The county’s Tuberculosis Program was working with the Metropolitan Transit System Tuesday to notify riders of the trolley’s Blue Line that they were potentially exposed to and are at risk for tuberculosis.

The exposure happened between Jan. 27 and Feb. 29 of this year, and the specific impacted routes are:

• The Blue Line between 24th Street Transit Center and Barrio Logan Transit Center, on Monday to Friday, on an inconsistent schedule but typically between 10:30 a.m. and 2:30 p.m. in the above time frame
• The Blue line between San Ysidro Transit Center and Old Town Transit Center roughly between 5 a.m. and 7 a.m., and from Old Town to San Ysidro between 6 p.m. and 7 p.m. on Friday, Feb. 16

Since exposures occurred at inconsistent hours, the likelihood that any rider had long cumulative exposure times is low, according to the county. These exposures are not known to be associated with any previously reported exposures on the MTS system.

TB is an airborne disease that is transmitted from person-to-person through inhalation of the bacteria from the air. People with frequent and prolonged indoor exposure to a person who is sick with TB should get tested.

“Symptoms of active TB include persistent cough, fever, night sweats and unexplained weight loss,” Dr. Wilma Wooten, county public health officer, said in a statement.

“Most people who become infected after exposure to tuberculosis do not get sick right away. This is called latent TB infection. Some who become infected with tuberculosis will become ill in the future, sometimes even years later if their latent TB infection is not treated. Blood tests and skin tests are effective in determining whether someone has been infected.”

Taking medicines for latent TB infection can cure the infection and keep people from ever getting active TB disease.

According to the county, the chance of TB infection is highest for people with many hours of cumulative indoor exposure to a person who is sick with TB. Brief interactions with an ill rider are less likely to lead to TB infection than are prolonged or repeated exposures.

The County TB Control Program recorded 193 TB cases in the county in 2020, 201 people in 2021 and 208 people in 2022. In 2023, the county recorded 243 people with active TB disease.

An estimated 175,000 people in San Diego County have a latent TB infection and are at risk for developing active TB without preventive treatment, health officials said. People who test positive for TB, but who do not have symptoms of active TB, should get a chest X-ray and talk to a medical provider, as they may likely have a latent TB infection.

Anyone who would like more information on this potential exposure should call the county TB Control Program at 619-692-5565.

City News Service contributed to this article.

San Diego County’s Tuberculosis Program and the Metropolitan Transit System are working to notify some area travelers that they were potentially exposed to a tuberculosis infection earlier this year.

The warning was issued to riders who used certain Trolley Blue and Green lines and bus riders and drivers who used Route 901.

It applies to the following:

• the Trolley Blue Line between Balboa Ave Transit Center and Old Town Transit Center, and the Green Line between Fashion Valley and Old Town, roughly between 6 a.m. to noon Monday to Sunday from Feb. 16 to Aug. 15
• bus route 901 from Iris Avenue Transit Center to Palm Ave., and Eighth Street 10-11 a.m. and 6-8 p.m. from April 22 to July 15

“Trolley exposures did not occur on a specific schedule,” a county statement read. “As such, large numbers of people may have had exposures, but the likelihood that any particular rider had long cumulative exposure times is low.”

Brief interactions with an ill rider are less likely to lead to TB infection than are prolonged or repeated exposures.

“Symptoms of active TB include persistent cough, fever, night sweats and unexplained weight loss,” said Dr. Wilma Wooten, county public health officer. “Most people who become infected after exposure to tuberculosis do not get sick right away. This is called latent TB infection. Some who become infected with TB will become ill in the future, sometimes even years later, if their latent TB infection is not treated. Blood tests and skin tests are effective to determine whether someone has been infected.”

While the MTS follows recommended sanitation practices of the U.S. Centers for Disease Control and Prevention, TB is airborne and not spread by touch, so cleaning practices do not impact the risk of tuberculosis in transit vehicles or stations, according to the county.

Other MTS riders with TB have been previously reported in August and September 2022, and in February 2023. The county Health and Human Services Agency does not have any evidence directly linking the rider or riders most recently diagnosed with TB to the other MTS riders. Additional lab tests will be conducted to determine if there might be linkages.

