key: cord-0786084-zgbbihpb authors: Sood, Akshay; Pollard, Charles; Suer, Kyla Le; Vlahovich, Kevin; Walker, Jolene title: Caring for Miners During the Coronavirus Disease‐2019 (COVID‐19) Pandemic date: 2020-04-11 journal: J Rural Health DOI: 10.1111/jrh.12444 sha: 69ab790870ae8a7bc20d9a89f6acf75321723549 doc_id: 786084 cord_uid: zgbbihpb nan disease has spread to rural areas, where its prevention and treatment may be more challenging because of the lower concentration of medical and public health resources. 5 Data indicate that men are more susceptible than women, and that smoking affects outcomes adversely. 4, 6 Given that miners, mostly men and often smokers, have a dispoportionately high prevalence of hypertension and diabetes (other risk factors for COVID-19 1,7 ), miners may constitute a susceptible population for this disease. The pandemic has caused various professional organizations to support discontinuing routine pulmonary function test (PFT) studies. The American College of Occupational and Environmental Medicine (ACOEM) explains that "spirometry tests require performance of a forced expiratory maneuver, which could spread droplets in the air if an infected person is tested, even if asymptomatic. 8 10 This means that filters may provide little or no protection from viral transmission. Lung volumes, diffusing capacity, and cardiopulmonary exercise studies require collection of gases within a closed system. The virus could contaminate the inside chambers, requiring time-consuming decontamination. Consequently, a number of rural test laboratories and clinician offices temporarily stopped testing or started performing only urgent studies. With the unknown risk, ATS and ACOEM recommend health care providers don personal protective equipment such as N95 respirators during urgent testing to limit aerosolized droplet acquisition by staff, and enhanced cleaning of the testing space. Although PFTs are infrequently required for making acute clinical decisions in miners, they form the foundation for surveillance, diagnosis, preemployment physical assessment, impairment assessment, and research. These activities are likely to be delayed by months due to the pandemic, causing significant disruption in the care of miners. Fewer than half of New Mexico (NM) miners in a study did not have a primary care provider (PCP). 1 Without a PCP to call, many miners will rely on unverified information, and some will go to the hospital, perhaps unnecessarily; others will wait too long to seek care. 11 For those with a PCP, the rapid transition to telemedicine, although welcome, will create new difficulties in communication, particularly for miners with limited English proficiency, those who lack access to videoconferencing, and those with concomitant hearing deficits who rely on visual cues. 11, 12 The EEOICP provides home health services to uranium miners and other energy workers, a service that can help keep rural patients away from overburdened hospitals during the pandemic. Home health staff have been constrained by a lack of protective gear and training on its use, inadequate training on the care of potentially infected patients, physical and mental exhaustion, high staff turnover rates, and fear. Teletraining staff can help address several constraints. Although not currently covered by the program payer, it is likely that telemonitoring in home care will receive more attention during the pandemic. Pulmonary rehabilitation is a recognized treatment for chronic lung diseases in miners. Rural mining communities have limited access to these programs 3 and many of those that do have access have encountered program closures due to the pandemic. Potential alternatives, such as rehabilitation at home or telehealth rehabilitation with remote online supervision, should be considered. 13 Rural local chapters of support groups, such as the American Lung Association Better Breathers Clubs have also shut down. While telehealth can help relieve isolation, support appropriate education, and assist in patient care, 14 lack of Internet access still continues to be a barrier in some rural mining communities. 15 The professional expertise available to care for miners has decreased over time in the pneumoconiosis mortality hotspot regions of Appalachia and the Mountain West. 1, 16 There is a tremendous need to train these rural professionals across the multidisciplinary aspects of the management of complex mining-related diseases. Following the pandemic outbreak, many directors of spirometry courses approved by the National Institute for Occupational Safety and Health (NIOSH) postponed their training programs, based on the concern for transmitting infection. 8 Structured longitudinal telementoring of rural health care professionals could create a virtual "community of practice" that would facilitate team management of complex miningrelated diseases in rural areas. 14 The strategy of "moving knowledge" instead of "moving patients" has been shown to be effective in managing other chronic diseases in medically underserved areas using the Extension for Community Health Outcomes (ECHO) model for telementoring. [17] [18] [19] [20] Ironically, the New Mexico-based Miners' Wellness Tele-ECHO program temporarily stopped in April 2020 to help meet the high demand for tele-education of rural providers on the management of the COVID-19 infected patients. Key professional conferences such as the May 2020 American Thoracic Society International Conference were canceled. Given that the pandemic is expected to last several months, there is tremendous need to utilize systems that are already in place for rapid scaling of the Miners' Wellness TeleECHO Program and NIOSH approval for virtual spirometry training courses. Laboratory research activities slowed but continued with social distancing measures. On the other hand, clinical research involving miners at our institution was significantly impacted, out of concern for the safety and welfare of human subject participants and research staff. Recruitment for new studies was delayed and existing studies disrupted. Conducting virtual study activities by phone or video conferencing requires additional institutional review board (IRB) approvals. The National Institutes of Health (NIH) noted that research grant recipients were likely to encounter delays to ongoing research. 21 The compensation programs for US miners are complex, requiring specialized input from benefits counselors, attorneys, and judges. Infamous for delayed judgements, many claims in the Black Lung program are awarded to widows, long after the death of the miner. Benefits and legal counseling are complex and difficult during social distancing. 22 It is likely that the COVID-19 pandemic will adversely impact the clinical, educational, research, and legal/benefits needs of miners and/or professionals taking care of miners in the rural US, with significant setbacks in the fight against the resurgence of pneumoconiosis. Rahm Emanuel, former White House Chief of Staff once said, "You never let a serious crisis go to waste. And what I mean by that it's an opportunity to do things you think you could not do before." The COVID-19 pandemic should prompt us to expand the use of telemedicine, tele-education, telementoring, and telemonitoring in rural mining communities, as was presciently recommended by the 2019 US COPD National Action Plan prior to the pandemic. 14 An Innovative Approach to Enhancing Access to Medical Screening for Miners using a Mobile Clinic with Telemedicine Capability Radiographic disease progression in contemporary US coal miners with progressive massive fibrosis. Occupational and environmental medicine Urban-Rural County and State Differences in Chronic Obstructive Pulmonary Disease -United States Rural Miners Are at Greater Odds for Lung Disease Than Nonrural Miners Prediction of Epidemic Spread of the 2019 Novel Coronavirus Driven by Spring Festival Transportation in China: A Population-Based Study Sex difference and smoking predisposition in patients with COVID-19 Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? 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