Month: August 2021

“The horse has left the barn.”

Those six words, said by my husband’s oncologist, changed our lives forever, although the sense of impending loss had begun weeks earlier with a blood test. There would be more tests, exams, and visits to specialists. As George and I waited for a definitive diagnosis, we bargained with ourselves and with the universe. When we finally met with the cancer treatment team to review all the tests, George’s 6-foot 2-inch frame struggled to fit into the space at the small table, where we strained to follow the conversation. Hearing the word metastatic — meaning cancer had spread throughout his body — was like fingernails on a blackboard.

But there’s no real way to prepare for grief, an inescapable feature of the human condition. Its stress following the death of a loved one can lead to physical illness: cardiovascular diseases, broken-heart-syndrome (takotsubo cardiomyopathy), cancers, and ulcers. Emotional distress often sparks physical distress known as somatic symptoms. How each person navigates grieving varies. Comfort takes different forms for different people. While my journey is individual, my story touches on universal themes, particularly for those grieving in the time of COVID-19.

Anticipatory grief strikes first

George’s diagnosis was advanced metastatic prostate cancer, spread to lymph nodes and bone. There would be no surgery. No radiation. No chemotherapy. Only palliative care.

Some days George wanted to talk only with me. Other days he wanted to talk with those who were “in the same boat.” He saw himself as washed up on the shores of a new, unknown continent. I felt washed up with him. The National Cancer Institute describes these feelings as anticipatory grief, a reaction that anticipates impending loss.

In time, we returned to everyday routines. Sometimes we laughed and didn’t think about his illness. George even conceived of and hosted an annual party for his best friends — men who would be his pallbearers — and their partners. The “pallbearer party,” as it came to be known, was a wonderfully raucous event. Grown men laughed until they cried. Each year, by the end of the night, I knew the tears were for anticipated loss.

George lived another 11 years, more than twice what was expected. But anticipating his loss did not cushion my broken heart.

Acute grief following a death

George died in May 2020, at the beginning of the COVID-19 lockdown. Despite the pallbearers’ dress rehearsals, there was no funeral, no gathering of loved ones. Nothing to soothe my overwhelming pain.

In those first few weeks, time seemed stretched thin, moments repeating themselves like musical notes on a scratched record. I felt untethered, unmoored, adrift. My sides ached from crying; my knees were unsteady. I don’t recall eating.

At the funeral home, when I saw George in a casket, the large room seemed bright from lights hitting the shiny wood floor. Later, I realized the room was much smaller and dimmer than I remembered, its floor not shiny but covered by oriental rugs. Burgundy drapes kept out the sun. As I took in the scene, so different from my recollection, my chest heaved and spasmed.

Such physical reactions and perceptions are common in acute grief. The death of a loved one is accompanied by waves of physical distress that can include muscle aches, shortness of breath, queasy stomach, and trouble sleeping. Food may have no taste, and some experience visual hallucinations. The grief-stricken may not believe their loved one is dead.

Grief in the time of COVID-19

Restrictions to help prevent the spread of COVID-19 disrupted social rituals that connect us during grief. In The Atlantic, Ed Yong describes this absence of much-needed support as the “final pandemic betrayal.”

Although my husband died of cancer, not COVID, I experienced the loss of comforting rituals and the sense that my grief was never truly acknowledged. Experts call this disenfranchised grief. Some predict that prolonged grief disorder driven by this pandemic may reach rates seen only in survivors of natural disasters and wars.

Grief is proof of love

Losing loved ones is not easily incorporated into our life story, though it becomes part of it. The finality and acceptance of a monumental loss takes time. In The Year of Magical Thinking, Joan Didion captures the sudden tragic death of her husband: “John was talking and then he wasn’t.” Life changes in an instant. Yet it takes time to untangle and embrace all that it means.

My life must now be reconfigured and re-envisioned without George. Letting go of grief happens haltingly. Gradually, I noticed that more of my memories of George were happy ones, slowly crowding out the all-consuming early intensity of grief. With time I began to re-engage with the world.

Just as George had, I found I wanted to talk with others in the same boat. A bereavement group helped. I began to exercise more. That helped too. When our dogs died, I got a new puppy. Above all, I learned to be kind to myself.