People with TB could be sick for many months before they are diagnosed, and as such, exposure periods can be long.

TB is an airborne disease that is transmitted person-to-person through inhalation of bacteria. The chance of infection is higher for people with prolonged indoor exposure to a person who is sick with TB.

Individuals who want more information on this potential exposure can call the County TB Control Program at 619-692-8621.

According to county data, the number of people diagnosed with active TB in San Diego County has decreased since the early 1990s and has stabilized in recent years. There were 192 cases in 2020 and 201 people reported with active disease in 2021. In 2022, 208 people were reported with active TB disease in San Diego County.

City News Service contributed to this article.

The slate of five bills in the California Legislature proposed by the vaccine working group fails to recognize that while COVID-19 vaccines do provide protection against serious and life-threatening infections, they do not block transmission. That makes vaccination a personal health choice based upon individual risk. It does not justify mandating vaccination. 

Mandates for a vaccine that does not block transmission are discriminatory. They force unvaccinated individuals to comply in order to attend school or keep their job.

This is discrimination by coercion: Vaccinated individuals are as likely to spread viral particles as unvaccinated people, yet their activities are not restricted. The reasoning behind these mandates is not supported by current science-based data.

Assemblymember Buffy Wicks (D-Oakland) had the wisdom to cancel the scheduled March 30 hearing for Assembly Bill 1993. This bill would have required employees in California public and private businesses to be vaccinated against COVID-19, with financial penalties imposed on employers who failed to comply. Wicks cited the waning of the pandemic, along with opposition from police and firefighters unions, when she canceled the hearing.

These bills, however, are still under consideration: 

Senate Bill 871 mandates COVID vaccination for children ages 0 to 17 in order to attend school or day care, without waiting for FDA approval, and without allowing religious or personal-belief exemptions. This same bill also mandates vaccination for hepatitis B, a blood-borne and sexually transmitted disease, in order for students to enter seventh grade.

Senate Bill 866 allows children age 12 and older to be vaccinated without their parents’ knowledge or consent. It does not specify which vaccines.

Assembly Bill 2098 threatens doctors and health care workers with disciplinary action if they share information with patients that strays from the state and federally approved messaging and treatments for COVID-19. 

Senate Bill 1464 requires law enforcement to oversee compliance with these and other public health orders.

The passage of such bills will do nothing to stop the virus, but will widen the vitriolic divide that has resulted from poorly thought-out public health policy and media influence.

Research has shown that the immunity induced by COVID-19 vaccination, and even the booster shots, wanes over weeks to months. In addition, as the virus has mutated, the original vaccine has proven to be less effective against new variants, such as omicron and omicron2.

For children in the 5- to 11-year-old age group, the drop in vaccine effectiveness was dramatic. A recent study found that one month after vaccination, protection from the omicron strain was only 12%.

In addition, the Centers for Disease Control and Prevention has reported that the vaccine does not stop transmission. Vaccinated individuals continue to shed and spread the virus if they become infected. More studies showing the vaccine’s inability to stop transmission can be found here and here.

Individuals should act responsibly in order to minimize infecting others. If people feel ill, they should get tested and stay home. While home, they should isolate and wear a high-quality mask. 

The COVID virus has become less virulent as it mutates. As it has moved through the population, we have been building protection against COVID-19 (referred to as herd immunity), both through naturally acquired immunity and vaccine-induced immunity.

As a result, we are seeing the numbers of cases, hospitalizations and deaths head downward in California and the United States. Across the country and throughout California, vaccine mandates and mask mandates have been dropped, and cases, hospitalizations and deaths have continued to decline. 

This slate of bills undoubtedly was conceived at a time when COVID-19 was raging and it seemed that the vaccine was the only light to lead us to safety. As the science around COVID vaccines and the disease itself has evolved, however, these bills have become obsolete. Legislators should shelve the entire slate and encourage personal health responsibility.

