr. Weiss tracks telehealth visits daily.

From March 2020 through April 2020, CHOC telehealth visits zoomed to 14,457, from 2,233 prior to the pandemic, he says.

Since the pandemic began through early February 2021, CHOC telehealth visits totaled 95,757. The average number of telehealth visits per month during COVID-19 have remained in the 8,500 range.

Telehealth visits at CHOC have grown dramatically in both primary and specialty care.

In January 2021, the most visits (370) in CHOC’s Primary Care network were recorded at Orange Primary Care, followed by Pediatric and Adult Medicine (338), Clinica Para Ninos (286), Breathmobile (176), Los Alamitos Pediatrics (149) and Boys and Girls Clinic Santa Ana (92).

In January 2021, the most visits (1,498) in CHOC’s Specialty Care network were recorded at Providence Speech and Hearing Center, followed by endocrinology (1,017), mental health (991), gastroenterology (893), neurology (481), pulmonary (450), the Thompson Autism Center (407), and outpatient rehabilitation (301).

Kathleen says she looks forward to continuing Matthew’s treatment at CHOC – in person when possible, and virtually, too. She finds telehealth visits especially useful when doctors want to go over test results.

“There’s definitely a time and a place for it,” Kathleen says. “And I just feel so privileged to have CHOC so close to us.”

Learn more about telehealth at CHOC

Virtual pediatric lecture series: COVID-19 in children

The CHOC virtual pediatric lecture series continues with a session on COVID-19 in children.

This online discussion will be held Thursday, Oct. 15 from 12:30 p.m. to 1:30 p.m. and is designed for general practitioners, family practitioners and other healthcare providers.

Dr. Antonio Arrieta, medical director of pediatric infectious disease at CHOC, and Dr. Jasjit Singh, assistant medical director and medical director of infection prevention and control, will present information on COVID-19 in children and the world of infectious disease. Particular focus will be given to counseling patients about the importance of influenza and other routine vaccines this fall. Given the current pandemic and concerns that flu season may exacerbate it, this timely lecture is ideal for providers looking to address preventative matters with patients.

This virtual lecture is part of a series provided by CHOC that aims to bring the latest, most relevant news to community providers. You can register here.

CHOC is accredited by the California Medical Association (CMA) to provide continuing medical education for physicians and has designated this live activity for a maximum of one AMA PRA Category 1 Credit™.

Please contact CHOC Business Development at 714-509-4291 or BDINFO@choc.org with any questions.

How COVID-19 survivors can support others through plasma donation

For Steve Emfinger, donating his blood plasma at CHOC was fast, painless and a way to give meaning to his battle with COVID-19.

“It was very simple,” he said. “And to know it’s helping kids is very cool.”

Man donates plasma to help COVID-19 patients
Steve with his COVID-19 convalescent plasma donation at CHOC Blood Bank.

Registered with the U.S. Food and Drug Administration, the CHOC Blood Bank is available to collect and process blood plasma donations from COVID-19 survivors. These donations are being used to help patients at CHOC and throughout the community.

“We’re still learning about COVID-19, but it’s possible that those who have recovered from the disease have produced antibodies to protect them from the infection,” says Dr. Antonio Arrieta, a pediatric infectious disease specialist who is studying the use of convalescent COVID-19 plasma at CHOC. “If so, their blood plasma would contain these antibodies and may be helpful in the treatment of COVID-19 disease in others.”

Since CHOC began collecting and processing blood plasma donations from recovered COVID-19 patients this spring, more than a dozen CHOC patients have benefited.

And as COVID-19 diagnoses continue to mount in Orange County and fall approaches, the need for blood plasma donations will only grow at CHOC, Dr. Arrieta says.

A surprising diagnosis

Typically, an early riser with boundless energy, Steve just felt zapped in late winter. Attributing the lethargy to two back-to-back trips he’d just taken, Steve decided to work from home. 

Though his symptoms – including a slight cough and dizziness – were minor, Steve’s energy shift was so atypical that he ultimately decided to go to a local hospital. There, he was tested for the flu and strep throat and had a chest scan, which all came back negative.

Steve had one more test – for COVID-19. A couple days later, he got word the test was positive.

Steve hunkered down at home, and notified any friends, family and neighbors he’d been in contact within the weeks before his diagnosis. Some days he felt good – able to work remotely and cook meals – and others were much more challenging.

All in all, though, Steve felt fortunate to have mild symptoms, never experiencing a fever, body aches or significant respiratory problems, despite a lifelong mild case of asthma.