If you, too, are struggling with loss, experts advise some basics: try to eat, sleep, and exercise regularly; consider a bereavement group or seek out others experiencing grief; stay open to new possibilities — new hobbies, people, and opportunities. Talk to a professional if, after months, you are preoccupied with thoughts of your loved one or find no meaning in life without them. These may be signs that your grief is stalled or prolonged. Effective treatment can help.

Every “first” without George — the first birthday, first wedding anniversary, first anniversary of his death — awakened the early days of intense grief. Still, the experience of living through each made me realize I could survive. I think George would be pleased.

Additional resources

Grief and Loss, CDC

NIH News in Health: Coping with Grief, National Institutes of Health

The Center for Prolonged Grief, Columbia University

About the Author

Martha E. Shenton, PhD, Contributor

Dr. Martha Shenton is professor of psychiatry and radiology at Harvard Medical School, and director of the Psychiatry Neuroimaging Laboratory at Brigham and Women’s Hospital in Boston. She and her team have pioneered in developing neuroimaging … See Full Bio View all posts by Martha E. Shenton, PhD

It’s an old line: everyone complains about the weather but no one is doing anything about it.

But if you’re a person with bad allergies or asthma, stormy weather can be more than an annoyance; it can be a serious threat to your health. “Thunderstorm asthma” was first reported in the 1980s in England and Australia, and cases continue to crop up. Just after severe thunderstorms passed through Melbourne, Australia in 2016, more than 9,000 people sought urgent medical care for asthma during one notable event. Medical facilities were overwhelmed and at least eight people died. That’s unusual, but if you do have asthma — or seasonal allergies, as it turns out — understanding this trigger can help you stay well.

What is thunderstorm asthma?

The term describes an attack of asthma that starts or worsens after a thunderstorm. It can occur in anyone with asthma, but it most often affects people with seasonal allergic rhinitis, which many people know as hay fever or allergies. Heralded by a runny nose, sneezing, and itchy eyes, seasonal allergies are often worst in the spring, summer, or early fall.

Rain tends to lower pollen counts by cleansing the air, and many people find that rainy weather tends to reduce asthma symptoms triggered by allergies. But thunderstorms can make asthma worse because of a unique sequence of events:

• Cold downdrafts concentrate air particles, such as pollen and mold
• These air particles are swept up into clouds where humidity is high
• In the clouds, wind, humidity, and lightning break up the particles to a size that can readily enter the nose, sinuses, and lungs
• Wind gusts concentrate these small particles so large amounts can be inhaled.

What raises risk for experiencing thunderstorm asthma?

According to a new study in the Journal of Allergy and Clinical Immunology, a whopping 144 out of 228 people with seasonal allergies reported experiencing thunderstorm asthma — that’s 65%! And many of the asthma attacks set off by thunderstorms weren’t mild. Nearly half of people who had an attack sought emergency hospital treatment.

Among people with seasonal allergies, risk factors for experiencing thunderstorm asthma include having

• poorly controlled asthma symptoms (assessed by a standard asthma questionnaire)
• a low score on a rapid exhalation test (a common breathing test for asthma)
• higher levels of a certain antibody (ryegrass pollen-specific IgE)
• higher numbers of certain blood cells (eosinophils, which tend to increase when people have allergic conditions)
• higher levels of exhaled nitric oxide (one measure of lung inflammation among people with asthma).

Not everyone with these risk factors will develop thunderstorm asthma. And even among those who do, asthma attacks won’t necessarily occur with every storm. But it may be useful to know if you’re among those at risk, especially if you live in an area where thunderstorms are common.

The bottom line

Thunderstorm asthma may seem like more of a curiosity than a serious threat to public health. But when it affects a large population area, emergency rooms can become overwhelmed, as happened during the 2016 Melbourne event. A better understanding of when these events are expected could lead to advanced warning systems, enhanced emergency room preparedness, and even preventive treatment.

In the US, 25 million people have asthma and more than 20 million have seasonal allergies. Odds are good that millions have both, which puts large numbers of people at risk for developing thunderstorm asthma.

If you’re among them, the weather forecast may be much more than just a guide on what to wear or whether to bring an umbrella. Knowing thunderstorms are headed your way may serve as an advance warning to double check that you are taking your asthma medicines properly, have a supply of rescue medicine handy, or simply plan to stay indoors until the storm has passed.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

By now, you’ve probably heard that there is a monkeypox outbreak traveling around the globe. Cases have spread far and wide, including in the US, Canada, Europe, and Australia. It’s the largest outbreak ever recorded outside of western and central Africa, where monkeypox is common.