Dr. Eileen S. Natuzzi, a retired surgeon and public health epidemiologist, worked at the San Diego Department of Public Health on its COVID response until April 2021. Elisa Carbone is a freelance writer and researcher. The authors wrote this for CalMatters, a public interest journalism venture committed to explaining how California’s Capitol works and why it matters.

Despite indications the state was on the verge of lifting its mask-wearing requirement in schools, the state’s Health and Human Services secretary said Monday the requirement will remain in place for now, pending a Feb. 28 reassessment of COVID-19 case rates and other pandemic metrics.

Dr. Mark Ghaly said a lifting of the mandate is inevitable, saying it is just “a question of when.” He expressed confidence that the mandate would be lifted after that Feb. 28 reassessment, barring another sudden spike in virus infection rates and hospitalizations.

Ghaly gave a lengthy presentation noting significant downward trends over the past month statewide in COVID case rates, hospitalizations and testing positivity rates. But he said as far as schools are concerned, the state is only “close to a point” where such a move can be made, so no immediate change will be made.

“Parents should not hear that we aren’t making a move,” Ghaly said, insisting the state is only “taking a little more time” to ensure pandemic metrics continue on a downward path.

He said he respects that many parents who have been calling for a lifting of the mandate will be upset by the decision, but he insisted there are others who maintain uncertainty about whether lifting the requirement in schools is safe for students and staff.

Gov. Gavin Newsom has expressed a desire to ease up on the school masking mandate, although he noted last week there has been some resistance from teachers’ unions who still have safety concerns.

Ghaly noted that even when the state lifts its requirement for masks in schools, individual counties or school districts could still require them.

The state on Wednesday will lift its mask-wearing requirement for vaccinated people in most indoor public spaces, but some counties — most notably Los Angeles County — will continue to require face coverings indoors.

Look no further than your favorite restaurant, your kid’s school or your local hospital to see the effect of California’s latest bout of infections.

Cases have skyrocketed since the holidays, reaching nearly 7 million people infected since the pandemic began. That means so many workers are calling in sick that many businesses and offices are left understaffed and fellow workers are stretched thin. 

Health officials are walking a fine line between keeping essential services and the economy afloat and controlling the spread of the virus. But a labor shortage has noticeably influenced national and state COVID-19 policies — even temporarily allowing for health care employees to continue working despite a positive test as long as they feel no symptoms and wear an N95 respirator. These guidelines have prompted questions about safety and whether public health is being jeopardized.

Since the start of the pandemic, California’s top officials have been adamant that the state’s COVID-19 response is based on science. But these policies also have to be flexible, Gov. Gavin Newsom recently told reporters. 

“It’s called dealing with reality,” the governor said in defense of recent health workplace guidelines during his Jan. 10 budget briefing. “The pragmatism — not what you want, but what you need to do at a time of challenge.”

Experts note that the virus and the pandemic environment are fast-changing, and policies in response have to adjust quickly.

But labor needs and politics aside, when it comes to returning safely to work, what are experts and research telling us about omicron? When is it safe for an infected employee to return to work and how dangerous is it to shorten that period? What if you have no symptoms? And what should your employer be doing to keep you and your coworkers safe? Here’s what you need to know. 

With Omicron, People Are Infectious Quicker

A red flag with omicron is that early research suggests that the incubation period — the time between when one becomes infected and when one starts to show symptoms — is shorter with this variant — about three days, compared to the four to five days of earlier strains.

Usually the day before symptoms start and the day symptoms appear are when people are the most infectious, said Sanghyuk Shin, director of UC Irvine’s infectious disease science initiative. 

That means people can become highly infectious faster with omicron than with the previous variants. For example, if person A is infectious and A infects B, person B can then infect person C quicker with omicron than they may have with delta.  

“This creates epidemic dynamics that are really hard to get in front of,” said Andrew Noymer, epidemiologist and professor of public health at UC Irvine. “Because it’s so rapid.”

Here is how fast omicron is moving: It was first identified in late November; in the week ending on Dec. 18, the omicron variant was responsible for about 38% of the cases in the U.S., according to the CDC’s variant monitoring system. By the week ending on Jan. 15, omicron made up 99.5% of cases.

