Vicki Hertzberg is a Professor at Emory University in the Nell Hodgson Woodruff School of Nursing, where she has founded and directs the Center for Data Science. Her research focuses on, “developing and applying statistical methods for the analysis of network data as well as microbiome data.” Specific topics include infectious diseases on networks, dynamic networks and microbiome of the airplane cabin.
Chart Nightingale used to track the spread of disease.
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Pennington: Most people know Florence Nightingale as the founder of modern nursing. She first came to fame while nursing wounded British soldiers during the Crimean war. After the war, she founded what is considered to be the first secular school of nursing in the world, but the lady with the lamp also made significant contributions to the field of statistics. As the 200th anniversary of Nightingale’s birth approaches, her statistical work is the focus of this episode of Stats and Stories, where we explore the statistics behind the stories and the stories behind the statistics. I am Rosemary Pennington. Stats and Stories is a production of Miami University’s Departments of Statistics and Media, Journalism and Film, as well as the American Statistical Association. Joining me in the studio are regular panelists John Bailer, Chair of Miami’s Statistics Department and Richard Campbell former Chair of Media, Journalism, and Film. Our guest today is a returning guest, Vicki Hertzberg. Hertzberg is the Director of the Center for Nursing Data Science at Emory University. Thank you so much for being here today.
Hertzberg: Thanks for having me.
Pennington: How did Nightingale’s nursing work inform her statistical work?
Hertzberg: She was very politically astute, and she understood that evidence is very persuasive. And in order to have evidence, you have to have data. And that’s how she was able to make such an impact in her work in nursing.
Campbell: So, I have a question about my own kind of general knowledge of Florence Nightingale. Always knew about her nursing, never knew about her statistics stuff. Why is that? Why was I that ill-informed about this? Because when you look at her Wikipedia site today, it calls her English social reformer and statistician and founder of modern nursing, that’s her line there.
Hertzberg: Right, right. I think because the focus has been so much on nursing and that the statistics kind of gets shoved aside.
Bailer: So, can you just summarize for folks that may not have seen this, I mean like Richard was just describing, you know what were some of her statistical kind of contributions to the discussions we are having?
Hertzberg: Well, she was not really an advanced theoretical statistician, but she was great at accumulating data and thinking about ways in which to visualize it. And one of her inventions was what’s called the rose pot, which is basically a circular histogram. And she was using that to demonstrate the seasonality of death in the Crimean war. And that’s- she has a whole treatise on injuries in the Crimean war and contributions to it. And so, what’s remarkable about that is kind of the graphics she used to display the data.
Campbell: What I loved about this graph and I don’t know, did you know about this graph? Because this is amazing. You can look at it just as a – I mean this is from the 1850s but you can look at it and see how she made the argument about how – I think her main argument was about how mortality was being caused by disease not by wounds in the Crimean War, and then her nursing, I think, tactics really lowered the amount of deaths I think from one year to the next, is that right?
Hertzberg: That’s right. That’s right. And that was a pretty remarkable achievement back when we really didn’t know so much about infection.
Campbell: Now did she, did this particular- what did you call this particular kind of graph? Did she invent this or was this just something she used?
Hertzberg: I’m not sure if she invented it or not, but it really gained popularity because of her use. I call it a rose plot; some people call it a wind rose pot and it’s actually one of my favorite graphs.
Campbell: Mine too, it’s really cool.
Bailer: Well, when you think about the training that people got at the time, I mean this was a serious design project.
Pennington: Vicki, so this feels like perhaps the beginning of nursing data science or a movement towards it, how do we move from Florence Nightingale producing this beautiful rose plot to you are now the director of a center for nursing data science. What does that look like and what is nursing data science now?
Hertzberg: Well, it’s a center where we’re trying to grapple with the phenomenon of big data in nursing. In nursing research, nursing practice, and nursing education. And for a long time in nursing research, a big data set was 100 people.
[Laughter]
Hertzberg: So, it’s really come a long way and so we’re working with nursing faculty, with our practitioners at Emory hospitals in determining what are the problems that they have, and how can we best address them using the tools of data science?