“I think I’m blessed to know that I had minor symptoms and was able to get through it and my family didn’t get sick,” he says.

As Steve’s diagnosis came early into the pandemic’s spread in Southern California, he was initially reluctant to share his story with a broader network of friends, family and colleagues. But as he got more comfortable, Steve’s decision to tell others proved fortuitous.

A friend who worked at CHOC told Steve about the COVID-19 convalescent plasma program and how badly donations were needed.

“I had heard that blood plasma was needed, but I didn’t know where to find a donor center,” he said. “I called CHOC the next day to make an appointment.”

The process to donate plasma to support COVID-19 patients
Steve has already donated plasma twice at CHOC to help support others fighting COVID-19.

Steps to donate

Potential donors must meet some criteria to be eligible:

  1. Donors must show laboratory test proof of their COVID-19 diagnosis either through a diagnostic test (nasopharyngeal swab) at the time they were sick, or a positive serological test for SARS-CoV-2 antibodies after they recovered.
  2. Donors must have been symptom-free for at least 14 days before they donate.
  3. They must meet all other health requirements for blood donors.
  4. Though donors may be male or female, female donors will need to meet some additional requirements that the Blood Bank team will help explain further.

Confirming these requirements takes about a week. Once donors are confirmed and at the Blood Bank, the simple donation process takes about two hours. Donors can return every 28 days to donate again.

Steve is already on his second donation at CHOC and plans to continue in the future – in addition to donating blood and platelets.

“To help someone else makes it all worth it,” he says.

To schedule an appointment or learn more, call the CHOC Blood Bank at 714-509-8339.

Leprosy antibiotic is safe treatment for M. abscessus infections, CHOC infectious disease team finds

An oral antibiotic used to treat leprosy is safe and well-tolerated in the treatment of children with challenging-to-treat mycobacterium abscessus infections, the CHOC infectious disease team has found.

In their study, clofazimine was given to 27 patients during an outbreak of odontogenic mycobacterial infections as part of a multidrug regimen. Though clofazimine performed well in test-tube experiments against M. abscessus, reports in children were previously limited.

This group of patients represents the highest number of children to receive clofazimine outside of leprosy treatment settings.

The study findings were published in the July 2019 Journal of the Pediatric Infectious Disease Society. Its authors are CHOC infectious disease specialists Dr. Felice Adler-Shohet; Dr. Jasjit Singh; Dr. Delma Nieves; Dr. Negar Ashouri; and Dr. Antonio Arrieta; as well as Cathy Flores, a CHOC clinical research nurse coordinator, and Tuan Tran, an infectious disease pharmacist at CHOC.

The patients who received the antibiotic were among a large group of children who underwent pulpotomy procedures at a dental practice with a contaminated water system.

CHOC’s team added clofazimine to its original first-line medication regimen after receiving special use approval from the Food and Drug Administration.

An additional benefit of use of clofazimine was the ability to stop use of an intravenous antibiotic given thrice daily that prompted many side effects, the team found.

Learn how to refer a patient to CHOC infectious disease specialists.

2015 CHOC – UC Irvine Child Health Research Awards

We are pleased to announce that we just completed another round of the CHOC – UC Irvine Child Health Research Awards, our annual call for proposals that enhance research collaborations between CHOC and UC Irvine and further the Mission, Vision and strategic aims of the CHOC-UCI Child Health Research Strategic Plan. Intended to support research and collaboration in targeted areas of research excellence that align research strengths for focused growth and maximal translational impact, our call this year specifically solicited applications for two funding mechanisms, Pilot Collaborative Research Awards and Clinician Investigator Awards.

Child Health Research Award - UC Irvine Infographic

Pilot Collaborative Research Awards are intended to provide funds for collaborative projects in need of initial start-up funding to enable procurement of other independent support. These awards are designed to promote novel, translational research efforts that coalesce talented clinicians and researchers from CHOC and UC Irvine. Projects bring investigators from multiple disciplines from CHOC and UC Irvine together to identify targets for improved diagnosis, prevention, or treatment of a pediatric health problem relevant to the goals of the CHOC-UCI Child Health Research Strategic Plan.