Experts Suggest Isolating Until Testing Negative

In late December, the Centers for Disease Control and Prevention shortened the recommended isolation period for a person who tests positive but no longer has symptoms from 10 days to five. Those who were exposed but haven’t tested positive should also quarantine for five days, the agency said. 

The CDC said the change was motivated by growing data showing that much of the transmission was occurring earlier “generally in the one to two days prior to onset of symptoms and the two to three days after.”

But this move came with quite a bit of pushback and criticism from some in the public health and medical communities who deemed it too lax, especially because the federal rules don’t require a negative test to leave isolation. California updated its guidance to align with the CDC’s, but the state does ask that people remain isolated until they receive a negative test.

Some research has shown that people can still be contagious after five days of testing positive. A small study from Harvard, for example, took a look at infected NBA players and found that 25% of players infected with omicron were still infectious on day six after their first positive test and 13% were still contagious on day seven. The study has yet to be peer-reviewed.

“Having people who might still be infectious return to work, could of course lead to more people getting infected and additional workers being forced to isolate,” Shin said. 

The World Health Organization says people with symptoms should isolate for a minimum of 10 days after the first day of symptoms, plus another three days after their symptoms end. Meanwhile, asymptomatic people should isolate for a minimum of 10 days after a positive test.

While recommendations about isolation and quarantine can be hard to keep up with, the bottom line is that people should test negative before returning to work and gathering with others, regardless of symptoms, Noymer said. 

Asymptomatic Transmission Is a Big Deal

Asymptomatic transmission does occur and it’s a big reason why the pandemic has been so difficult to control.

“We can tell everyone who feels sick to stay home, but not everyone feels sick,” said Shin. 

Experts say the best public health practice is for anyone who tests positive to isolate, regardless of how they feel.

Studies — albeit, many conducted pre-omicron — have shown that a large percentage of COVID-positive people show no symptoms. Research published in December reviewed 95 studies consisting of about 30 million people worldwide. Of those who tested positive, 40% had no symptoms at the time of testing. ​​”The high percentage of asymptomatic infections highlights the potential transmission risk of asymptomatic infections in communities,” the research authors concluded.

Meanwhile, separate studies show that the viral loads of asymptomatic patients were comparable to those who had symptoms.  

Your Risks at Work Depend on Many Factors

Trying to calculate the odds that you’ll contract COVID at work is not really possible because there are so many factors to consider, experts say.

Research has shown that wearing masks indoors can substantially cut transmission, and with omicron, a high-quality mask is more important than ever. N95 masks are the gold standard, especially with a variant as contagious as omicron, Noymer said. Cloth masks are much less effective unless they have multiple layers and a nose wire. And it’s essential for masks to fit snugly around the mouth, nose and chin.

“A well-fitting N95 mask should do a pretty good job. But nothing is guaranteed,” he said. “Surgical masks do something, but they’re not great…and some masks are just pure theater.”

N95 masks can filter about 95% of particles in the air, according to the CDC. Experts at UC Davis say it is OK to reuse an N95 mask, but they recommend waiting one to two days between uses so that viral particles can die off. 

How crowded a room is also plays a big role. If you’re in a busy kitchen or warehouse without many windows, the risk will be greater, Shin said. 

Repeated Tests Are Best 

A molecular PCR test is the most sensitive and most likely to capture an infection, but rapid antigen tests are effective tools too, experts say. 

Antigen tests are often used for routine screening of people who are not sick. If being used as a precaution for an in-person gathering, for example, Shin says a repeat test could help rule out a false negative — a test the day before and a test the day of an event.

However, given the shortage of rapid tests, this could seem like a luxury. People with symptoms looking to confirm whether they’re infected or not, ideally would seek a PCR test, Shin said. But with a backlog in testing, results are sometimes taking more than three days.

Because of the heightened demand for testing, some California counties have come out with new recommendations. Some have urged residents to only get tested if they have symptoms and others have asked people to first seek tests from their health care provider rather than county-ran testing sites because they are overwhelmed.