Bailer: Can you go into a specific example, perhaps in practice, where you’re thinking, you know, what are some of the big data sets that are being used and what type of impact on practice might it have as you work with these data?
Hertzberg: Okay, well a colleague of mine is in the process of gaining access to some data from Medicare that’s looking at hospitalizations and looking at hospital-acquired infections in those people. And kind of looking at how all that happens, and that is a huge data set. And we have a signature project at the school called project NELL. NELL stands for Nursing Electronic Learning Laboratory. And it is a compilation of data from the clinical data warehouse at Emory healthcare. So, the data have all been de-identified, as per standard methods, and we now have them and are creating a graphical interface so that our faculty and students can use them.
Bailer: Use to do what?
Hertzberg: Questions at their interest. So, we had a student who was interested in looking at the cost of care for different kinds of providers for people undergoing a procedure called TAVR, which has something to do with aortic valve replacement. Or other people who are looking at foot care procedures. I’ve got a student right now who is looking at what’s called the cascade of care for hepatitis C patients in the baby boomer generation. And so, how many people go to get screened to then be tested positive, to be confirmed and then on and on down the line, to then finally becoming cured? So, she was able to use the data from the project to do this.
Pennington: I have a question that is getting back to, I think, something Richard raised early, so when I was a kid my dad used to bring home all these books about like famous females figures, to sort of say you can be whatever you want. And I was obsessed with these biographies of Florence Nightingale and Clara Barton that my dad brought home, I thought that I wanted to be a doctor or a nurse and grew up and realized I did not because I am not good around bodily fluids. But I remember reading those books and was so inspired by them and the fact that these young women and you’re living at this time with these less sophisticated technologies were doing these things. But the memory I have of them is the sort of being these nursing angels and not so much the scientific thinking that went behind the work they were doing. And so, I wonder if part of the reason we don’t know as much about Florence Nightingale’s statistical work is that we just don’t really, broadly, as a broad public, understand the work that nurses do, and the kind of data nurses are collecting.
Hertzberg: You’re absolutely right. When you’re sick and in the hospital, you see your physician when they round, when they are performing a procedure. But you’re seeing that floor nurse quite often. That’s the person that’s going to be there to hold your hand when you die if you don’t have anybody else, and that’s so so important. But for years nursing- you know it was only until the late ‘70s that nursing began to raise up its level with better credentialing. In the late ’70s accreditation for schools of nursing began to insist on having numbers of people- faculty with doctoral degrees, up until then typically you could teach with just a master’s in nursing. And so at that point, there were really no nursing Ph.D. programs to go through, so a lot of people, a lot of nursing faculty began to reach out in other areas and got doctoral degrees in anthropology, education, psychology, epidemiology and it wasn’t until probably the late ‘90s a push for doctoral training in nursing specifically really came to catch on.
Bailer: You know, one thing, as a follow-up to Rosemary’s question- this idea- this perception of that there’s treatment that physicians are doing that you think of medical treatment and procedures, and research into those procedures or research into pharmaceutical agents that you might be having as well. It’s not as clear to think about framing a research question for people when they first encounter this in nursing research. Could you talk a little bit about a nursing research question and how it might be framed and the kind of data that might be gathered to address it?
Hertzberg: Well, we have an NIH funded center to study the metabolomics and microbiome in multiple chronic conditions. And looking at the symptoms have, and our particular focus is that- it’s all around hypertension and the effects of hypertension, but then we’re looking at not only hypertension but other chronic conditions that might coexist. So, it might be obesity and chronic hypertension, it might be HIV and hypertension, it might be some cardiovascular disease and hypertension. And so we’re looking at these different populations that have all this commonality of hypertension and then we’re getting a sample so that we can characterize the gut microbiome, and also looking at what’s going on metabolically in these patients, and then looking at the relationship of all of this to three different symptoms, and those are anxiety, fatigue, and depression.
Pennington: You’re listening to Stats and Stories and today we’re talking with Emory University’s Vicki Hertzberg.