But controlling this outbreak demands preventive measures, such as avoiding close contact with people who have the illness and vaccination. One method of vaccination, called ring vaccination, has worked well in the past to contain smallpox and Ebola outbreaks. It may be effective for monkeypox as well.

How can monkeypox be contained?

According to the Centers for Disease Control and Prevention (CDC) and the World Health Organization, monkeypox is unlikely to become a pandemic. At this time, the threat to the general public is not high. The focus is on identifying possible cases and containing the outbreak as soon as possible.

Three important steps can help stop this outbreak:

1. Recognize early symptoms

• Usually, early symptoms are flulike, including fever, fatigue, headache, and enlarged lymph nodes.
• A rash appears a few days later, changing over a week or two from small flat spots to tiny blisters similar to chickenpox, then to larger, pus-filled blisters.
• The rash often starts on the face and then appears on the palms, arms, legs, and other parts of the body. If monkeypox is spread by sexual contact, the rash may show up first on or near the genitals.

2. Take steps to stop the spread

• Monkeypox spreads through respiratory droplets or by contact with fluid from skin sores.
•  Anyone who has been diagnosed with monkeypox, or who suspects they might have it, should avoid close contact with others. Once the sores scab over, the infected person is no longer contagious.
• Health care workers and other caregivers should wear standard infection control gear, including gloves and a mask.
• In the current outbreak, many cases began with sores in the genital and rectal areas among men who have sex with men, so doctors suspect sexual contact spread the infection. As a result, experts are encouraging abstinence when monkeypox is suspected or confirmed.

3. Use vaccination to help break the chain

• Monkeypox is closely related to smallpox. People who received a smallpox vaccine in the past may have some protection from monkeypox. (The US smallpox vaccination program was discontinued in 1972, and smallpox was declared eradicated worldwide in 1980.)
• Stockpiled smallpox vaccinations and newer vaccines that can be used for monkeypox or smallpox are also available.

Ring vaccination

Monkeypox differs from the virus that causes COVID-19. People with monkeypox usually have symptoms when they’re contagious, and the number of infected persons is usually limited.

This means it’s possible to vaccinate a “ring” of people around them rather than vaccinating an entire population. This selective approach is called ring vaccination.

Ring vaccination has been used successfully to contain smallpox and Ebola outbreaks. It may come in handy for monkeypox as well. Here’s how it works:

• As soon as a case of monkeypox is suspected or confirmed, the patient and their close contacts are interviewed to identify possible exposures.
• Vaccination is offered to all close contacts.
• Vaccination is also offered to those who had close contact with the infected person’s contacts.

Ideally, people should be vaccinated within four days of exposure.

This approach requires widespread awareness of monkeypox, rapid isolation of suspected cases, and an efficient contact tracing system. And of course, vaccines must be available whenever and wherever new cases arise.

Are the vaccines used for monkeypox effective?

According to the CDC, the smallpox vaccine is 85% effective against monkeypox.

While a newer vaccine (JYNNEOS) directed against monkeypox and smallpox has only been tested for effectiveness in animals, it is also expected to be highly effective in humans.

Of course, vaccinations can only work if people are willing to receive them. We’ll learn more about this as more people are offered the option for vaccination.

Are the vaccines used for monkeypox safe?

As with most vaccines, the most common side effects include

• sore or itchy arm at the site of the injection
• mild allergic reactions
• mild fever or fatigue.

Fortunately, more severe side effects, such as significant allergic reactions, are rare.

The bottom line

In light of the current monkeypox outbreak, you may soon be hearing more about ring vaccination. Then again, if appropriate measures are taken to prevent its spread, this outbreak may soon be over. Either way, this won’t be the last time an unusual virus shows up seemingly out of the blue in unexpected places. Climate change, shrinking animal habitats, rising global animal trade, and increasing international travel mean that it’s only a matter of time before this happens again.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

This spring, many parts of United States experienced historic heat waves. Now summer is officially underway, and experts are predicting hotter than normal temperatures across most of the country.

Extreme temperatures increase health risks for people with chronic conditions, including heart problems. If you do have a heart condition, here’s how to keep cool and protect yourself when temperatures rise.

How does hot weather affect the heart?