In an ideal world with no supply shortages, workers who come in contact with large numbers of people, such as those who work in customer service or in grocery stores, would be able to access testing easily and test repeatedly and routinely, experts say.

That said, routine testing of essential workers should go hand-in-hand with adequate paid sick leave, Shin said. “I’ve definitely known people who have said they don’t want to get tested because they don’t know what to do if they test positive. They can’t not go to work, they need to pay rent.”

California’s COVID sick leave expired in September and legislators and labor unions are negotiating how to reinstate it. 

Workplaces Can Do a Lot to Minimize Workers’ Risk

Shin said there is room for more education of workers on how the virus spreads. For example, if someone is in an office space alone, they might think it is safe to take their mask off, but if that same space is occupied by others throughout the day, then people should keep their masks on because COVID-19 is airborne and infectious respiratory particles can remain in the air for up to three hours. 

Improving ventilation helps, too.

“Opening windows seems like a no-brainer, but opening windows reduces risk,” Shin said.

Workplaces should also consider investing in high grade filtration systems or high efficiency particulate air (HEPA) filters, experts say. According to the Environmental Protection Agency, filters need to be able to remove small air particles in the size range of 0.1 to 1 microns to help remove viruses. 

CalMatters is a public interest journalism venture committed to explaining how California’s state Capitol works and why it matters.

Former resident Bill Clinton will remain overnight in an Orange County hospital following a urological infection, but he has continued to make “excellent progress” and is expected to be discharged on Sunday, his spokesman said in a statement on Saturday.

The 75-year-old, who served as president from 1993 to 2001, entered the UC Irvine Medical Center on Tuesday evening after suffering from fatigue.

Clinton spokesperson Angel Urena said the former president was doing well.

“He is in great spirits and has been spending time with family, catching up with friends, and watching college football,” Urena said in a statement posted on Twitter.

Clinton’s wife, former Secretary of State and 2016 Democratic presidential nominee Hillary Clinton, was at the hospital on Saturday.

The former President also received a phone call Friday from President Joe Biden.

“Oh, I wanted to see how he was doing,” Biden told reporters while traveling in Connecticut. “He’s doing fine. He really is. And he’s going to be released from the hospital. And we talked about, which we were going to do before, getting together. I haven’t seen him in a while, and for him to come over and have some lunch and talk.”

Since his admission to the hospital’s intensive care unit, he has received fluids and antibiotics, his doctors said.

Clinton, who was in California to attend a dinner and reception for his foundation in Los Angeles County, has dealt with health problems in the past. He had quadruple bypass operation in 2004 and a procedure to open a blocked artery in 2010.

City News Service and Reuters contributed to this article.

Former President Bill Clinton was being treated at UC Irvine Medical Center Thursday for a “non-COVID-related infection,” but doctors said they hope to discharge him soon.

In a statement, Clinton spokesman Angel Urena said, “On Tuesday evening, President Clinton was admitted to UCI Medical Center to receive treatment for a non-Covid-related infection. He is on the mend, in good spirits and is incredibly thankful to the doctors, nurses and staff providing him with excellent care.”

Urena also released a statement from Clinton’s doctors — Dr. Alpesh Amin and Dr. Lisa Bardack — who expressed confidence he would be sent home soon.

“President Clinton was taken to UC Irvine Medical Center and diagnosed with an infection,” they said. “He was admitted to the hospital for close monitoring and administered IV antibiotics and fluids. He remains at the hospital for continuous monitoring.

“After two days of treatment, his white blood cell count is trending down and he is responding to antibiotics well. The California-based medical team has been in constant communication with the president’s New York-based medical team, including his cardiologist. We hope to have him go home soon.”

Clinton, 75, was the 42nd president of the United States, serving from 1993 to 2001. The Democrat previously served as governor and attorney general of Arkansas.

In a study published Thursday, a team led by researchers at UC San Diego have discovered how glycans — molecules that make up a sugary residue around the edges of the spike protein — act as infection gateways for SARS-CoV-2, the virus which causes COVID-19, which may be a key to countering the virus.

Since the early days of the COVID pandemic, scientists have aggressively pursued the secrets of the mechanisms that allow the virus to enter and infect healthy human cells.