Bailer: You know Vicki, there’s been a lot of attention right now that’s addressed to COVID-19.
Hertzberg: Oh yeah.
Bailer: Oh yeah. We’re hearing a lot about this, there’s a lot of implications of travel, implications of behavior, health promotion issues are obviously at the forefront of a lot of what we’ve been discussing. You talked previously when you joined us about germs on a plane. Thinking about where you were located and the potential risk of health outcomes, adverse health outcomes. How might the work that you did then or other things that you’ve been thinking about in your current work provide insights into this current COVID-19 epidemic in ways that it might be transmitted, in ways we might become part of this epidemic?
Hertzberg: Okay, it’s all about social distancing for COVID-19. For respiratory infections that are spread by large droplets. So, large droplets are the things that you kind of spew when you cough or sneeze or even sometimes when you talk, and those are the ones that pretty much get taken over by gravity very quickly, and they drop to the floor within about a meter of you. So, those are the ones you have to typically worry about for diseases like influenza, which happens every year, by the way, and is of concern to air travelers. So, in our work, we were trying to figure out where could you cut down on those kinds of exposures? So, in our case, we settled on choosing an aisle seat on an airplane because you cut down on the people that are in close proximity to you. But it has other implications, for instance, I have a colleague that works in emergency medicine and we were similar- before we did the airplane study I actually worked with him about doing a similar study in the emergency room. And so, it has implications for say, how you seat people in the waiting room in the emergency room and how you move them around, etcetera. What we found there was actually that it’s not so much the sick patient you have to worry about, but it’s actually a sick staff member that comes in. And they spend a lot of time with other staff members. And so that’s actually trying to reengineer spaces at their work areas because they really don’t- in this particular emergency room there were actual exam rooms with doors and walls, and so the amount of time a provider or nurse or administrative person would be in his room would be relatively short and then they would go back to their work areas, where they’re working much more closely together and they spend a lot of time there. And so that’s really where you have the risk of spreading something. Both studies were motivated by SARS, another coronavirus. In the case of the emergency room, the first case that flew back to Toronto Canada was a woman who came in from Beijing and her son cared for her, and she died and he got sick and he went to a busy hospital to their emergency department. He was stuck in a hall waiting for a bed assignment for hours and as a result of that exposure, as well as him just being in the hospital, there was something like 120 other either direct transmissions or later indirect transmissions because of exposures due to those direct transmissions, that came down with SARS, some of whom died, some of whom were staff, etcetera, so that was really my colleague’s motivation for this. Similarly, when the SARS epidemic came just like we’re seeing now, airline business slowed down. One of the airlines in Canada, I believe, don’t quote me on this, but I believe had to either came close to or actually underwent bankruptcy reorganization. And in those circumstances, airlines aren’t buying airplanes. So, a colleague of mine at Georgia Tech knew about the work I’d been doing in the emergency room and he had been approached by the Boeing company. The Boeing company is in the business of selling airplanes, and if people are worried about getting sick on airplanes and they’re not flying, Boeing is not going to be able to sell their product, and so they funded us to do the germs on a plane study as well. It’s had some implications for them to kind of rethink some of their cabin design, for instance, and their ventilation, in addition to just seating.
Campbell: So, Vicki, this morning in the New York Times there was a story that the airlines are worrying they may lose up to $100 million if this epidemic gets really big. Do you have any sort of practical advice? I know my wife and I- she just wanted to cancel a flight to- we were going to go visit relatives in Arizona. So, at this stage of this epidemic how would you advise people just sort of flying domestically in the United States, from what you know?
Hertzberg: From what I know, I’m not canceling any panned trips on the basis of concern about the coronavirus. And I would not advise anybody to do that, unless they were planning to travel to China, Iran, or Italy, Korea, Japan where there are big outbreaks. But how many million people in the United States? Over 300 million people, how many have been infected with Coronavirus so far in the U.S.? It’s really a very infinitesimally small probability that you are going to come into contact with someone on an airplane.