Clinician Investigator Awards are intended to provide funds for clinician-investigator initiated projects in need of funding to advance study into a clinically relevant and important topic that has a high likelihood of impacting clinical practice and the positive experience of pediatric/ adolescent patients and their families. Priorities are given to proposals that are closely aligned with the research themes identified in the CHOC – UCI Child Health Research Strategic Plan. Projects identify targets for improved diagnosis, prevention, or treatment of a pediatric health problem relevant to the goals of the CHOC-UCI Child Health Research Strategic Plan. Collaborations between CHOC and UCI faculty are strongly encouraged, but not required.

This year we received 18 proposals, an increase of 13% over last year, covering a wide range of topics and specialties. After external academic peer reviews and committee discussions, we decided to fund 6 projects, 3 Pilot Collaborative Research Awards and 3 Clinician Investigator Awards.

Congratulations to the well-deserving recipients of the 2015 awards! They are listed below, in order of award type and Principle Investigator’s last name.

Pilot Collaborative Research Awards.

Principal Investigator: Dr. Gurpreet Ahuja

Collaborators: Drs. Nguyen PhamKevin Huoh, Naveen Bhandarkar, Carolyn Coughlan, Joon You

Project Title: NIR Imaging of Pediatric Sinuses

Principal Investigator: Dr. Tami John

Collaborators: Drs. Lilibeth Torno, Daniela Bota, Grace Mucci, Mary Zupanc, Jack Lin

Project Title: Cognitive Training to Promote Neuroplasticity and Neural Re-circuitry in Chemotherapy

Associated Cognitive Impairment

Principal Investigator: Dr. Calvin Li

Collaborators: Drs. John Weiss, Hong Yin, William Loudon

Project Title: A Tunable Engineered Tissue Graft Model for Repair of Traumatic Brain Injury

 

Clinician Investigator Awards

Principal Investigator: Dr. Antonio Arrieta

Collaborators: Drs. Katrine Whiteson, David Michalik

Project Title: Addressing the Fear Factor in Neonatal Serious Bacterial Infections: Distinguishing E Coli From Bacteremia, Urinary Tract Infection, and Bacteremic Urinary Tract Infection in Infants <28 Days vs. >28 Days to 90 Days Old by Pairing E. Coli Genome Analysis with Clinical Data

 

Principal Investigator: Dr. Joanne Starr

Collaborators: Drs. Richard Gates, Sharief Taraman, Mary Zupanc, Paul Yost, Michele Domico, Juliette Hunt, Tammy Yoon, Kimberley Lakes

Project Title: Seizures and Neurodevelopmental Outcomes in Mild Hypothermic Cardiopulmonary Bypass

 

Principal Investigators: Dr. Sharief Taraman and Ruth McCarty

Collaborators: Drs. William Loudon, Frank Hsu

Project Title: The Use of Traditional Chinese Medicine (TCM) as a Complementary Treatment of Pediatric and Young Adults with Post-Concussive Syndrome

CHOC Researchers to Present at Upcoming Conference

CHOC will be well represented at a prestigious upcoming pediatrics conference, with two research projects set to be presented.

At the 2015 Pediatric Academic Societies annual meeting later this month, CHOC infectious disease physicians will present the outcomes of a study that examined the efficacy of the pneumococcal disease vaccine in Orange County youth.

The study shows that the incidence of invasive pneumococcal disease has decreased in Orange County children every year since the 13-valent pneumococcal conjugate vaccine (PCV-13) was introduced in 2010, says Dr. Antonio Arrieta, chief of infectious disease at CHOC.

CHOC Children's Research Institute

Researchers looked at all Orange County children who developed invasive pneumococcal disease, found each case’s bacteria serotype, and determined whether it was a vaccine type.

“We were able to show that the difference was for the whole population and more noticeable in children 5 and younger, who are more susceptible,” Dr. Arrieta says. “The vaccine is doing its job.”

The results show that PCV-13 has improved upon the already good outcomes from the vaccine’s previous incarnation, PCV-7, which was released in 2000.

“The vaccine is very expensive, so we are putting our money on something that is working,” Dr. Arrieta says. “It was very important to ascertain that the vaccine worked because when this was approved, it was approved without clinical trials. It was approved only with immunogenicity data.”

Drs. Michele Cheung, Delma Nieves and Jasjit Singh, as well as Stephanie Osborne, a CHOC clinical research nurse, also authored the study, which was conducted in partnership with the Orange County Health Care Agency and Kaiser.

Also, the conference will feature a project co-led by Dr. Dan Cooper, CHOC’s chief academic officer, on exercise biomarkers and translational research in child health.

The annual meeting will be held April 25-28 in San Diego.