Early in the pandemic, UCSD’s Rommie Amaro, a computational biophysical chemist, helped develop a detailed visualization of the SARS-CoV-2 spike protein that efficiently latches onto our cell receptors.

Published Thursday in the journal “Nature Chemistry,” a research study led by Amaro, co-senior author Lillian Chong at the University of Pittsburgh, first author and UCSD graduate student Terra Sztain and co-first author and UCSD postdoctoral scholar Surl-Hee Ahn, describes the discovery of glycan “gates” that open to allow SARS-CoV-2 entry.

“We essentially figured out how the spike actually opens and infects,” said Amaro, a professor of chemistry and biochemistry and a senior author of the new study. “We’ve unlocked an important secret of the spike in how it infects cells. Without this gate, the virus basically is rendered incapable of infection.”

Amaro said she believes the research team’s gate discovery opens potential avenues for new therapeutics to counter SARS-CoV-2 infection. If glycan gates could be pharmacologically “locked” in the closed position, then the virus is effectively prevented from opening to entry and infection.

The spike’s coating of glycans helps deceive the human immune system since it comes across as nothing more than a sugary residue. Previous technologies that imaged these structures depicted glycans in static open or closed positions, which initially didn’t draw much interest from scientists. Supercomputing simulations then allowed the researchers to develop dynamic “movies” that revealed glycan gates activating from one position to another, offering an unprecedented piece of the infection story.

“We were actually able to watch the opening and closing,” said Amaro. “That’s one of the really cool things these simulations give you — the ability to see really detailed movies.

“When you watch them, you realize you’re seeing something that we otherwise would have ignored,” she continued. “You look at just the closed structure, and then you look at the open structure, and it doesn’t look like anything special. It’s only because we captured the movie of the whole process that you actually see it doing its thing.”

The simulations were first run on “Comet” at the San Diego Supercomputer Center at UCSD and later on “Longhorn” at University of Texas, Austin. Such computing power provided the researchers with atomic-level views of the spike protein receptor binding domain, or RBD, from more than 300 perspectives. The investigations revealed glycan “N343” as the linchpin that pries the RBD from the “down” to “up” position to allow access to the host cell’s receptors. The researchers describe the glycan activation as similar to a “molecular crowbar” mechanism.

–City News Service

As medical tourism, in which a person travels to another country for medical care, becomes more popular, it’s important to understand the pros and cons. 

According to the Centers for Disease Control and Prevention, each year millions of U.S. residents engage in medical tourism, traveling to Mexico and Canada, as well as Central America, South America, the Caribbean and the far East.

Medical tourism is widespread within the United States. People may travel from city to city, or state to state to find the right physician and facility that meets their medical needs. This kind of medical tourism can be very safe and achieve positive results.

But medical tourism outside of the United States is different. Some patients travel because of cultural preferences, seeking to be treated in their country of origin. Others may need a procedure or medication unavailable or not approved in the United States. The primary motivation, though, is cost. Many procedures, including those in my field of plastic surgery, may be cheaper in other countries. But anyone considering this option must understand the potential risk.

In the United States a plastic surgeon needs to follow the highest clinical standards. These standards do increase the cost of health care, but they also increase safety.  When you see lower costs, you must ask yourself what elements of safety and recovery are not included.

Recently I took over the care of a woman from Pennsylvania who looked abroad for plastic surgery options. She found a physician in Mexico to perform her “tummy-tuck.” The woman underwent surgery the day after her arrival without any pre-operative protocols. 

The attending physician and staff did not have full access to the patient’s history, which included susceptibility to resistant infections. So she received insufficient pre-operative antibiotics, and as a result suffered a severe infection that was not caught promptly. When it was diagnosed, the woman could not be treated at the facility that performed the operation.  Instead, she was sent back to San Diego for emergency care.

After two weeks at the hospital, she returned to Pennsylvania for continued management of infection and wound care. She survived her complications but was left with permanent deformities of her body.