Pennington: One of the things I’ve been struggling with, Vicki, as I’ve been reading about COVID-19 is that flu takes down thousands of people every year, and thousands of people die every year of flu, and it seems like we can’t get people to get flu vaccines. And then there’s the coronavirus, which, certainly seems bad in a handful of countries but it feels to me the response- it’s hard to know how much of the response I’m seeing is an overreaction to a disease that people don’t understand really well yet -and yes we can fly you just said, but are there other precautions that you think are being pushed out there that is advisable or how would you suggest someone who is consuming all of this information about coronavirus and COVID-19 navigate all of this information?
Hertzberg: Well the WHO and the CDC have very good websites for people to consult as this problem evolves, and it will evolve. I agree influenza is a concern. So, a lot of these public health measures that we’re talking about social distancing, washing your hands, don’t touch your face, get your vaccine, those are applicable year after year after year. I think with COVID-19 it was scary because initially there was so much of it in one city and nobody kind of knew and it was a pretty scary disease. But as they have begun to- especially the Chinese, as they began to get in – you know get people under ventilators or getting people ECMO, that the mortality rates have gone down a lot. And that was what was initially so terrifying. We don’t have a vaccine for coronavirus, that I am aware of. And so – and it will be a couple of years before we have an effective vaccine against this particular virus. So, some of these other travel things have been done, I think, for other reasons. I know the American Physics Society canceled its big meeting in Denver earlier this week. So, it was supposed to start on Monday, and it was canceled on Sunday and that was really because they were expecting a lot of international attendees from countries such as Italy, Iran, Korea, etcetera, and did not want that exposure. But on the other hand, I have another colleague who is scheduled to go to Rwanda next week and that trip has been canceled because they don’t want to get stuck. So, they don’t want to get stuck in a quarantine situation for two weeks. Here at Emory, they’ve banned all business travel to those countries for the time being. And anybody returning has to self-quarantine for 14 days.
Bailer: So, one thing that you’ve talked about when we’ve chatted previously was the idea of other transfers. You talk about the social distance for some of the infections spread by large droplets, but you’ve talked about some indirect transfer risks as well. Is that something that’s been commented on with COVID-19? What is this indirect transfer and how might we limit our exposure through indirect transfer?
Hertzberg: It’s when the virus or the particles that carry it land somehow, on a physical object. So for instance I cough or sneeze in my hand, I leave the room and I use the doorknob to shut the door, and then a few hours later you come into the room and you touch your hand, you take your hand and touch the doorknob and twist it to open and then you somehow touch your face thereby transferring [inaudible] that are still alive on that surface into the mucosal areas of your face, and that’s how the virus enters the body. I have heard that the virus is alive on surfaces. I do know that other viruses can survive on surfaces for hours and it’s really dependent on the type of surface.
Bailer: So, I shouldn’t take back this pen I just loaned Richard?
[Laughter]
Campbell: I was just sitting here thinking I think I’m going to get a pen here.
Hertzberg: But if you’re on an airplane, for instance, you might want to think about, besides observing good hand hygiene, is when you’re touching that video pad that’s in the seatback in front of you, perhaps covering your finger with tissue to do that touching. When you’re in the lavatory and you’ve washed your hands and you’re ready to exit, use a paper towel to open the door, and then throw it away. So that you’re kind of trying to preserve that hand hygiene as much as you can.
Pennington: Nothing makes you realize how much you touch your face like being told don’t touch your face.
[Laughter]
Pennington: Well Vicki, that’s all the time we have for this episode of Stats and Stories. Thank you so much for being here today.
Hertzberg: Well, thank you for having me.
Pennington: Stats and Stories is a partnership between Miami University’s Departments of Statistics and Media, Journalism and Film, and the American Statistical Association. You can follow us on Twitter or Apple podcasts or other places where you can find podcasts. To share your thoughts on the program send your email to statsandstories@miamioh.edu or check us out on statsandstories.net and be sure to listen for future editions of Stats and Stories, where we discuss the statistics behind the stories and the stories behind the statistics.