Not only does exposure to high heat increase the risk for heat exhaustion and heat stroke, but it can also place a particular burden on heart health. It stresses the cardiovascular system and makes the heart work harder. This can increase the chance of heart attacks, heart arrhythmias (irregular heartbeat), and heart failure.

According to the Environmental Protection Agency, the interaction of high heat and cardiovascular disease contributes to about a quarter of heat-related deaths.

And the higher the temperature, the greater the threat. A recent study in the journal Circulation looked at cardiovascular death rates over seven years in Kuwait, where daytime temperatures can reach triple digits in the hottest months. The researchers found a link between rising temperatures and the risk of cardiovascular deaths, with most occurring between temperatures of 95° F to 109° F.

“Climate change is giving us more, and unprecedented, heat that can be deadly, especially for people with heart disease,” says Dr. Aaron Bernstein, interim director of the Center for Climate, Health, and the Global Environment at Harvard T.H. Chan School of Public Health.

How does the body shed heat?

Your body is designed to shed extra heat in two major ways, each of which may affect the heart:

Radiation. When the air around you is cooler than your body, you radiate extra heat into the air. This process requires rerouting blood flow so that more of it goes to the skin.

Evaporation. Evaporating sweat helps cool you down by pulling heat away from your skin. When the air is dry, this works well. But when it’s hot and humid, sweat just sits on the skin as your body temperature rises.

When air temperature approaches or exceeds body temperature, especially in high humidity, the heart has to beat faster and pump harder to help your body shed heat. On a hot and humid day, your heart may circulate two to four times as much blood each minute compared with a cool day.

Some medicines meant to help the heart can add to problems on hot days. For example, beta blockers slow the heartbeat and hinder the heart’s ability to circulate blood fast enough for effective heat exchange. Diuretics (water pills) increase urine output and raise the risk of dehydration.

How can you protect yourself and your heart when temperatures rise?

While exposure to high heat and heat waves affects everyone, having existing heart problems raises your risk for heat-related illness and hospitalization. So it’s especially important to try to follow basic strategies for staying cool, including these:

• Monitor weather forecasts for heat advisories and stay inside on those days. If home is too hot, check with your town or city health department for cooling centers and other options to help you stay cool. If you venture outside, evening and early morning are often the coolest times. Rest in the shade whenever possible.
• When outside, try to drink 8 ounces of water every 20 minutes. Set a timer to remind you. “Never wait until you’re thirsty to drink,” says Dr. Bernstein. If you have heart failure, ask your doctor how much fluid you should drink daily, since fluids can build up and cause swelling. If you take diuretics, ask how much you should drink during hot weather.
• Avoid soda or fruit juice and limit alcohol. Soda and fruit juice may slow the passage of water from the digestive system to the bloodstream. While research is limited, some studies have found that excessive alcohol intake may raise risk for heat stroke during scorching weather.
• Protect your skin. Sunburn affects your body’s ability to cool down and increases dehydration. Wear a wide-brimmed hat, wraparound sunglasses, and lightweight, light-colored, loose-fitting clothing. Also, apply plenty of broad-spectrum or UVA/UVB protection sunscreen with SPF 30 or higher to all exposed skin 30 minutes before going out. Reapply every hour.

About the Author

Matthew Solan, Executive Editor, Harvard Men's Health Watch

Matthew Solan is the executive editor of Harvard Men’s Health Watch. He previously served as executive editor for UCLA Health’s Healthy Years and as a contributor to Duke Medicine’s Health News and Weill Cornell Medical College’s … See Full Bio View all posts by Matthew Solan

Here we are, well into year three of the COVID-19 pandemic, and now we’re having an outbreak of monkeypox? Is this a new virus? How worried should we be? While new information will continue to come in, here are answers to several common questions.

What is monkeypox?

Monkeypox is an infection caused by a virus in the same family as smallpox. It causes a similar (though usually less severe) illness and is most common in central and western Africa. It was first discovered in research monkeys more than half a century ago. Certain squirrels and rats found in Africa are among other animals that harbor this virus.

Currently, an outbreak is spreading fast outside of Africa. The virus has been reported in at least a dozen countries, including the US, Canada, Israel, and in Europe. As of this writing, Reuters reports more than 100 confirmed or suspected cases, making this the largest known outbreak outside of Africa. So far, no deaths have been reported.