When complications do occur, the money saved quickly evaporates. A patient’s medical insurance rarely covers incidental expenses incurred in a country outside the United States. Medical tourism physicians may be reluctant to order expensive antibiotics and other medications, and the facility may not have access to a qualified recovery unit or hospital. Often, no family is present when severe complications occur.

Negative outcomes do not always happen with medical tourism, but they are avoidable in the first place. The missing component in medical tourism is standard of care.

In the United States we have the gold standard in terms of safety and regulations. When followed correctly, each patient is scheduled for a first visit so that they meet their doctor. Their discussion assures full understanding of the surgery, outlines what preparations the patient will need to take in advance, and addresses any concerns the patient may have. 

The meeting is a precursor to obtaining a complete history of the patient. A full physical is performed, labs ordered, and health status determined. This is followed by a workup plan and assurances that all issues are addressed.  Surgery takes place in a fully accredited facility with a board-certified anesthesiologist and board-certified plastic surgeons. Post-surgical recovery should include the attending surgeon’s participation to assure continuity of care.

Not all countries follow these standards. Many sacrifice health standards and safety to save money. When traveling to other countries time is limited. The CDC notes that complications depend on the destination, the facility where the procedure is being performed, and whether the patient is in good physical and psychological condition for the procedure.

Other issues that can increase the risk of complications include infectious disease. All medical procedures have some risk of complications, but those associated with procedures done in other countries can include wound, bloodstream and donor-derived infections, as well as diseases such as hepatitis B, hepatitis C, and HIV.

Antibiotic resistance is a real concern and a global problem. However, you are more likely to get an antibiotic-resistant infection outside the United States and not have access to the appropriate medications.

Quality of care differs significantly in some countries where requirements for maintaining licensure, credentialing, and accreditation may also be less than what would be required here. In some countries, counterfeit medicines and lower quality medical devices may be used.

Communicating with staff at the destination and healthcare facility may be challenging. Receiving care at a facility where you do not speak the language fluently could lead to misunderstandings about your treatment and care.

For people considering medical tourism, I recognize that excellent surgeons exist all over the globe. In the United States, though, we have the most advanced and regulated training for surgeons in the world.

For example, plastic surgeons in the United States are required to have six to nine years of training after they receive their medical degree. We are observed over years by a committee of peers before and after obtaining board certification. This is followed by acceptance into the American Society of Plastic Surgeons and American Society for Aesthetic Plastic Surgery for continued training and education.

The bottom line is if you are considering medical tourism as a cost-effective option for plastic surgery, consider a board-certified doctor in the United States first. Talk to your plastic surgeon, ask as many questions as you like and investigate his or her credentials as well as the accreditation of the surgical center where you will be operated. Then, you can compare all this information. Cost savings are never worth your health and well-being — or even your life.

Dr. Hector Salazar-Reyes is a board-certified plastic surgeon with the La Jolla Cosmetic practice.

Los Angeles and Orange counties appear headed for the red tier in the weekly California COVID-19 infection rankings released Tuesday, but San Diego likely has another two weeks to go.

San Diego County had an adjusted case rate of 8.8 per 100,000 population for the week ended Feb. 27, just above the threshold of 7.0 for remaining in the purple tier.

In Los Angeles and Orange counties, where coronavirus cases peaked earlier than in San Diego, the rates were 5.2 and 6.0, respectively. If those counties maintain the low rates for another week, they’ll drop into the red tier.

Like San Diego, Riverside County will likely be in the purple tier for another two weeks, with a case rate of 8.3 per 100,000 people in the latest report.

Moving out of a tier requires two full weeks at a lower case rate. The California Department of Public Health assesses counties on a weekly basis and schedules updates for Tuesdays.

However, there’s a chance that San Diego County could move into the red tier next week due to an increase in statewide vaccinations. Next Tuesday, the threshold for purple is expected to move up to 10.0 cases per 100,000 people. San Diego is already below that, and there’s a possibility the state will retroactively classify this week’s number as red tier.

In the red tier, schools can reopen for indoor instruction, and restaurants, movie theaters and gyms can resume indoor operation at limited capacity.

Updated at 2:30 p.m., Tuesday, March 9, 2021