Naturally, news about an unfamiliar virus spreading quickly internationally reminds us of the start of the COVID-19 pandemic. But monkeypox is not new — it was first discovered in 1958 — and several features make it likely to be far less dangerous.

What are the symptoms of monkeypox?

The early symptoms of monkeypox are flulike, and include

• fever
• fatigue
• headache
• enlarged lymph nodes.

The rash that appears a few days later is unique. It often starts on the face and then appears on the palms, arms, legs, and other parts of the body. Some recent cases began with a rash on the genitals. Over a week or two, the rash changes from small, flat spots to tiny blisters (vesicles) similar to chickenpox, and then to larger, pus-filled blisters. These can take several weeks to scab over. Once that happens, the person is no longer contagious.

Although the disease is usually mild, complications can include pneumonia, vision loss due to eye infection, and sepsis, a life-threatening infection.

How does a person get monkeypox?

Typically, this illness occurs in people who have had contact with infected animals. It may follow a bite or scratch, or consuming undercooked animal meat.

The virus can spread between people in three ways:

• inhaling respiratory droplets
• directly touching an infected person
• less often, through indirect contact such as handling an infected person’s clothing.

The respiratory route involves large droplets that don’t linger in the air or travel far. As a result, person-to-person spread typically requires prolonged, intimate contact.

Is monkeypox a sexually transmitted illness?

Monkeypox is not considered a sexually transmitted illness (STI) because it can be spread through any physical contact, not just through sexual contact. Some of the recent cases have occurred among men who have sex with men. That pattern hasn’t been reported before.

Can monkeypox be treated?

Yes. Although there are no specific, FDA-approved treatments for monkeypox, several antiviral medicines may be effective. Examples are cidofovir, brincidofovir, and tecovirimat.

Can monkeypox be prevented?

Vaccination can help prevent this illness:

• Smallpox vaccination, which was routine in the US until the 1970s, may be up to 85% effective against monkeypox.. The US government has stockpiled doses of smallpox vaccine that could be used in the event of a widespread outbreak.
• Additionally, the FDA approved a vaccine (called JYNNEOS) in 2019 for people over 18 who are at high risk for smallpox or monkeypox. The makers of this vaccine are ramping up production as this outbreak unfolds.

If you are caring for someone who has monkeypox, taking these steps may help protect you from the virus: wear a mask and gloves; regularly wash your hands; and practice physical distancing when possible. Ideally, a caregiver should be previously vaccinated against smallpox.

How sick are most people who get monkeypox?

Monkeypox is usually a mild illness that gets better on its own over a number of weeks.

Researchers have found that the West African strain of monkeypox is responsible for the current outbreak. That’s good news, because the death rate from this strain is much lower than the Congo Basin strain (about 1% to 3% versus 10%). More severe illness may occur in children, pregnant people, or people with immune suppression.

What else is unusual about this outbreak?

Many of those who are sick have not traveled to or from places where this virus is usually found, and have had no known contact with infected animals. In addition, there seems to be more person-to-person spread than in past outbreaks.

Is there any good news about monkeypox?

Yes. Monkeypox usually is contagious after symptoms begin, which can help limit its spread. One reason COVID-19 spread so rapidly was that people could spread it before they knew they had it.

Outbreaks occur sporadically, and tend to be relatively small because the virus does not spread easily between people. The last US outbreak was in 2003; according to the CDC, nearly 50 people in the Midwest became ill after contact with pet prairie dogs that had been boarded near animals imported from Ghana.

Perhaps the best news is this: unlike SARS-CoV2, the virus that causes COVID-19, monkeypox is unlikely to cause a pandemic. It doesn’t spread as easily, and by the time a person is contagious they usually know they’re sick.

How worried should we be?

The growing numbers of cases in multiple countries suggest community spread is underway. More cases will probably be detected in the coming days and weeks.

It’s still early in the outbreak and there are many unanswered questions, including:

• Has the monkeypox virus mutated to allow easier spread? Early research is reassuring.
• Who is most at risk?
• Will illness be more severe than in past outbreaks?
• Will existing antiviral drugs and vaccines be effective against this virus?
• What measures can we take to contain this outbreak?

So, monkeypox is no joke and researchers are hard at work to answer these questions. Stay tuned as we learn more. And let your doctor know if you have an unexplained rash or other symptoms of monkeypox, especially if you have traveled to places where cases are now being reported.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD