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Check back often as we continue to post timely updates on COVID-19. 


Successful pandemic innovations: A line team takes charge of placing lines in the covid ICU.


December 7, 2021

The CMS puts its vaccine mandate on hold

pause-buttonIn response to legal challenges, the CMS has suspended its vaccine mandate for all health care workers in facilities that participate in the Medicare and Medicaid programs. HealthLeaders reports that the CMS has appealed two federal injunctions granted in late November that affect mandatory vaccinations for health care workers in all states. The CMS points out, however, that hospitals are free to pursue voluntary vaccination requirements among their workers. Meanwhile, OSHA has also suspended its mandate requiring employers with 100 or more employees to mandate either vaccination or regular testing, and that agency has extended the public comment period on the requirement.

How to keep clinicians in the workforce

The pandemic has not only caused providers an unprecedented level of burnout and exhaustion, but it’s subjected them to harassment and distrust due to vaccine misinformation and misinformation. To meet those challenges and to preserve the health care workforce, opinion writers in Annals lay out a 10-point manifesto they call on hospitals and organized medicine to help implement. “(T)he entities that employ us,” they write, “must move beyond suggesting stress-reduction activities, such as yoga and meditation, to provide the tactical support clinicians need.” Among other necessary actions, that support includes ensuring clinicians’ on-the-job safety through vaccine mandates, PPE, and ventilation; providing professional development to help clinicians manage anger when dealing with unvaccinated patients; extending support to parents in the form of flexible scheduling; offering free and confidential mental health resources; removing all questions about mental and physical health diagnoses from credentialing and employment applications; and implementing suicide prevention strategies, including wellness check-in for clinicians in hard-hit areas.

December 6, 2021

Omicron: more contagious but less severe?

With omicron now confirmed in more than a dozen states, very early data contain possible clues about its transmissibility and severity. A report from South Africa on one district’s early experience there indicates that most patients hospitalized with the variant didn’t require supplemental oxygen or ICU-level care. News items point out, however, that the report is based on a small patient sample, while experts do note how rapidly caseloads in South Africa are rising. That hints at omicron’s greater transmissibility vs. delta’s. Another early indication: Reinfections with omicron may be more frequent than with previous variants. The Atlantic lays out both the worst- and best-case scenarios of the new variant. The author argues that a strain that causes broad infection but causes only mild symptoms might be a good thing.

December 3, 2021

mRNA vaccine safety—and which one is the winner

covid-vaccine-comparisonMore evidence that mRNA vaccines—or at least the Pfizer vaccine—are safe among older patients: French researchers in a nationwide study find no jump in the number of heart attacks, strokes or pulmonary emboli among patients ages 75 or older in the two weeks after each vaccine dose. The authors looked at close to 3.9 million people. As for the efficacy of mRNA vaccines, an NEJM study comparing the effectiveness of the Pfizer and Moderna vaccines finds that Moderna’s performed better in preventing infection, hospitalization and death. The research followed close to 450,000 veterans over six months. Compared to those receiving Pfizer vaccine, those given Moderna’s had a 21% reduced infection risk and a 41% lower risk of being hospitalized. An editorial, meanwhile, points out that Moderna’s edge in that research makes it only “marginally more effective” and reaches this conclusion: “The message is that the best vaccine is the one that’s available.”

If antivirals are the next frontier, how will patients access them?

An FDA advisory panel this week (narrowly) recommended authorization of Merck’s molnupiravir, which if approved would be the first oral antiviral to fight covid. While recent manufacturer results give molnupiravir an only 30% relative risk reduction in covid hospitalizations or deaths, not the 50% originally indicated, the drug—if authorized—could appreciably reduce the number of covid patients in hospitals. But patients would need to receive it within the first few days of experiencing symptoms, and the author of a new MedPage Today opinion piece points out that 25% of patients in the U.S. don’t have a primary care physician. To ensure adequate delivery, he recommends expanding access to telehealth; he is a chief medical officer of a telehealth company, as well as a PCP. He also recommends allowing nonphysicians to prescribe molnupiravir and any other approved antivirals and fast-tracking antivirals so they can be sold over the counter.

December 1, 2021

Omicron arrives in California, Minnesota (updated Dec. 3)

Omicron-strainU.S. officials this week confirmed the omicron variant in a patient in California, the first case of the South African strain to be detected in the U.S. (It’s pronounced with a short o: aa-muh-krann.) That patient, STAT News reports, was fully vaccinated and had returned from South Africa on Nov. 22, testing positive with mild symptoms on Nov. 29. Additional patients with omicron have now been confirmed in several states. Studies are underway on omicron’s many and worrisome mutations, with 32 in the virus’s spike protein alone. News coverage in Israel, where cases have also been confirmed, notes that omicron infections in vaccinated people there have so far been mild, and very early data indicate that those who are fully boosted within six months have decent protection against the strain. As part of its response, the CDC now says that every American 18 and older should get a booster after six months of a two-dose course of Pfizer or Moderna vaccine and after two months post-J&J vaccine. As for covid cases driven by the delta variant, caseloads are up in the Northeast, Midwest and Mountain West, with more than 80,000 new U.S. daily cases being reported.

Staff shortages force cutbacks in elective procedures

Massachusetts this week began requiring hospitals in that state to reduce non-urgent elective surgeries and procedures. That’s not due to hospitals being overwhelmed with covid patients, but to try to manage staffing shortages and to preserve capacity for non-covid patients. FierceHealthcare reports that, according to state guidance, Massachusetts’ hospitals now have 500 fewer med/surg and ICU beds, due to being short-staffed. The requirement won’t affect urgent or necessary procedures. In other news about hospital staff, facilities in Florida must now contend with conflicting vaccine mandates. The CMS earlier this month began requiring all hospitals that participate in Medicare and Medicaid programs to mandate covid vaccinations for their workers. But the Florida legislature two weeks later passed a bill prohibiting vaccine mandates in the state. Meanwhile, a federal judge has blocked enforcement of that vaccine mandate in 10 rural states until a court decides whether the federal government has the jurisdiction to issue it.

Who deserves hero pay?

State and local governments are struggling to decide which frontline workers should be eligible for hazard pay due to the risks they took in their jobs in the months before covid vaccines became available. As part of a pandemic relief package, the federal government made funds available for “hero pay” and suggested various occupations—including farm and child care workers, truck drivers and janitors—that should be eligible for it. According to PBS coverage, interim federal rules allow relief funds to pay essential workers up to $13 an hour, with each worker receiving no more than $25,000. The state legislature in Minnesota, for instance, has $250 million to disburse, but lawmakers can’t agree how to distribute it. Republicans in the state senate there want to give those funds as bonuses to workers who took very high risk, including nurses, long-term care staff and first responders. Democrats, however, want the funds to be more broadly distributed including to food-service and supermarket employees. Some unions, meanwhile, are pressuring state governors to give some money to all essential workers in both public and private sectors who worked during the pandemic pre-vaccines

November 30, 2021

Omicron arrives in North America

Officials in Ontario this week announced that the omicron variant—a highly-mutated covid strain first detected in South Africa—has been confirmed in two cases there, both in travelers who tested positive after being in Nigeria. The variant is causing concern because of mutations that could make the strain more transmissible and allow it to avoid immune responses, including ones produced by vaccines. Some countries have already imposed travel bans and closed their borders. Studies are underway on the variant’s many mutations, with 32 in the virus’s spike protein alone. According to coverage in Israel, where cases have also been confirmed, omicron infections in vaccinated people have so far been mild.

November 19, 2021

Why are so many health care workers leaving their jobs?

healthcare-worker-leaving-hospitalAn Atlantic article takes an in-depth look at why nearly one in five health care workers have quit their job since the pandemic began. The report talks about the “deep psychological scars” that health care workers have suffered from witnessing death “on a scale” they had never seen before. And since so much of that death and suffering has become preventable because of vaccines, many people feel a lack of compassion that is sending them to the exits. The article also notes that typical covid patients are changing, with some becoming increasingly belligerent and vocal and resisting basic medical procedures. One of the article’s conclusions: “Health-care workers aren’t quitting because they can’t handle their jobs. They’re quitting because they can’t handle being unable to do their jobs.”

Overdoses and eating disorders rose during the pandemic

Two new side effects of the pandemic came to light this week: a record-breaking number of overdoses and a rise in eating disorders in hospitalized patients. Fierce Healthcare reports that CDC data found more than 100,000 Americans died of a drug overdose between April 2020 and April 2021. That’s a whopping 28% increase in overdose deaths compared to the previous one-year period. It’s also the first time the country has seen 100,000 overdose deaths in a one-year period. Public health experts say the jump is in part due to a spike in fentanyl overdoses, which saw a 50% increase during that period. And a study in JAMA Network Open found that inpatient stays for eating disorders rose during the pandemic. The number of inpatients receiving care for eating disorders doubled in May 2020 from 0.3 per 100,000 people to 0.6 per 100,000 people. The increase was seen in patients with anorexia nervosa, bulimia nervosa, and other eating disorders.

As cases begin to surge, boosters take on a higher profile

With cases of covid rising and raising fears about a winter surge, public health officials are expanding their focus on the role booster shots can play in staving off a new wave of infections. An NPR report says that growing outbreaks in the Northeast and Midwest are fueling the rising numbers even in well-vaccinated areas. In response to these numbers, public health agencies are moving to authorize boosters for all adults, not just people who are over 65 or facing a higher risk of infection. The New York Times reports that the CDC is meeting today to examine data on the Pfizer vaccine and is expected to expand the number of Americans who are eligible for the shot. And the FDA is also scheduled to meet today to discuss making booster shots of the Moderna vaccine available for all adults. A number of states like Arkansas, California, Colorado and New Mexico have already opened up boosters to most adults, deciding not to wait for a green light from public health agencies. While public health officials would like to raise overall vaccination rates around the country, Anthony Fauci, MD, this week said that booster doses are vital in changing covid from a pandemic to an endemic. A Medscape report quoted Dr. Fauci as saying that expanding the availability of boosters to everyone could help meet that goal by the spring of 2022. Data published in the American Journal of Infection Control found that 70% of U.S. health care providers are fully vaccinated, with the highest vaccination rates in children’s hospitals (77%) and people in metropolitan counties (71%). Researchers noted that vaccination rates increased quickly between January of 2021 (36%) and April of 2021 (60%), but that the increase in rates has slowed since then.

Patient concerns about vaccine effects down, but misinformation is up

In the struggle to fight covid misinformation, doctors around the world are reporting good news and bad news. A survey by the social media company Sermo of physicians around the world has found that fewer patients are concerned about the side effects of the covid vaccine than six months ago (59% vs. 72%), but more patients are coming to them with vaccine misinformation than six months ago (53% vs. 45%). Common misperceptions include the idea that the vaccine modifies patients’ DNA; it causes infertility; it contains a microchip; and it gives you covid. The survey also found that most physicians (62%) say their patients are asking for the Pfizer vaccine, that most patients are more reluctant to vaccinate their children than themselves, and more physicians believe that the biggest hidden consequence of covid will be the long-term financial impact on the health care system.

November 6, 2021

The battle over vaccine mandates heats up in health care

With the Biden administration announcing that health care workers at facilities that accept Medicare must be vaccinated by Jan. 4, the vaccine mandate wars are heating up. One news report says that Kaiser Permanente is denying the vaccination exemptions based on religious beliefs because of “similar or nearly identical” language used to describe the requests for an exemption. The health system heard reports that employees were having “open discussions” on how to misuse the religious exemption to get out of the vaccine mandate. Kaiser was in the news last week thanks to a nurse who posted a viral video of her being escorted out of a hospital after refusing to get vaccinated. In the video, which has the title, ” Kaiser-Permanente goes full Nazi: Fires nurse for not taking experimental shot,” the nurse claims she’s being deprived of her freedom because the health system won’t honor her religious beliefs. The U.S. Supreme court last week turned away a group of nine health care workers from Maine seeking a religious exemption to their state’s vaccine mandate. A Reuters report says that six members of the court voted to deny the request, but that three of the conservative justices sided with the health care workers. Maine voters last year rejected a referendum that would have overturned the state’s vaccine mandate for health care workers. But in Louisiana, a state appeals court ruled that a health system can’t fire or discipline workers for refusing the vaccine while the mandate is being hashed out in the courts. An AP report says that if the ruling holds, it could eventually affect the enforcement of mandates across the state.

Post-infection vaccines give big boost to immunity

New data from the CDC say that people who have had covid but never got vaccinated are five times as likely to get infected again when compared to fully vaccinated people who were never infected. MDedge coverage says that researchers concluded that for at least six months, vaccination can provide higher, stronger and more consistent level of immunity against covid than being infected. Another study in Cell Reports also shows that getting vaccinated after a covid infection will help ensure a “robust” immune reaction. Getting vaccinated after an infection, researchers found, offers more protection than two vaccine doses give people who haven’t ever had covid.

Two studies examine mental health fallout of the pandemic

Two new reports provide a look at how the pandemic is affecting the mental health of physicians and frontline clinicians. A study of just over 5,000 physicians in Italy, Spain and the UK in the spring of 2020 and the early winter of 2020 found reports of anxiety and depression were worse in female and younger physicians. A Medscape report says those symptoms were more prevalent in physicians who felt vulnerable or exposed at work, and in physicians who reported normal/below-normal health. Physicians in Italy, for example, where physicians reported some of the worst shortages of PPE, had the highest levels of moderate anxiety and moderate/above moderate depression. Because the levels of these symptoms didn’t decrease between the two surges, researchers concluded that they are likely “persistent.” A prospective study of 50 health care workers in the New York City area found significant mental health affects of the pandemic in emergency medicine physicians, nurses, residents, nurse practitioners and physician assistants who served on the front lines during the pandemic. Another Medscape report says the study found that 48% of subjects were positive for acute stress, 37% were positive for depressive symptoms, and 30% were positive for anxiety symptoms. Researchers also found no significant differences in these symptoms among housestaff, attendings and nurses.

Hospitals struggle to keep fully staffed, beds open

Facing their own version of the Great Resignation, hospitals around the country are trying to cope with an exodus of employees by raising wages, but smaller hospitals often find themselves at a disadvantage. A HealthLeaders report says that smaller hospitals often can’t compete in bidding wars for employees not only when it comes to pay and benefits packages, but retention strategies. Nursing shortages—spurred in part by higher wages offered by travelling positions—have forced some Mississippi hospitals to close beds. A Mississippi Public Broadcasting report notes that the state’s emergency management agency brought in contract nurses for 60 days, but that expired at the end of last month.

“Vax” named the 2021 word of the year

One of the most controversial aspects of the covid pandemic has captured the attention of linguists. The Oxford English Dictionary has named “vax” its word of the year for 2021. “A relatively rare word in our corpus until this year, by September it was over 72 times more frequent than at the same time last year,” the dictionary said in a statement. “No word better captures the atmosphere of the past year than vax.” To accompany its announcement, the publication has released a report on the language of vaccines. The dictionary last year chose dozens of terms for its word of the year honor. That list featured several pandemic-related words including “coronavirus,” “lockdown” and “social distancing.”
November 3, 2021

Covid hurting the finances of PCPs and hospitals

covid-moneyTwo new reports say that the financial crisis in health care caused by the pandemic is showing no signs of letting up for PCPs and hospitals. A new survey by the Primary Care Collaborative found that less than one-third of practices said they are financially healthy and 32% said their practice revenue has yet to recover from the pandemic. Perhaps even more alarming, 52% of practices reported that pandemic-related strain is now severe/near severe. (A survey conducted in May/June of 2020 found that same level of strain.) While some physicians have reported in other surveys that telemedicine has helped them weather the financial storm by bringing in new revenue, 21% of practices said they had to pull back on telemedicine because of reduced payments for the technology, and 25% worried that telemedicine would weaken primary care over time. On the hospital side of the equation, finances are also looking shaky. The National Hospital Flash Report from the consulting firm KaufmanHall found that hospitals are financially strapped from a combination of rising expenses and sagging volumes compared to pre-pandemic levels. HealthLeaders reports that between August and September of this year, the median operating margin at hospitals dropped 18%. Hospitals in areas hit the hardest by covid took the biggest hit to their operating margins in part because they’re treating sicker patients who are staying longer.

Payment delays, denials heating up in covid?

Further hurting the finances of hospitals and physicians is what a new report is calling a “revenue grab” by insurance companies. A Medscape report says that even though insurers have reported record profits during the pandemic, they are delaying payment on claims and putting up more barriers to any form of payment for more complex claims. One practice consultant said that complex claims (those with -25 modifiers) now routinely generate requests for more information, which slows down payments. And an internist interviewed by Medscape said that multiple payers are now asking for documentation for prepayment review for higher-level claims for established and new patients. One academic system recently made a complaint against Anthem in which it said that the insurer is requiring itemized bills for any claims over a certain dollar limit, asking for detailed medical records for even clean claims, and requiring the system to upload documents to a Web portal that has technical issues and loses claims. The complaint says that the insurer owes $171 million in claims that are over 90 days old.

October 29, 2021

Hospitals face increasing lawsuits and threats over ivermectin

The fight over the use of the anti-parasitic drug ivermectin to treat covid continues to heat up around the country. In Montana, a Helena hospital is accusing three high-ranking officials from the state government of threatening and harassing physicians who refused to give the drug to their covid patients. A MedPage Today report says that the hospital has not named the three, but the state attorney general’s office claims that officials got involved at the request of covid patients who were denied ivermectin. A state senator admits that she contacted the hospital (although denies making any threats), saying that if the patient was “circling the drain,” she should be allowed to “take responsibility” for her medical care as “a free American adult.” Around the country, at least two dozen lawsuits have been filed seeking to force hospitals to give the drug to covid patients. A Medscape report says that several of the lawsuits have been filed by one western New York lawyer, and that results have been mixed. In at least two of the cases, the patients received the medication and survived to be discharged. Finally, an article in the Atlantic looks at 30 reports that support the use of ivermectin to treat covid. Reporters found that some of the papers have been withdrawn and that research methodologies in other reports are so “shoddy” that the results probably should be withdrawn. Registration may be required to read the piece, but it’s worth a look.

Immunity from covid infections could fade in as little as 3 months

Modeling says that natural immunity from being infected with covid will fade quickly. A study in The Lancet Microbe used modeling to project how much protection immunity covid infection may actually offer. Researchers estimated that reinfection could occur in a median of 16 months after peak antibody response, but the lead author said reinfection could reasonably happen within three months. Becker’s Hospital Review says the study predicts that reinfection will become “increasingly common” as covid transitions into an endemic disease.

October 22, 2021

It’s official: the FDA OKs Moderna, J&J boosters

The FDA this week gave the green light to booster shots for those originally vaccinated with Moderna and J&J vaccines. The extended EUA for Moderna is for the same vaccinated populations as were approved earlier for a Pfizer booster: those 65 and older, those 18 and older at high risk of severe covid, and those 18 and older with frequent institutional or occupational exposure—like health care workers. The Washington Post reports that the J&J booster was authorized for anyone 18 and older, and patients will be eligible for that booster two months after their original single dose. As for the Moderna booster, which is half the dose of the primary series, people need to wait at least six months after their second original dose. While the FDA also endorsed a “mix and match” strategy, allowing people to access a different vaccine booster than the one they originally received, the agency had no recommendations as to the best vaccine-booster combination.

Is another cold weather spike on the way?

cold-weather-covidSouthern states including Georgia and Florida are finally seeing some relief with falling case rates, hospitalizations and deaths. But cases in cold spots are on the rise, the same pattern seen last year. CNN reports that, based on data from Johns Hopkins, five states this week saw case rates rise 10% over last week’s: Iowa, Oklahoma, Alaska, Vermont and New Hampshire. The New York Times reports that while Alaska now has the highest number of new cases per capita, five other states have the fastest rising caseloads: Vermont, Colorado, New Hampshire, Michigan and Minnesota, all states where the weather has turned cold. Experts chalk rising caseloads up to people staying indoors, poor ventilation and the lack of mask mandates in schools. They warn that it’s too soon to do away with mitigation strategies like masking and social distancing, even in areas with high vaccination rates.

Study: Overweight, obesity linked to worse symptoms

Previous findings have found that patients who are overweight or obese are at higher risk of severe covid outcomes including ICU admission, ventilation or death. A new study now finds that overweight and obese patients have a greater range and number of symptoms, even in mild covid, and they experience those symptoms longer. In the prospective study, which appeared in Influenza and Other Respiratory Viruses, 59% of overweight and obese covid patients were symptomatic vs. 49% of those who were not, while overweight and obese patients experienced three vs. two symptoms. Further, they had significantly higher coughing, shortness of breath and altered taste. In study coverage, MedPage Today reports that adolescents who were overweight or obese were significantly more likely to be symptomatic than those who weren’t (67% vs. 34%) and to have a higher median number of days with respiratory symptoms (seven vs. four).

October 18, 2021

FDA panel green-lights J&J booster

An FDA advisory panel last Friday endorsed a booster shot for those who received J&J’s one-dose vaccine. Further, the panel noted that those people could get a booster dose only two months after their initial one—an opinion that had experts pointing out that, probably, J&J should have been administered as a two-dose vaccine all along. The New York Times notes that, according to the company’s own data, a booster raises the vaccine’s efficacy against mild to severe disease to 94% vs. 74% for a single dose. However, other data find that a J&J booster within two months of an initial dose raises efficacy to 74%, up from 66%. Preliminary (non-peer reviewed) data also indicate that those who received an initial J&J vaccine may get better immunity with an mRNA booster. A final decision from the FDA on both the Moderna and J&J boosters may come in a few days.

Surge seen in nursing school enrollment

While the pandemic is burning out nurses, particularly those in hospitals, nursing schools report a spike in enrollment. News reports indicate that enrollment in nursing programs—bachelor’s, master’s and doctoral—rose 5.6% in 2020 from 2019 figures. While enrollment figures for the 2021-22 year aren’t yet available, the University of Michigan received 1,800 applications for its 150 slots available this year, up from 1,200 applications in 2019. But increased enrollment is coming up against the fact that many senior nurses—including those in faculty—are retiring or burning out as a result of the pandemic. In related news, experts say that nurses in hospitals don’t need wellness resources from administrators and leaders. Instead, they need trauma support.

Possible new mRNA side effect?

A French monitoring report highlights Parsonage-Turner syndrome as a possible side effect of mRNA vaccines, even though the effect is very rare. According to coverage of the report, the syndrome has shown up in six patients who received the Pfizer vaccine, with four of those cases occurring in the first two weeks of September, and in two patients who received the Moderna vaccine. The condition, which is more common in men than women, is characterized by severe and sudden-onset shoulder pain followed by arm paralysis. The flu vaccine has also been implicated in some reports of the syndrome.

October 15, 2021

Moderna booster and the mix-and-match vaccine strategy

covid-19-vaccinationAn FDA panel this week recommended a Moderna booster for many of those who received that vaccine six months or more out from their second dose. The panel’s endorsement was for a half-dose booster for those 65 and older or younger people at high risk due to their medical conditions or employment. The FDA this Friday is also considering findings from a new NIH study, released in preprint, that indicate that mixing and matching vaccines—using a different type of booster than the original vaccine given—not only works but appears to be safe. News outlets report that study subjects were divided into groups based on their original vaccinations, then given a booster of either Pfizer, Moderna or J&J. Their antibodies were measured at both two and four weeks. Those who got two doses of Moderna originally and then a Moderna booster had the highest level of antibodies, followed by those with Pfizer originally and a Moderna booster, than by Pfizer/Pfizer. Significantly, those originally given J&J got the best antibody response when receiving either a Pfizer or Moderna booster. For the study, researchers used full-dose vaccines as boosters, although the Moderna booster the FDA is considering is only half dose.

Delta’s deadly September

Case and death rates continue to drop in the U.S. from the delta surge that swamped parts of the country in August and September. New data now indicate that during September, covid was the second leading cause of death in the U.S. overall (at 1,899 deaths per day), trailing only heart disease (2,078 per day)—but it was the No. 1 cause of death in the country among people ages 35 to 54. One indication of how lethal delta has been: In July 2021, before the delta surge, covid had fallen to the No. 7 leading cause of death overall in the U.S. The highest covid death toll occurred in December 2020 and January 2021 before mass vaccination was available; during those periods, covid was the country’s leading cause of death. The data were part of an analysis published by the nonprofit Peterson Center on Healthcare and the Kaiser Family Foundation.

October 14, 2021

Violence in hospitals may be on the rise

Hospitals have always been a dangerous place to work, particularly in the ED where patients with psychiatric and substance use disorders first present. But Kaiser Health News reports that the pandemic is exacerbating that problem in hospitals, just as it is in school board meetings, sports stadiums and on airplanes. According to the coverage, patients are threatening to bring guns to the hospital if visitor restrictions aren’t waived, while covid patients can become confused from low oxygen, then combative. Part of the problem is that thinly-stretched staff don’t have the time to recognize conflict in the making and de-escalate it. Hospitals are responding by beefing up security staff, installing cameras, teaching de-escalation techniques and even bringing in guard dogs, as well as giving individual workers panic buttons to put on their badges. National nursing unions are asking Congress to pass laws that require hospitals to draw up violence-prevention plans. In related news, scientists who speak out about covid are also facing threats. A feature in Nature reports on a survey in which more than 300 scientists across several countries who had spoken to the media or posted on social media about covid were asked about any harassment or abuse. The findings: 15% had received death threats, while more than 20% had reported threats of physical or sexual violence, and more than 40% admitted to emotional or psychological distress because of threats they’d received.

October 8, 2021

Multidisciplinary review committee slashes discharges to SNFs

Given how dangerous covid infections can be for SNF patients, clinicians at Illinois’ NorthShore University Health System last year set about to reduce the number of patients being discharged to SNFs. Their solution: creating a multidisciplinary committee that met one hour a day, six days a week, to review possible SNF discharges. Results, which were published by the Journal of Hospital Medicine, indicate that implementation of that review saw total SNF discharges fall from 25.5% of discharges to 12.8%, while the number of new SNF discharges tumbled from 17.5% to 5.8%, a better than two-thirds reduction. The authors also saw no increase in readmissions or in patients’ length of stay, and they estimate that the steep drop in discharges to SNFs helped prevent one covid infection every 5.6 days of the intervention. The review committee consists of physicians (half are hospitalists and half are outpatient—case managers), social workers, physical and occupational therapists, and the director of the health system’s home health agency.

FCC telehealth disbursement program: There’s plenty more

If you applied to the FCC’s covid-19 telehealth program for funds but missed out on the latest round of approvals, take heart: mHealth Intelligence reports that remaining applicants can revise their proposals and try again. The FCC last month awarded more than $41 million to more than 70 health care organizations to help them expand their telehealth platforms. Those awards came on top of close to $42 million awarded to 62 health care organizations earlier this summer. But the FCC’s telehealth program, which received a budget of close to $250 million from Congress for this year, still has more than $160 million to disburse. The FCC program functions via reimbursements, with providers having to submit invoices and supporting documentation to be paid for eligible telehealth services and expenses.

October 6, 2021

The four stages of pandemic emotion

First, there were last year’s horror, which gave way this spring and summer to hope as Americans rushed to be vaccinated and normal life again seemed possible. But that turned into rage this summer as the delta variant tore through unvaccinated populations, filling hospitals and morgues once again. Now, according to a STAT article, some experts are cautiously optimistic that case rates and hospitalizations will continue to trend down and that high-enough percentages of the population will either be vaccinated or previously infected, stopping further catastrophic spread. However, article sources point out that “moving on” looks very different for college students, for instance, who are back to normal with some restrictions than for health care workers, many of whom are either angry or numb. And some public health officials warn that it’s way too early to celebrate, noting how often the pandemic’s end has been predicted prematurely.

October 4, 2021

More milestones passed: 700,000 dead in the U.S., 5 million worldwide

death-covidLate last week, the U.S. tallied 700,000 dead from covid, while the global death toll surpassed 5 million. Reuters reports that while it took more than a year for the death toll worldwide to hit 2.5 million, the second 2.5 million deaths have occurred in less than eight months. With covid now the deadliest pandemic in U.S. history, experts estimate that close to 200,000 deaths in the U.S. could have been prevented if those patients had been vaccinated. Some good news, however: New U.S. cases have dropped by more than one-third in the past month, another example of what New York Times coverage is calling a two-month covid cycle, with cases surging for two months than declining for the same amount of time. Explanations for what drives those cycles include seasonality as well as the social distancing and precautions people take in response to high local case- and death rates. Over the past month, the number of covid hospitalizations has dropped 25%, while the number of deaths in the past two weeks has declined 10%.

Vaccine mandates much riskier for rural hospitals

The question of whether a vaccine mandate will work in your hospital and not cause a brutal exodus of staff has a lot to do with where your hospital is located. That’s according to the Washington Post, in an article describing how the stakes for rural hospitals in terms of staff quitting or being fired over mandates are much higher than in urban or suburban facilities. Across Virginia, several hundred health care workers have already been suspended or fired. But rural hospitals in the state are harder hit because more staff in rural areas have vaccine hesitancy or resistance, and those hospitals don’t have larger staffs to cushion the blow of losing some members. The article contrasts two health systems in Virginia: Inova in northern suburban Virginia, and Ballad Health, which has several rural hospitals in the southern part of the state (as well as in Tennessee). With a mandate in place, Inova lost less than half of one percent of its staff—and the health system finds that having a vaccine mandate in place helps to recruit new staff to fill those slots. But the CEO of Ballad Health says that if the health system put a mandate in place—which it hasn’t—it might lose up to 5% or even 10% of its staff. That’s too much of a hit for the health system to take, particularly because it’s much harder for rural hospitals to recruit new staff than in urban or suburban ones.

October 1, 2021

Sign of the times: individual panic buttons on the wards

panic-button

A hospital in Missouri this year is issuing hundreds of panic buttons to its ED and inpatient staff, having staff members attach them to their ID badges and use them to call security if they need to. The move comes in response to the number of assaults, which have tripled over the past year, on staff by patients in the hospital. Business Insider reports that the hospital in 2020 logged 123 assaults, up from 40 in 2019, and that injuries among staff from assaults in 2020 numbered 78 vs. 17 the year before. The hospital’s health system piloted the use of the buttons at another of its hospitals. The distress calls will be displayed through the nurse-call system. In response to increasing incidents, The Guardian notes, some hospitals are limiting their number of public entrances and are training staff in de-escalation techniques.

Breakthrough infections in hospitals: Don’t let up

In July, Israeli researchers published findings about early breakthrough infections among health care workers in their medical center, the largest in Israel. Their conclusion: Breakthrough infections were rare. In a new NEJM correspondence, several of the same authors point out that their earlier research looked at breakthrough infections caused by the alpha variant. With the delta variant now circulating, many more fully vaccinated workers in their center over the summer came down with breakthrough infections and 71% were symptomatic, although none needed to be hospitalized. “These findings,” they write, “call for further rigorous preventive measures, such as booster vaccinations, in-hospital social distancing, extensive use of personal protective equipment, judicious out-of-hospital behavior, and frequent molecular testing after the occurrence of symptoms or known exposure to infected contacts.” (The authors found that rapid tests missed many positives.) In some bright news, the CDC this week predicted that the number of covid deaths in the U.S. will decrease over the coming month—for the first time since June. The CDC forecast also called for fewer new covid hospitalizations. Currently about 2,000 people are dying per day, CNN reports, and 114,000 new daily cases are being detected.

Short on nurses? LPNs can fill the gaps

According to a HealthLeaders article, Pittsburgh’s Allegheny Health Network is easing the nursing shortage in its hospitals by once again hiring licensed practical nurses (LPNs; also referred to as licensed vocational nurses or LVNs). Over the last decade, LPNs have been squeezed out of acute care, as hospitals moved to hire nurses with bachelor’s degrees and LPNs gravitated to nursing home and other post-acute care settings. Now, however, Allegheny is piloting programs with LPNs in the hospital as part of “blended” bedside teams led by RNs; those teams include LPNs and nursing assistants. So far, the bedside teams have delivered lower hospital lengths of stay and have been successfully integrated in med-surg units, rehab floors and orthopedics. The health system plans to roll out the nursing team model in the ED. In a Philadelphia Inquirer commentary, several nurses shared their experiences working through the pandemic. One veteran ICU nurse retired after weeks of seeing several patients a day die from covid, while others report unprecedented turnover rates and brand-new nurses having to take on many more—and much sicker—patients than is safe.

A good fit, but telehealth in rural America isn’t getting off the ground

While the use of telehealth has exploded since the beginning of the pandemic, rural America is largely being left behind. The lack of access to high-speed Internet remains a huge barrier, but an article in STAT highlights other challenges: poor reimbursement, interstate licensing rules and a lack of trained clinicians. While telehealth has made major inroads in suburban and urban settings, the disparity in access to telemedicine in rural areas is exacerbating other inequities in income and infrastructure. Some telehealth companies are trying creative solutions, partnering with rural schools to provide care to children via their school computers and putting telehealth kiosks in rural grocery stores.

September 29, 2021

CDC: Third-dose side effects mirror second-dose ones

If you experienced no adverse effects from your second covid vaccine dose, chances
are you won’t after your third dose either. That’s according to early data from the CDC, which were drawn from 12,500 submissions to the CDC’s smartphone-surveillance network from people receiving a third dose of either the Pfizer or Moderna
vaccine. (Submissions were made over five weeks in August and September and came from immunocompromised patients receiving a third dose of either vaccine.) In a report, the CDC notes that 79% of those administered a third dose experienced local or systemic reactions vs. 78% of those who had similar reactions after their second dose, and “no unexpected patterns of adverse reactions were observed.” As of Sept. 19, the CDC said, more than 2.2 million people in the U.S. had received additional vaccine doses after their primary series. In other vaccine news, Pfizer this week submitted data on the efficacy of its vaccine in children ages 5 through 11 to the FDA. The AP reports that, if the FDA does authorize the use of the vaccine in young children, shots may not be available until November.

September 27, 2021

Vaccine mandate: Time’s up for unvaxxed New York health care workers (Vaccine mandates may be working- updated Oct. 1) 

Vaccination-mandatory-workplace-signIt was crunch time for health care workers in New York this week, with workers in that state needing to have at least  one dose of covid vaccine or face possible termination. The mandate appears to be effective, with the New York Times= reporting that vaccination rates (with at least one shot) among health care workers in New York jumped this week to 92% vs. only 82% of nursing home workers and 84% of hospital workers just one week ago. To offset potential staff shortages, New York’s governor declared a state of emergency, allowing the state to deploy National Guard members to fill staff positions. The governor also waived licensing requirements to allow health care workers from other states to come to New York. According to Fierce Healthcare, hospitals and health systems around the country with vaccine mandates have seen better than 90% compliance. In other vaccine news, the CDC announced that, according to early data, most people receiving their third dose of covid vaccine are having similar side effects to the ones they had after their second dose. And while Pfizer submitted data to the FDA this week on the efficacy of its vaccine in children ages 5 through 11, news organizations indicate that, if the FDA does authorize vaccine in young children, shots may not be available until November. And Merck today announced this first: Trial results for its antiviral pill, molnupiravir, indicate that the treatment reduces patients’ risk of hospitalization and death from covid by close to half. The  company plans to seek emergency authorization for the pill from the FDA.

Delaware judge backs hospital in ivermectin case

Headlines in August noted that hospitals were being sued by patients or family members insisting on having covid treated with ivermectin in the hospital—and that courts were siding with those patients. However, a Delaware judge in a similar case has ruled in a hospital’s favor, refusing to order the hospital to administer the drug and saying that patients can’t compel providers to use ivermectin outside the standard of care. According to coverage in U.S. News & World Report, the judge’s ruling noted that “the right of self-determination” in health care allows patients to accept or refuse treatments but not to dictate specific treatment outside care standards. While ivermectin has inhibited the growth of covid cells in a lab, the NIH has announced that patients would need to take doses up to 100-fold higher than have been approved in humans to achieve the same effect. In New Mexico, state health officials last week announced that two people in that state have died of ivermectin toxicity.

September 24, 2021

Pfizer boosters get nod from FDA and CDC, others make their case

The FDA and CDC this week signed off on booster shots of the Pfizer vaccine, although for slightly different populations. The FDA gave the green light for Pfizer boosters for people 65 and over and for individuals over 18 who have a high risk of severe covid because of medical conditions or where they work. Last night, the CDC’s Advisory Committee on Immunization Practices (APIC) approved boosters for adults age 65 and older and residents of long-term care facilities and adults 18-64 with an underlying condition that may increase their risk if they get infected. Unlike the FDA, the CDC committee did not approve boosters for adults who live or work in a place where the risk of transmission is high, a group that includes health care workers. This morning, CDC director Rochelle Walensky, MD, reversed that position, aligning CDC policy with the FDA’s by endorsing boosters for people at risk because of their jobs. In other vaccine news, a CDC study published last Friday found that the Moderna vaccine offered longer protection than the Pfizer vaccine over time. The study found that over a four-month period, the efficacy of the Pfizer vaccine in preventing hospitalization fell from 91% to 77%. During that same time period, the efficacy of the Moderna shot remained statistically the same. Finally, J&J unveiled data showing that its vaccine is more effective when given as a two-dose regimen. Two doses of the vaccine prevented 75% of moderate to severe cases of covid, up from 53% after one dose. (The J&J vaccine was originally estimated to be 66% effective in preventing moderate to severe covid, but that number was updated last week.) J&J has not announced that it has applied to the FDA for authorization for a second dose, but that move is expected soon.

Hospitals billing average of $320,000 for complex covid care

How much does a hospital stay for covid cost? According to new research, hospitals billed private insurers an average of just under $320,000 for complex covid cases and just under $75,000 for less complex cases. MedPage Today reports that insurers paid out $98,139 for complex cases and $33,525 for general cases. While those are big amounts, they won’t help the bottom line of most hospitals. An analysis from the American Hospital Association projects that U.S. hospitals collectively stand to lose $54 billion in profits in 2021 because of a combination of sicker patients, fewer outpatient visits and increased costs of labor and supplies. HealthLeaders reports that U.S. hospitals could face even bigger losses because the AHA analysis was based on hospital performance before the delta variant caused caseloads to surge again.

New data: Remdesivir reduces hospitalization in high-risk outpatients

New data show that remdesivir can reduce the risk of hospitalization from covid by 87% in high-risk patients who are diagnosed early and not hospitalized. The data, which were published this week by Gilead in a press release, also found that the therapy was associated with an 81% reduction in medical visits due to covid. STAT notes that the administration of remdesivir is challenging because it must be given intravenously, which can be difficult for patients who aren’t sick enough to be hospitalized. While remdesivir has FDA approval to treat covid and is widely used, not all studies have found that the drug helps covid patients. An EU study released last week found that the drug offered little benefit to covid patients who had been admitted to the hospital for COVID-19, were symptomatic for more than 7 days and required oxygen support. And a large trial led by the World Health Organization found the drug offered little benefit in preventing covid deaths.

September 21, 2021

This hospital has a high bar for vaccine exemptions based on religious beliefs

hurdle obstacleThere are signs that hospitals are going to make employees who want an exemption from covid vaccines work for it. An Arkansas health system is requiring staff who want a religious exemption from a vaccine also promise to forgo basic medications like Tylenol, Tums and Preparation H. Becker’s Hospital Review reports that Conway Regional Health System decided to act when it noticed a jump in requests for vaccine exemptions that cited the use of fetal lines in the development and testing of vaccines. The health system created a list of 30 medicines that make use of fetal cells and asked employees requesting a vaccine exemption to attest that they won’t use those the medications on the list—and others like them. Conway’s CEO told Becker’s that the goal of the form was not only to make sure people requesting exemptions were sincere in their beliefs, but also to raise general awareness about how fetal cells are used in testing and developing common medicines. Employees who are granted exemptions are also told they may need to be periodically tested for covid and could be reassigned to a new position to protect patients and staff.

Researchers taking a close look at long covid

The NIH is studying the lingering symptoms of long-haul covid, which can be debilitating for people recovering from covid. A Medscape report says early research shows that about one-third of people infected with covid will go on to have symptoms for months once they’ve recovered from the acute phase of covid. A recently published review found that symptoms persist for one to two months after initial diagnosis in 13% of patients, but 4.5% experienced symptoms beyond two months and 2.6% had symptoms for three months or longer. A MedPage Today report says the found that fatigue, headache and dyspnea were the most common symptoms, but cough, chest pain, anxiety/depression and loss of smell and taste were also recorded in significant numbers of long haulers. The review, which covered 143 reports published through May, also found that less common symptoms included concentration/memory deficits, tinnitus and sensory neuropathy.

September 17, 2021

Vaccine mandates have hospitals worried about staffing

The Biden administration’s vaccination mandate for health care workers has hospitals worried that requiring vaccinations will have the unintended consequence of making it impossible to get fully staffed. Under the plan, the CMS will require health care facilities that participate in Medicare or Medicaid to vaccinate their estimated 17 million workers. Fierce Healthcare says that while the American Hospital Association supports the widespread vaccination of nurses, it also worries that the mandate will exacerbate the already difficult task of hiring nurses. (The article also notes that a large nursing union is accusing hospitals of deliberately understaffing nurses to boost profits. Several large health systems have said they’re struggling with labor costs.) Becker’s Hospital Review points out that hospitals in Texas will face an even bigger challenge, since the governor of that state has issued an executive order banning public hospitals from enacting vaccine mandates. One rural hospital in Texas estimates it will lose 25% of its workforce if it enforces a vaccine mandate, and a potential loss of its Medicare/Medicaid funding—about 80% of its budget—if it doesn’t. Vaccinations for staff are such a hot-button issue in some parts of the country that some health systems were until recently using a lack of a vaccine mandate as a recruitment tool before the Biden administration unveiled its mandate.

Inpatient costs of treating preventable covid tripled in August

A new report from the Kaiser Family Foundation says that the country has spent $5.7 billion on covid hospitalizations that could have been prevented by vaccinations—and that $3.7 billion of that spending occurred in the month of August. The report notes that in August alone, U.S. hospitals cared for 187,000 cases of covid that could have been prevented by vaccines. In June, by comparison, the nation treated 32,000 preventable cases, and in July the number was 68,000. Fierce Healthcare reports that Kaiser estimates that each case of covid costs $20,000. That number is based on studies that found the inpatient costs of caring for a single covid patient ranged from $17,000 to $24,000. But because that estimate doesn’t include outpatient or follow-up costs, the report says it is probably underestimating the true financial impact of the virus.

Conspiracy theorists flood Chicago hospital with calls for ivermectin

Last week we offered a glimpse into harassment medical workers face from anti-maskers and anti-vaxxers. This week, there’s a new wrinkle in the abuse being directed at people working in health care: medical conspiracy theorists harassing them via the phone and in person. MedPage Today says that a Chicago hospital treating a well-known anti-vaxxer was flooded with hundreds of calls—including several to 911—from the patient’s supporters. The callers demanded that the hospital provide alternative forms of care including the antiparasitic ivermectin. A well-known lawyer used his Instagram account to tell his followers to “go to war” against “medical tyranny.” When the patient died from covid, the lawyer branded it a “medical murder.” Reports say that 20-30 cars with supporters showed up at the hospital. One staff member called the police when an “irate” supporter wouldn’t leave the hospital property.

September 16, 2021

Will the U.S. give boosters? The debate heats up

With the FDA scheduled to review the evidence behind booster shots of the Pfizer covid vaccine today, the debate among scientists and public health officials has heated up. New York Times coverage says that a series of “dueling reviews” of evidence released this week are taking opposite stances on the data on booster shots. A study published in the New England Journal of Medicine offers data from Israel that show that those who received boosters were less likely to develop severe covid than people who had received two shots. But a review by FDA staffers released this week says that while the vaccines’ effectiveness may have faded somewhat, they are still protecting against severe disease and death. And a Lancet article written by two of the FDA’s top vaccine scientists says that there’s no evidence that the effectiveness of covid vaccines in protecting against severe disease significantly wanes over time. The New York Times article notes that the Biden administration’s plans to roll out boosters as soon as next week has been endorsed by eight physicians in charge of the nation’s public health agencies. However, the administration’s plan needs a green light not only from the FDA, but also the CDC, which is scheduled to convene a panel next week. A Medscape poll indicates that U.S. physicians and nurses are divided about need for boosters, with 75% of physicians and 66% of nurses supporting an extra vaccine.

September 12, 2021

What led to a summer outbreak among San Diego health care workers?

sharing medical staffA research letter in the New England Journal of Medicine examines the factors that led to a resurgence of covid among a group of vaccinated health care workers at the University of California San Diego Health. While 87% of the staff were vaccinated by July, infections spiked up during that same month, and more than half of the 227 who tested positive had been vaccinated. For health care workers vaccinated in January or February, the “attack rate” was 6.7 per 1,000 people. For workers who were vaccinated later (March through May), the rate of infection was 3.7. Among the unvaccinated, the attack rate was 16.4. A report in Medscape quotes one of the of the letter’s authors as saying that while covid vaccines are still protecting the vaccinated, the waning effectiveness of the shots along with the spread of the delta variant and loosened mask rules all worked together to help reduce the effectiveness of the vaccines from 94.3% to 65.5%. (Cases in San Diego spiked shortly after California loosened its mask mandates.) The authors of the letter say the case illustrates the need not only for vaccinations, but nonpharmaceutical interventions like indoor masking and intensive testing strategies.

September 10, 2021

Tensions bubbling up between traveling, permanent nurses

While nurse burnout has been growing since the beginning of the pandemic, there’s a new source of frustration building among the nation’s RN workforce. A report in Healthcare Dive says that there is tension between the core nursing staffs at hospitals and the traveling nurses, in part because traveling nurses are typically paid much more than their permanent colleagues. But a survey of a small—and limited—number of nurses found that the issues go beyond money. While permanent nurses often work mandatory overtime, traveling nurses are typically not required to work beyond the hours specified in their contracts. Permanent staff said that they often view traveling nurses as outsiders, while half of the traveling nurses felt they were treated poorly by permanent staff and assigned heavier caseloads. The survey found that both groups are suffering from burnout and that nearly one-quarter of all nurses surveyed were considering leaving nursing altogether.

September 9, 2021

Amid stretched resources, rationing hits Idaho hospitals

covid-icuThe crush of covid patients has hospitals in Idaho rationing care to stretch their already-stretched supply of hospital staff and beds. AP reports that Idaho public health officials announced this week that they had activated “crisis standards of care,” which allow 10 hospitals and health care systems in the state to allot resources like ICU beds to the patients most likely to survive. Patients who can’t be placed in an ICU bed will still receive care, but they might go without some life-saving medical equipment or wait for full ICU care. As of Sept. 1, more than 500 people in the state were hospitalized with covid; half of them were in the ICU. Public health experts predict that if the current covid surge continues, the state could be facing 30,000 new covid cases a week by mid-September. The AP report says that other states are considering similar measures. Hawaii last week released hospitals and health care workers from legal liability if they need to ration care.

September 8, 2021

Booster shots show promise in Israel, on FDA docket next week

The idea of giving a third shot of the covid vaccine got a boost from Anthony Fauci, MD, who last week said that Israeli efforts to stem the current wave with a third shot of the Pfizer vaccine are encouraging. MedPage Today reports that after giving 1.1 million Israelis a third dose of the Pfizer vaccine, researchers in the country saw a “greater than tenfold diminution” in confirmed covid infections and severe disease. In the U.S.,the FDA is holding a Sept. 17 advisory meeting that will examine the idea of giving a third of shot of the Pfizer vaccine. Fierce Healthcare says that Pfizer has submitted data that people who received a third shot five to eight months after their second shot generated three times as many antibodies than after their second dose. If the FDA and the CDC give their approval, the White House plans to begin administering third doses of the Pfizer vaccine in late September. The plan has been criticized by public health officials and physicians who question the science behind the decision. Coverage from STAT examines questions about the science behind the rationale for a third shot. It also questions whether the shot should even be called a booster, with some arguing that it should be more accurately described as a third and final shot in the covid vaccine series.

September 7, 2021

Threats against health care workers grow in number, intensity

Remember the good old days when you were considered a hero for saving lives during the pandemic? In some parts of the country, health care workers are now just as likely to be considered a villain. The Texas Tribune reports that the number of attacks—both verbal and physical—on health care workers has been growing. At hospitals in the state, attacks have included screaming and cursing, broken bones and noses, and knives being pulled. Many of the incidents revolve around masks and screening protocols that patients and family members vehemently disagree with and don’t have to follow outside of health care settings. Tempers are also running high because of understaffed and overwhelmed health care facilities. In Georgia, things have gotten so bad that the state’s health commissioner has joined Governor Brian Kemp in urging residents to stop harassing, threatening and bullying health care workers giving covid vaccines. Becker’s Hospital Review reports a mobile vaccine site in north Georgia had to be closed when an organized group of anti-vaxxers showed up to harass and ridicule the people staffing it. Perhaps the most unsettling example of health care workers being threatened can be seen in a video on Twitter of anti-maskers in Nashville harassing medical professionals after a school board meeting shows protesters shouting things like, “You will never be allowed in public again! We know who you are! You can leave freely, but we will find you!”

September 3, 2021

Patients suing for—and winning—their right to invermectin

defensive medicineDespite warnings from the CDC against using the horse dewormer invermectin to treat or prevent covid, patients are suing hospitals to force them to administer the medicine—and some are winning. Newspaper coverage reports that an Ohio judge has ruled that a hospital must give invermectin to a covid patient who has been in the ICU for several weeks with covid. The patient’s wife found a physician who claims he’s an “expert” on using the drug to treat covid to write a prescription, but the hospital balked at fulfilling it. The judge ruled that the hospital must give 30mg of invermectin to the patient daily for three weeks. MedPage Today reports that more hospitals are being sued by patients demanding the drug, which has been promoted by media figures on conservative news outlets like Fox News.

Shortages of tocilizumab grow, but bamlanivimab/etesevimab is back

As one covid treatment inches toward critical shortages, another therapy that was put on hold is making a (limited) comeback. Amid rising shortages around the world of the arthritis drug tocilizumab around the world, the World Health Organization is pressuring its maker, Roche, to help other companies manufacture the drug to bolster supplies. The WHO is also calling for the drug to be distributed equitably to all countries. Forbes magazine notes that the drug is already in short supply in U.S. hospitals and that shortages are expected for at least the next several weeks. Roche responded to the WHO by saying that it will not enforce its patent rights on the drug in low- and middle-income countries. In other news, Eli Lilly’s antibody combo bamlanivimab and etesevimab is now back on the market in states where variants that can evade the drug account for less than 5% of covid cases. Fierce Healthcare reports that the FDA’s reauthorization of the combination therapy means it will be available in 20 states, including Colorado, Connecticut and Ohio. The therapy cannot be used in states with big covid caseloads like Florida and Texas.

Rates for four infections rose during the pandemic

Rates for four routinely tracked healthcare-associated infections rose at significant rates during the pandemic, reversing years of progress in reducing their numbers. Research published in Infection Control & Hospital Epidemiology found major increases in four types of infections from 2019-2020: central line-associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated events and antibiotic resistant staph infections. These infections likely increased during the pandemic because of the number of patients who required more frequent and longer use of catheters and ventilators, along with staffing and supply challenges. A statement from the Association for Professionals in Infection Control and Epidemiology says the report shows that U.S. health care has lost nearly a decade of progress in reducing incidence of these infections.

CDC’s APIC panel debates the need for boosters

As the debate over booster shots for covid heats up, the CDC appears to be considering a “risk-based” strategy that would target people with severe disease and critical infrastructure jobs. MedPage Today reports that during a meeting of the agency’s Advisory Committee on Immunization Practices this week, the panel reviewed evidence showing that covid vaccines offer weakened protection against the delta variant, but there wasn’t exactly consensus on how to respond. Some on the panel argued that getting unvaccinated Americans to get the shot would be more effective than moving onto boosters, but others pointed out that the two strategies aren’t mutually exclusive. The Biden administration’s decision to start authorizing booster shots for certain people beginning in late September has unleashed a fury of criticism from multiple sources. STAT reports that some worry that endorsing booster shots before the FDA has weighed in with a review of the evidence is causing confusion.

August 30, 2021

Covid takes a bigger toll on teens, children

As the pandemic grinds on, it’s taking an outsized toll on children and teenagers. Medscape reports 16- and 17-year-olds now have the highest infection rates of all age groups. While that age group accounts for 2.5% of the U.S. population, it now accounts for 2.6% of all covid cases. In total, nearly 800,000 16- and 17-year-olds have been infected with covid. Children are also accounting for a huge percentage of covid. In the week of August 131-19, there were just over 180,000 cases of children becoming infected. That number represents a 48% increase over the number of pediatric cases reported the week before and the second highest jump in pediatric cases since January of this year.

August 27, 2021

Tracking covid in the U.S. by the numbers

If you’ve been trying to track just how bad the latest wave of covid in the U.S. has become, it’s been a busy week. The Washington Post reports that for the first time since Jan. 30, more than 100,000 Americans are hospitalized with covid. The numbers are highest across the South. Florida alone has nearly one-fifth (17,000) of the country’s covid patients. Texas is next with more than 14,000. On a national level, three-quarters of ICU beds are full. According to The Hill, 28% of patients in those beds have covid. Almost half of U.S. states say their hospitals have exceeded 75% capacity of their ICU beds. And a record number of 30-somethings are hospitalized with covid. The hospitalization rate for 30- to 39-year-olds reached 2.5 per 100,000 people last week, beating the previous record of 2 per 100,000 back in January. MDedge reports that new admission for this group reached an average of 1,113 a day last week. That number had been 908 in the previous week. To combat the latest surge, more than 5,000 military medical personnel have been deployed to 14 states to help care for covid patients. MDedge says that while the focus of a similar effort last year was the coastal states (New York, California and New Jersey), attention has shifted to the southern states.

Survey: Most nurses vaccinated, support mandates

In one bright sign, U.S. nurses seem to be supporting the science behind the fight against covid. A survey of more than 4,500 nurses found that they overwhelmingly support vaccines, mandates and boosters. HealthLeaders reports that the survey found that 88% of nurses said they were vaccinated or planned to get vaccinated, 58% support vaccine mandates and 84% will get a booster shot if it is recommended.

August 25, 2021

The high price of treating the unvaccinated

A new report estimates that covid surging among unvaccinated Americans led to 113,000 unnecessary hospitalizations—just in June and July. That report, which was issued by Kaiser Family Foundation, also found that those preventable hospitalizations cost U.S. health care $2.3 billion. Other findings from Kaiser Family Foundation indicate that covid hospitalizations and treatment are becoming more expensive for some individual patients: Among the two largest private health insurers in each state and the District of Columbia, 72% are no longer waiving out-of-pocket costs for treating covid. Kaiser Health News reports that about half of all the monoclonal antibody shipments since mid-July have gone to Florida, Texas, Mississippi and Alabama—states with some of the lowest vaccination rates in the country. The cost of each infusion dose (being picked up, at least for now, by the federal government) is about $1,250, while each dose of each vaccine dose costs about $20.

Doctors issue personal appeals

Physicians in covid hotspots around the country are appealing directly to the public, asking those who are unvaccinated to consider the devastating impact of that decision on their larger communities, including health care workers. Several dozen emergency physicians and physician assistants in Eugene, Ore., released an open letter this week, describing the torturous hospitalizations from covid among younger, healthier patients who aren’t vaccinated. The clinicians point out that their hospitals are running out of beds to treat other patients with serious or life-threatening conditions. Their call was backed up by the Oregon chapter of the American College of Emergency Physicians. In Florida, more than 70 physicians, nurses and executives from five competing hospitals in Palm Beach County issued an emotional plea at a press conference, describing their physical and psychological exhaustion and the need to protect the children in their community. In an opinion piece posted this week, a hospitalist at Tampa General Hospital notes that her facility is currently treating three times as many covid patients as it was last summer. “I haven’t said anything about what’s going on with #COVID here in FL,” that doctor wrote earlier in a tweet, “bc I haven’t had the words to describe it.”

August 24, 2021

FDA warning: Don’t self-dose with ivermectin

deworm-horseThe FDA is again warning the public about the dangers of self-dosing with ivermectin to treat or prevent covid. Mississippi now reports a spike in phone calls to its poison control centers due to individuals buying ivermectin at livestock supply centers—the drug is used to deworm horses and livestock—and ingesting animal formulations. Those formulations, which are much more concentrated for large animals, can be toxic to humans. A recent study from the U.K. noted that several clinical trials are now ongoing to test the use of ivermectin (in human formulation) in covid. However, the FDA has not approved the drug as a covid therapeutic, and the agency notes that ivermectin can interact with other medications including anticoagulants. In tablets, the drug has been approved to treat intestinal strongyloidiasis and onchocerciasis, while the FDA has also approved topical forms for external parasites like head lice and for some skin conditions.

August 23, 2021

Full approval for Pfizer

The FDA today announced full approval for the Pfizer covid vaccine, the first such approval to be granted in the U.S. That approval is for people age 16 and older, while the emergency use authorization for the Pfizer vaccine for those between ages 12 and 15 remains in effect. The New York Times reports that the move is expected to unleash an avalanche of vaccine requirements for employees as well as for 1.3 million active-duty troops. The approval was based on data that Pfizer supplied to the FDA on 44,000 clinical trial participants from around the world, which showed that the vaccine was 91% effective against infection. A recent poll indicates that three out of every 10 Americans who are holding off on being vaccinated are more likely to do so if the vaccine has full approval. Moderna has also submitted data to the FDA, seeking full approval for its vaccine; that decision is expected in several weeks. In the meantime, the FDA hasn’t given the Moderna vaccine emergency authorization for use in adolescents between the ages of 12 and 17. The Washington Post reports that the FDA continues looking at data on the risk of myocarditis with the Moderna vaccine in younger patients, particularly males.

August 20, 2021

Hospitals scramble to find beds

full-covid-hospital-wardHospitals in covid hotspots are shipping critically ill covid patients across state lines, in a desperate attempt to find beds. While the number of covid patients now hospitalized is below that during the winter surge, patients during this wave are competing with other ED and surgical patients for beds. As a result, urban academic centers have few beds to give smaller hospitals for transfers. The search for beds is even more challenging, given the staffing shortages—particularly in nursing—being reported nationwide. Mississippi, which is hard hit, isn’t able to use close to 1,000 of the beds in that state because they aren’t staffed. In Georgia, the governor this week announced that the state will spend another $125 million on hospital staffing, in addition to the $500 million it already allocated to fund 1,300 staff members at close to 70 hospitals in the state. One in five ICUs around the country has either reached or is surpassing 95% capacity.

August 18, 2021

Booster shots and vaccine effectiveness: Does Moderna best Pfizer against delta? (updated Aug. 20)

doctor-vaccine-patientThe administration this week announced that, pending the FDA’s review and decision, it would begin offering third vaccine shots in September to people eight months after they received their second dose of either the Pfizer or Moderna vaccine. That means that those vaccinated in the earliest days of the vaccine roll-out—which includes health care providers, nursing home residents and some seniors—should be eligible for booster shots beginning the week of Sept. 20. Some scientists pushed back against the announcement, claiming it’s based more on anxiety than on science. New research quantifies how much vaccine effectiveness is waning over time, with one new preprint finding that the effectiveness of both the Moderna and Pfizer vaccines fell after seven months in terms of preventing infection—but fell further for Pfizer than for Moderna. (Comments on MedPage Today about the study indicate that the study cohorts “received at least one” vaccine dose, suggesting that some may have not received both doses.) Another large study, this one from the U.K., compared Pfizer’s effectiveness to that of AstraZeneca. The conclusion: “By roughly 4 1/2 months after the 2nd dose, Pfizer’s shot will probably be about on par with Astra’s at preventing infections with a high viral burden.” By comparison, Pfizer’s effectiveness against high viral loads at 14 days after the second dose was 92% vs. 69% for AstraZeneca. Health Affairs reports that vaccines delivered in the early months of the rollout—through May 9—may have prevented close to 140,000 covid deaths.

Babies and toddlers are worse spreaders at home than teens

A large Canadian study that looked at household transmission reached this conclusion: Teens bring the virus home more often than young children do, but it’s babies and toddlers who are more likely to spread the virus to other household members. Why? Family members provide much more hands-on care to very young children who aren’t able to self-isolate. According to New York Times coverage of the study, the research doesn’t resolve whether infected children are as contagious as adults. But experts quoted in the article say the results underscore the importance of protecting children against infection as they return to school and day care. In the study, an infected child didn’t transmit the virus to other household members. But in 27% of the households studied, other residents became ill when a child was the index infection.

August 17, 2021

Weekly cases come close to pre-vaccine levels

More than 900,000 new covid cases were counted in the U.S. over the last week, the
Washington Post reports, the highest weekly tally since January. For the week ending Aug. 15, more than 911,000 cases were reported across the country, with a daily average of more than 130,000 new cases. According to CNBC, the average number of new cases hit record highs in five states: Florida, Oregon, Mississippi, Louisiana and Hawaii. However, Oregon and Hawaii have much higher vaccination rates so are seeing many fewer hospitalizations than in Florida, Mississippi and Louisiana. ICUs are filling up
again, with one in five ICUs around the country either reaching or surpassing 95% capacity.

August 13, 2021

Compassion fatigue?

compassionAfter a brutal year and a half, health care workers are now confronting a new problem: “compassion fatigue,” which is kicking in at least for some when treating patients who’ve refused to be vaccinated but are now sick with covid. That’s according to Chavi Eve Karnowsky, MD, an OB in New York City, writing in The Atlantic. Doctors see plenty of evidence of the bad choices their patients make, she writes, but choosing to remain unvaccinated in the face of a deadly virus is different and “much more personally threatening to my colleagues and me.” Some of her colleagues also find it maddening to see people who doubt the science behind vaccines then expect the best care science can provide once they are sick. After so many losses—of lives, jobs, the education for tens of millions of American children—health care workers are risking another: the loss of the belief that this society can come together to solve the problem.

Pandemic fallout: NPs are in hot demand, while doc salaries fall

In its latest annual review of physician and advanced provider recruitment incentives, staffing firm Merritt Hawkins reports these findings: The number of recruitment searches fell 25% last year as facilities and practices dealt with pandemic-related revenue losses. Further, for the first time in 14 years, NPs, not family physicians, were the firm’s hottest search candidate due to NP demand from both urgent care and telehealth. The report is based on close to 2,500 recruiting searches that the firm conducted between April 2020 and March 2021. Over that year, starting salaries were up 12% for NPs and 14% for physician assistants, while starting salaries for most doctors were down slightly. (The exceptions were neurology, cardiology and psychiatry.) In 2020-21, the firm had only 27 searches for hospitalists, down from 71 the year before and from 228 in 2015-16. The report also noted a decrease in the percentage of searches that offered sign-on bonuses. Only 61% of searches featured such a bonus, down from 72% in 2019-20.
August 11, 2021

Hospitals struggle with severe nursing shortage

Not news to most hospitalists: Hospitals are reporting dire nursing shortages, one that’s making it impossible to staff hospital beds even as inpatient medicine volumes rise and hospitals in the Southeast are overwhelmed with covid cases. The Texas Tribune reports that hospitals in that state have both historically low staffing numbers and “skyrocketing” covid cases, with pandemic burnout cited for why nurses are leaving the profession as well as the high wages traveling nurses are being offered to hit the road. To entice new hires, one hospital in Arkansas is offering a $25,000 sign-on bonus, while executives with Jackson Memorial Health System in Miami say that nurses in their health system are being lured to other hospitals that offer two or three times the nurses’ current salary. Hospitals in that system are now giving retention bonuses to nurses as well as time-and-a-half for working extra 12-hour shifts—and a $500 bonus per shift.

Pediatric hospitals sound the alarm

It remains unclear whether the delta variant is causing more severe infections among children. What is clear, however, is that children’s hospitals, particularly in the South, are seeing their highest number of covid cases yet, even as children in that region are getting ready to go back to school. According to a report from the American Academy of Pediatrics, “child cases have steadily increased since the beginning of July,” with almost 94,000 new cases emerging in the first week of August. While the report notes that severe illness remains uncommon among children, the rise in pediatric cases indicates that the variant is hypertransmissible and may suggest a more rapid progression of more severe disease.

August 10, 2021

More data on breakthrough infections

breakthrough-covid-infectionNew research out of the U.K. sheds more light on the differences between vaccinated and unvaccinated patients infected with the delta variant. Researchers looked at covid tests drawn for more than 98,000 people between June 2021 and the end of July. Vaccinated people who were positive were 59% less likely to have symptomatic infection, with unvaccinated infected patients 25 times more likely to be hospitalized. As for differences in viral loads, epidemiologist Katelyn Jetelina, MD, explained that vaccinated people in the study were found to be no longer infectious after nine days while those who weren’t vaccinated remained so for 16 days. “This confirms the higher rate of breakthrough cases than we anticipated,” Dr. Jetelina writes. “But the breakthrough cases continue to be far more mild than unvaccinated cases.”

Is post-vax myocarditis more common than previously thought?

According to a new JAMA research letter, myocarditis and pericarditis post-vaccination remain rare. But the conditions may be happening more frequently than previously reported. They also constitute two separate syndromes, MDedge reports, with myocarditis occurring in younger patients, usually after the second dose, and pericarditis turning up in older patients after either dose. The authors looked at the electronic health records of more than 2 million people vaccinated within the Providence health care system. The case rate they found was 1.0 per 100,000 for myocarditis and 1.8 per 100,000 for pericarditis. By contrast, the CDC, which has lumped pericarditis stats with myocarditis, has reported 4.8 cases per 1 million.

August 9, 2021

More good news for covid patients taking statins

statins-heart-covidResearchers publishing in PLOS ONE find that covid patients taking statins due to hypertension or heart disease may face lower mortality odds. The authors looked at data on more than 10,500 covid patients treated last year in 100-plus U.S. hospitals. Among those patients, 42% were found on admission to be taking either statins alone or in combination with anti-hypertensives. The use of statins, the analysis found, was associated with a more than 40% mortality reduction and a better than 25% reduction in developing severe covid. The authors point out that other studies had produced similar results but that those other studies were smaller or regional. “These observations support the continuation and aggressive initiation of statin and anti-hypertensive therapies among patients at risk for COVID-19,” they write, “if these treatments are indicated based upon underlying medical conditions.” The researchers also point out that randomized trials are already underway to see if statins can benefit covid patients even when patients don’t have underlying indications for taking the medications.

August 6, 2021

Trials identify covid patients who benefit from full-dose heparin

Can therapeutic heparin dosing (vs. a prophylactic dose) boost mortality in hospitalized covid patients? It can, according to new data published in NEJM—except not in critically ill patients or those with severe covid. In one study, which was conducted internationally, therapeutic dosing among hospitalized patients with moderate covid increased their probability of survival and lowered their need for cardiovascular or respiratory organ support. But that was not the case for critically ill patients, the same investigators reported in a separate trial. The author of an accompanying editorial suggested a reason for that difference, writing that inflammatory and thrombotic damage may be too far advanced in those with critical illness to be affected by therapeutic dosing. The editorial also urged physicians to weigh the benefits and risks of heparin, even in patients with moderate disease.

Time to reform evaluation, licensure of physicians with mental illness

Medicine is notorious for penalizing providers who seek help for mental illness. One resident with bipolar disorder has openly detailed his struggles, writing in an account last year about checking himself into a psychiatric hospital because of suicidality. Now, in a JHM perspective, he describes the process he had to undergo to return to work; that process included month-long outpatient treatment, a review by his institution’s physician well-being committee and a formal fitness-for-duty evaluation. That evaluation, he writes, went too far, mandating additional treatment in addition to the medications and therapy he was already undergoing. He and his co-authors recommend that fitness-for-duty evaluations instead be limited in scope and that any “return-to-duty” contracts that include treatment and monitoring should be crafted in collaboration with the physician and her or his treating clinician. They also write that such evaluations should include psychiatrists, independent oversight and an external appeals process. Further, they recommend state and federal changes including having state licensing boards limit licensing questions to any current impairment due to mental illness or substance use disorder.

August 4, 2021

U.S. passes 70% vaccination milestone, but cases are still rising sharply

vaccine-targetIt took an additional month, but the Biden administration—which aimed to hit this target by July 4—reported this week that 70% of all U.S. adults have now received at last one dose of vaccine. Further, the pace of vaccinations, including that for people getting their first dose, is accelerating, in response to rising infection rates. The New York Times is reporting a seven-day average of new daily cases in the U.S. of more than 80,000, while the number of hospitalizations as of last Saturday had risen 44% over the previous week and deaths were up 25%. One in three new cases in the country over the past week occurred in Florida and Texas.

Pfizer vaccine may get full approval by Labor Day

The FDA is speeding up its timeline to grant full approval to the Pfizer vaccine, according to the New York Times, with that approval possible by early next month. The hope is that full approval would convince some who are hesitating to be vaccinated to finally get off the fence. Also, full approval would make it easier for employers as well as cities, universities, hospitals and the defense department to mandate vaccine. Poll results published in June by the Kaiser Family Foundation found that three out of every 10 people who weren’t vaccinated said they were more likely to agree to be vaccinated if it received full approval. Moderna has also applied for approval for its vaccine, while J&J plans to later this year. In other vaccine news, the debate over getting a booster shot is heating up, with MedPage Today reporting that doctors are considering getting a third shot for themselves, their families and their patients out of concern for waning antibody levels. The CDC is warning people that antibody tests should not be used to gauge immunity post-vaccination. However, the WHO is calling for a moratorium on booster shots in developed countries until the end of September, urging that vaccine supplies go instead to low-income countries where vaccination rates are dangerously low.

August 2, 2021

CDC sounds the Delta alarm: “The war has changed”

cdc-covid-alarmDocuments first circulated within the CDC, then publicly released, are sounding the alarm on the Delta variant, saying the strain is as contagious as chicken pox and so transmissible that it’s being likened to a novel coronavirus. The agency looked at data on an outbreak in Providence, R.I., in early July in which three-quarters of the infections were among fully vaccinated patients. Further, MedPage Today reports that nearly 80% of all infections in the outbreak were symptomatic. Among 469 infections, however, only five people were hospitalized (four of whom were fully vaccinated) and no one died. (The town manager has since reported that more than 800 positive cases have been identified in the outbreak.) The data formed the basis for the CDC updating its guidance last week, calling on everyone—including those who are vaccinated—to use masks when indoors in public and for vaccinated patients to be tested if they’re exposed to someone with covid. According to the CDC, 35,000 symptomatic infections every week are cropping up among 162 million Americans who have been vaccinated.

Baricitinib gets expanded emergency use as a solo agent

The FDA last week expanded its EUA for baricitinib, allowing the agent to be used alone and not in combination with remdesivir. The FDA’s first EUA for the drug was issued in November, but that was for a baricitinib-remdesivir combo to treat adults and pediatric patients age 2 and older hospitalized with covid who require noninvasive oxygen, ventilation or ECMO. The expanded EUA is based on results of a trial, which have not yet been published. The research found that baricitinib significantly reduced all-cause mortality and progression to a ventilator when administered along with standard of care (vs. placebo and standard of care). In the trial, 79% of the patients were given steroids while 19% had remdesivir, and some patients had both.

July 30, 2021

Is another surge about to happen?

US-map-figures-covidA former CDC director had made this frightening prediction: The U.S. may within weeks again see the number of new daily covid cases climb to 200,000, a level not seen since January. Thomas Frieden, MD, who headed up the CDC during the Obama administration, says the number of daily cases may quadruple over the next four to six weeks due to the transmissibility of the Delta variant and the number of Americans who refuse to be vaccinated. According to Dr. Frieden, soaring numbers of new cases may not translate into more deaths, given that many older, more vulnerable Americans have already been vaccinated. At the same time, experts are puzzled over why case numbers in the U.K., where the Delta variant is completely dominant, have been falling, not rising as previously predicted. The Washington Post reports that experts have put forward three theories as to why: testing and tracking may be working; people may have stopped being tested because they don’t want to quarantine if positive; or the U.K. may have hit herd immunity, with more than 70% of adults fully vaccinated. Israel is launching a booster-shot campaign for adults older than 60 who received their last dose of vaccine at least five months ago. And new preprint results indicate that the efficacy of the Pfizer vaccine falls to 84% (from 96%) over six months, suggesting that efficacy drops 6% every two months post-vaccine.

HHS earmarks $100-plus million to fight burnout, promote wellness

The HHS plans to dedicate more than $100 million over the next three years to fight burnout and improve mental health among health care workers. According to Healthcare Finance, the funding is designed to support the implementation of strategies in health care organizations to help their workforce avoid burnout and promote wellness and resilience. Three separate funding opportunities are now accepting applications: The Promoting Resilience and Mental Health among Health Professional Workforce program will give out 10 awards to organizations to expand a wellness culture; the Health and Public Safety Workforce Resiliency Training program will grant 30 awards to educational and nonprofit institutions to help train early-career providers; and the Health and Public Safety Resiliency Technical Assistance Center will grant one reward for HRSA workforce resiliency programs. Applications are due Aug. 30.

July 28, 2021

CDC to (many) vaccinated people: Mask up!

The CDC this week issued updated mask guidance, calling for everyone—including those who are fully vaccinated—to once again use masks indoors when in public in areas of the country with widespread transmission. The update reverses CDC guidance issued only two months ago, and it comes in response to new concerns about the transmissibility of the Delta variant, which is now the country’s predominant strain. According to STAT, the Delta variant is causing breakthrough infections among vaccinated patients at higher rates than expected. Given the higher viral loads associated with that variant, even infected patients who are vaccinated are at risk of transmitting the virus. As to which areas have widespread transmission, the CDC’s Covid Tracking Web site breaks down community transmission by county, with people being urged to mask up indoors when in public in those areas that are either orange on the CDC county maps (designating substantial transmission) or red (high transmission). Because high transmission is linked to low vaccination rates, New York Times coverage makes this point: “The parts of the country that would benefit most from a new crackdown on Covid-19—including more frequent mask wearing—are also the places least likely to follow C.D.C. guidance.”

July 27, 2021

Vaccine mandate: The VA puts down the hammer

vaccine-mandateThe VA yesterday became the first federal agency to issue a covid vaccine mandate, announcing that all of its 115,000 front-line health care workers will need to be fully vaccinated within the next two months. According to the New York Times, the mandate will apply to doctors, RNs, dentists, physician assistants and some specialists, all of whom must be vaccinated within the next eight weeks or face penalties or even the loss of their jobs. Several VA centers around the country have had recent outbreaks, even though about 70% of the VA health care workforce is already vaccinated. Workers will be able to appeal for religious or medical reasons. In related news, several dozen health care organizations and societies—including SHM, ACP and the AMA—are calling for universal vaccination among all health care and long-term care workers. At the same time, GOP lawmakers around the country are working to restrict public health measures including the use of mask mandates. And seven states have already passed legislation restricting the ability of public schools to either mandate vaccinations for returning students or documentation of vaccine status. Those states include Alabama, Arkansas, Florida, Indiana, Montana, Oklahoma and Utah.

July 23, 2021

To boost vax rates, one hospital is offering to jab the hesitant in secret

private-secure-covid-vaccinationThis is how bad things are getting in Missouri: To convince the vaccine-hesitant to take the plunge and get the shot, Ozarks Healthcare in West Plains, Mo., is offering to vaccinate people on the down low if that will help boost immunization rates. In a statement, the system said “If you are afraid of walking into a public area where you might be seen getting your vaccine, we will work to accommodate even more of a private setting for you to receive your vaccine.” The health system noted that for some people, getting the vaccine may mean losing friendships and respect in the community. The offer seemed to have some effect last week, when its pharmacy gave twice as many vaccines one day as usual. Unfortunately, Ozarks is also seeing its largest number of covid cases since earlier this year.

Two covid treatments being questioned

The results of one of the largest trials of the drug ivermectin have been withdrawn by the online journal that first published them. MedPage Today reports that study, which had presented positive data about the drug’s ability to treat covid, was withdrawn because of concerns about plagiarism and data anomalies. Those data were used in two recent meta-analyses that received widespread attention because of their positive results. Also this week, new research on the antiviral remdesivir found that the drug didn’t significantly improve survival in VA patients but was associated with more days in the hospital. MedPage Today notes that CDC and IDSA guidelines recommend the use of remdesivir.

Spread of covid among hospital roommates hits 39% in one study

Research in Clinical Infectious Diseases found that among 31 inpatients who were exposed to covid via an diagnosed roommate, 39% tested positive for the virus within 14 days. In MedPage Today, the researchers explain that the only factor that was significantly associated with transmission was the roommate’s viral load, with PCR cycle thresholds of ≤21 considered the smoking gun. They noted that high transmission rates in these patients occurred despite the fact that inpatients are typically at least six feet apart and that hospitals have fairly good ventilation systems. It’s also evidence that the virus can be transmitted by respiratory aerosols and minimizes the importance of physical contact. The researchers suggest pairing vaccinated patients in a room, using portable HEPA filters between patient beds, and increasing testing of patients.

Will the J&J vaccine require a second shot to protect against variants?

More bad news emerged for the J&J vaccine this week when it comes to the shot’s ability to fight variants like Delta. A study published by the online journal bioRxiv found that the vaccine’s effectiveness was “significantly decreased” over time and that people who have received the vaccine may need a booster shot to stay protected against variants like Delta and Lambda. The New York Times notes that the research contradicts earlier smaller studies that were published by J&J, which found that the vaccine remained effective against variants up to eight months after the shot was given. But the new data are consistent with studies that show a single dose of the AstraZeneca vaccine has an efficacy rate of about 33% against the Delta variant. That’s significant because the AstraZeneca vaccine has a similar architecture as the J&J vaccine. The Times article quotes one virologist who pointed to several studies that have shown that the J&J vaccine is more effective when two doses are given.

Pfizer and AstraZeneca offer better protection against Delta

The news was somewhat better for two other vaccines when it comes to fighting off the Delta variant. A study published in the New England Journal of Medicine found that while the Pfizer and AstraZeneca vaccines give up some efficacy in combatting the Delta variant, they still offer significant protection. Researchers found that two doses of the Pfizer vaccine showed 88% efficacy against the Delta variant, while two doses of the AstraZeneca vaccine offered 67% efficacy. A Medscape article points out that the Pfizer vaccine is 94% effective against the Alpha or UK variant, while the AstraZeneca was 74% effective against it. One dose of either vaccine didn’t fare very well. One dose of the Pfizer vaccine was offered 49% efficacy, while one dose of AstraZeneca was only 31% effective. And the first large study to take a look at vaccine efficacy outside of the confines of a clinical trial found very good news about the two mRNA vaccines from Pfizer and Moderna. Research in in Annals of Internal Medicine found that among people who received two shots of an mRNA vaccine, efficacy was above 95% regardless of any patient characteristics.

July 16, 2021

Survey: Half of 12- to 15-year-olds not getting vaccinated

child-vaccinationWhile only a quarter of U.S. children aged 12-15 have been vaccinated, immunization rates among that group are plunging and cases for all children are rising. A Medscape article says that just over one-third of 12- to 15-year-olds have gotten at least one dose of vaccine, which may correlate to the rising caseloads among that group. According to an American Academy of Pediatrics report, there were 19,000 new cases of covid for the week ending July 8. The week before, that number was 12,000; two weeks before, it was 8,000. A survey of nearly 2,000 adolescents and their parents found that about half of both groups didn’t plan to have their child vaccinated or weren’t sure whether they would. Common reasons for vaccine hesitancy or outright refusal centered on concerns about safety and efficacy. A Medscape report notes that the decision to vaccinate can be an issue when divorced parents disagree.

Will we need booster shots to fight covid variants?

With covid surging in 46 states and the Delta variant accounting for half of those cases, the conversation early in this week was focused on whether a booster shot will be needed. Pfizer employees met with Biden administration officials on Monday to discuss the need for boosters, and while there was much public enthusiasm on social media for a third shot, public health officials have taken a more muted tone. A joint statement from the CDC and FDA, for example, said that fully vaccinated Americans don’t currently need a booster and placed the focus on continuing to expand the number of people who get the vaccines that are already available. And the director general of the World Health Organization criticized manufacturers that want to develop a booster shot, saying they should instead focus on delivering vaccines to underserved parts of the world, stating that “we’re making conscious choices right now not to protect those in most need.” An article in STAT said the official also pointed out that there are not yet any data indicating that a booster is needed.

With Delta, getting two mRNA shots is critical

Some relatively good news on the covid front: A preprint in Nature found that both shots of either the Pfizer or AstraZeneca vaccine neutralized the Delta variant in 95% of cases. One dose of either vaccine, however, “barely inhibited” Delta. The study echoes other data, which have found that getting a second shot can double the effectiveness of the vaccine. An English study, for example, found that the efficacy of the Pfizer vaccine jumped from 33% to 88% after the second dose. The data are significant because CDC this week announced that nearly 15 million Americans, or 10%, have missed their second dose of the covid vaccine. A MedPage Today report says that in June, 88% of people eligible for a second dose got their second shot. That number is down from the 92% completion rate earlier in the year. At the time the data were released, another 2 million people were eligible for their second shot but had not received it yet.

J&J vaccine linked to rare instances of Guillain-Barre Syndrome

Earlier this week, the FDA warned that J&J’s covid vaccine may trigger a rare neurological condition in a small number of people. The agency said there were about 100 preliminary cases of Guillain-Barre Syndrome out of the 12.8 million doses of vaccine that have been administered in the U.S. A STAT article says that of the cases reported, most developed about two weeks after the shot and were most common in older males. European health officials issued a warning last week saying that a similar condition may be linked to the AstraZeneca vaccine, but it said that the data could not establish a clear link between the vaccine and Guillain-Barre Syndrome.

July 9, 2021

How well do the vaccines protect against the Delta variant?

booster-vaccineA new study released this week says that the quick rollout of the covid vaccine in the U.S. saved about 279,000 lives and prevented 1.25 million hospitalizations. But how well will covid vaccines handle the surge in cases from the Delta variant? Pfizer yesterday released data showing that a third “booster dose” of its vaccine given six months after the second shot increased the strength of the antibodies against the original virus and the Beta variant by five- to 10-fold. A New York Times article says the company also announced that it was developing a version of its vaccine to target the Delta variant and will begin clinical trials in August. Israeli data on the Pfizer vaccine found that while it has lost some of its effectiveness, possibly because of the Delta variant, it remains effective at preventing serious illness. A Reuters report says the Pfizer vaccine’s effectiveness in preventing overall infection and symptomatic disease has fallen to 64%, but that it is 93% effective in preventing hospitalizations and serious illness. Johnson & Johnson offered some good news in an announcement that its covid vaccine offers protection against the Delta variant. A New York Times article says that while the vaccine is slightly less effective against the variant compared to the original virus, it is also more effective against the Delta variant than it was against the Beta variant.

Low vax rates sending case rates surging in hot spots

The emergence of the Delta variant as the dominant strain of covid combined with a lack of vaccinations is leading to surging covid caseloads in some parts of the country. A state-by-state analysis by Johns Hopkins University and NPR has found that in parts of the country with low vaccination rates, infections are exploding. In Ottawa County, Okla., for example, where the vaccination rate is 23%, cases have surged by 828%. While the CDC reports that 67.1% of American adults have received at least one dose of a vaccine, immunization rates in some rural parts of the South and Midwest are as low as 30%. A Becker’s Hospital Review article says those low rates are fueling a rise in covid hospitalizations in 17 states and a 5% jump in cases nationally. CoxHealth, a large rural health system, has already begun diverting patients to larger systems because of surges in covid patients and problems with nursing staffing. In a HealthLeaders article, the system’s CEO warns that covid surges could appear much more quickly than they did last fall, adding that health care systems “should get ready now.”

FDA withdraws authorization for some respirators

If your hospital is using KN95 respirators imported from China, your facility needs to make sure it’s meeting federal regulations. The FDA has started to withdraw some of the emergency approvals it made during the early days of the pandemic for respirator masks and hardware used to clean and re-use them. A Fierce Healthcare article says that because supplies of respirators approved by the National Institute of Occupational Safety and Health have rebounded, the FDA is instructing health care facilities to stop using nonapproved respirators. Emergency use authorizations for those devices expired June 30.

Acute stroke care in U.S. remained strong during covid

A seemingly rare piece of good news related to the pandemic:  Acute stroke care in the U.S. suffered relatively few disruptions during the pandemic. A study in Stroke found that among patients participating in a stroke registry, rates of IV alteplase and endovascular therapy remained strong during the pandemic. In addition, researchers found that door-to-CT times, door-to needle times and door-to-endovascular therapy times all showed no signs of slipping. Researchers did find that the number of patients presenting with stroke symptoms dropped 15% beginning in March 2020. A MedPage Today article notes that the results contradict another recent study that found a decline in stroke care around the world because of the pandemic.

July 8, 2021

NIH report: Covid surges drove spikes in mortality

An NIH study has concluded that covid surges raised mortality rates at the nation’s hardest hit hospitals. The research, which was published in Annals of Internal Medicine, found that high surge hospitals experienced a two-fold greater mortality than hospitals not experiencing surges. The data showed that nearly one in every four deaths, or a total of about 6,000 deaths, could possibly be attributed to the strain on hospital resources produced by covid surges. A HealthLeaders article says researchers examined the records of nearly 150,000 patients admitted to 558 hospitals between March and August of 2020. Researchers concluded that surging caseloads “potentially eroded” the benefits offered by emerging treatments.

July 6, 2021

Covid cases starting to grow again, fueled by Delta

Before the holiday weekend, CDC Director Rochelle Walensky, MD, warned that the daily count of new covid cases had started to climb, marking a 10% increase in new cases from the week before. A Medscape article says that hospitalizations and deaths remain low and the country’s covid caseload is still down 95% from the U.S. peak earlier this year, but hot spots are popping up in various parts of the country. Covid cases in Florida, for example, are up 42% from the previous week, and new cases in Los Angeles County doubled from the previous week. Johnson & Johnson offered some good news in an announcement that its covid vaccine offers protection against the Delta variant. A New York Times article says that while the vaccine is slightly less effective against the variant compared to the original virus, it is also more effective against the Delta variant than it was against the Beta variant. Israeli data similarly found that the Pfizer vaccine has lost some of its effectiveness, possibly because of the Delta variant, but that it remains effective at preventing serious illness. A Reuters report says the Pfizer vaccine’s effectiveness in preventing overall infection and symptomatic disease has fallen to 64%, but that it is 93% effective in preventing hospitalizations and serious illness. In the United States, officials are particularly concerned about states in the South and the Midwest, where vaccination levels in some counties hover around 30%. In a Healthcare Dive article, the CEO of a large rural health system says he is already having to divert patients to larger systems because of surges in covid patients and problems with nursing staffing. He warns that covid surges could appear much more quickly than they did last fall, and that health care systems “should get ready now.”

July 2, 2021

EDs in the Pacific Northwest reeling from the heat, violence

heatwave-covid-violenceThe heatwave gripping the northwest part of the United States is stressing the region’s emergency departments, adding to the existing challenges of overcrowding and understaffing. A MedPage Today article says that in Oregon and Washington, patient volumes have spiked because of a surge in heat-related illnesses. And because the wards in many hospitals are full, in part because of the lingering effects of covid and in part because of injuries that are the result of a spike in violent crime, the ED has nowhere to send patients who need to be admitted. The Medscape article notes that some patients presenting with heat-related issues can appear to be suffering from cardiac arrest. In related news, a survey of workers at an urban academic medical center found that nearly one-third have been physically assaulted at work and one-third have suffered verbal abuse. The problems are so constant and so expected that most victims didn’t bother to report the abuse or even mention it to colleagues.

The impact of India’s pandemic crisis on U.S. physicians

As covid ravages India, physicians in that country and in the United States are feeling the effects. In a STAT news article, three U.S. physicians of Indian origin discuss how the pandemic in their “motherland” is affecting them. Via a constant stream of messages platforms, such as WhatsApp, and social media postings, physicians of Indian origin working in the United States are learning about the struggles families and friends in India are facing. Physicians here are hearing status updates of relatives who have the virus, and they’re receiving pleas for help to find basic supplies like oxygen, hospital beds and even ambulance transport. The authors point out that the situation in India can affect the United States. Besides the obvious implications of the Delta variant leaving India and gaining traction in the U.S., nearly 40% of U.S. prescription medications come from India.

How soon after covid is it safe for elective surgery?

Surgeons are struggling to know when it’s OK to give patients who have had covid the green light for elective surgery. As a result, the lingering effects of covid are keeping some patients out of elective surgery for months, even in individuals who had relatively mild cases of the infection. A Kaiser Health News story says that a March study found that waiting at least seven weeks after a covid infection significantly reduced the mortality risk of surgery, but the mortality rate was still double that of surgery patients who never had covid. That same study concluded that for patients with lingering symptoms of covid, elective surgeries should be delayed even longer. The American Society of Anesthesiologists and the Anesthesia Patient Safety Foundation have issued guidelines saying surgery is OK four weeks after covid for patients who were asymptomatic or had mild, non-respiratory symptoms, but they also say that surgery should not happen for at least 12 weeks in people who were in an ICU because of covid.

One in three workers at larger hospitals not vaccinated

One in four hospital workers who have direct patient contact have not yet received a covid vaccine. At larger hospitals, that number is closer to one in three. A Medscape article says that the picture of exactly who in health care is vaccinated is murky because reporting on vaccination rates is voluntary, and only about half of U.S. hospitals have provided that information to the government. But the article also says that its projected vaccination rate in U.S. hospitals mirrors the vaccination rates of the general population. About 24% of Americans don’t plan to get the vaccine, and 12% plan to get vaccinated but want to wait. In a poll of health care workers conducted in May, about 12% of physicians said they were hesitant to get the shot.

June 25, 2021

Doctor’s mental health: Collateral damage

physician wellnessIt’s a longstanding crisis that, with covid, has taken on new urgency: Medicine is “a profession that punishes some doctors from getting mental health care,” as Vox reports in a new article. For physicians, structural barriers to mental health services are still in place and enforced by many physician groups, hospital credentialing systems and licensing boards; those stop doctors from getting help, for fear of jeopardizing their license and practice. Article sources note that part of the problem is that half of U.S. physicians work as independent contractors, falling outside labor law protections, and that doctors fall prey to chronic understaffing and traumatic experiences. The field also attracts “perfectionists who put tremendous pressure on themselves to succeed.” The Physician Support Line that was set up during the pandemic for doctors and medical students and is staffed with psychiatric volunteers has seen “explosive demand.” Article sources who have sought help say they’ve gone out of state to do so or have paid out-of-pocket so their mental health services aren’t reported to insurers or employers. In other news: When the pandemic began, The Nocturnists—the story-telling collaborative of health care professionals based in San Francisco—asked clinicians to record pandemic audio diaries. Those more than 700 sound diaries have now been donated to the Library of Congress.

Inflammation “extremely rare,” but mRNA vaccines get new warning

The FDA has decided to add a warning to the labels and fact sheets of both the Pfizer and Moderna vaccines about heart inflammation in young adults. But while CDC and ACIP officials this week noted a “likely association” between the cardiac issues and the mRNA vaccines, they also noted that myocarditis and pericarditis are “extremely rare.” A benefit-risk presentation finds that close to 500 cases of myocarditis among people younger than 30 have been reported, with more than 300 hospitalized. (Close to all have been discharged.) Most cases are in males, and most problems emerge within four days of receiving the second vaccine dose. According to an ACIP work group, “Currently, the benefits still clearly outweigh the risks for COVID-19 vaccination in adolescents and young adults.” In other news, younger Americans and African-Americans are increasingly at the highest risk of dying from covid.

June 23, 2021

U.S. will miss its original July 4 vaccine mark

The administration acknowledges that the U.S. will miss its ambitious vaccine goal of having 70% of American adults vaccinated by July 4. Instead, it’s set another goal that should be achieved by that date: 70% of those age 27 and older. NPR reports that the country will miss the original 70% goal by only a few percentage points, with 65% of the population having at least one shot right now and 56% fully vaccinated. The pace of vaccinations has slowed considerably from earlier this year, with fewer than 1 million shots being administered per day. The CDC points out that the states with the lowest adult vaccination rates (under 50%) are Mississippi, Louisiana, Wyoming and Alabama. At the other end of the spectrum, more than 80% of adults in Vermont, Hawaii and Massachusetts have been vaccinated.

With N3C, the U.S. finally centralizes some health data

Some of the best covid studies have come from the U.K., in large part because researchers there can access centralized NHS patient data. But in the U.S., patient data are trapped in a maze of proprietary systems behind a firewall of privacy protections that often contradict each other. According to an article in MIT Technology Review, that impasse led NIH researchers to create the National Covid Cohort Collaborative (N3C), a database now collecting information on millions of U.S. patients. That database contains records on 6.3 million patients, including more than 2 million Americans infected with covid. Those data are coming from more than 50 institutions around the country, with patient data stripped of personally-identifiable information for zip codes and services dates. So far, more than 200 research projects have been approved that can access some tier of those data.

June 21, 2021

Delta variant could create “two Americas”

Delta-variant

Given the wide regional variations in vaccination rates in the U.S. and the rise of the Delta variant, experts are warning that “two Americas” may emerge. In areas with high vaccination levels, people can expect to be protected against the variant. But in those with low vaccination rates, the Delta variant—which first emerged in India—may drive outbreaks this fall or winter. A recent study from Scotland published in The Lancet found that patients’ risk of being hospitalized when infected with the Delta variant was about twice that of the Alpha variant, which first emerged in the U.K. British data indicate that the Delta variant is also between 40% and 60% more transmissible than the U.K. variant

Could the vaccine rollout have been improved?

Close to 180 million Americans have had at least one dose of vaccine, but 100,000 Americans have died of covid since February when the vaccine rollout was underway. The New York Times asked experts what other vaccination strategies should have been pursued to cut that level of mortality. Experts offered five strategies: delayed second dosing, an approach taken in the U.K. and Canada, to stretch vaccine supplies among vulnerable patients; a younger rollout to include more people ages 50-64; a targeted rollout to get vaccine to the hardest-hit zip codes; faster congressional action, with money approved sooner for vaccine distribution; and a better public relations campaign to overcome vaccine hesitancy and provide more information about access.

June 18, 2021

Covid’s high toll among IMGs

A research letter points out that IMGs make up about 25% of the American physician workforce—but 45% of the doctors who’ve died from covid. With Abraham Verghese, MD, as its lead author, the letter looks at data on 132 physician deaths from covid as of late November 2020. The authors found that 60% of those deaths occurred among primary care physicians, even though primary care doctors make up only 37% of practicing physicians. (According to the letter, 40% of IMGs work in primary care.) As to why the IMG death toll was disproportionately high, the letter points out that close to 40% of physician deaths were in New York and New Jersey, which have high numbers of IMGs. Also, because those states were particularly hard hit during the early part of the pandemic, those doctors had higher rates of exposure. “The larger number of deaths among IMGs,” the authors write, “highlights their important contribution to patient care.”

Antibody cocktail cuts mortality in some hospitalized patients

Regeneron’s monoclonal antibody cocktail received an EUA in the U.S. to treat patients with mild to moderate covid. Results out of the U.K. this week, according to a press release, found that the therapy produced a mortality benefit among hospitalized patients whose own immune systems weren’t producing antibodies. Among such seronegative patients, use of the cocktail cut 28-day mortality rates by 20%, shortened length of stay and reduced the need for mechanical ventilation. (The therapy produced no benefits in hospitalized patients generating their own antibody response.) In the trial, close to 9,800 patients were randomized to either usual care plus the antibody combo or just usual care; among the usual care group, 30% were seronegative. One skeptic about the results quoted by Reuters noted the cocktail’s high price and said its efficacy would depend on being able to readily identify and treat the hospitalized patients who could benefit.

Got a startup?

New York’s Mount Sinai is launching an incubator program that’s looking for pre-seed and seed stage startups in health care and biotech. FierceHealthcare reports that the new incubator—called Elementa Labs—will offer accepted startups a 12-week virtual program as well as access to a champion and Mount Sinai’s network of experts. The new program is accepting applications through Sept. 30 from startups willing to trade some future equity. Mount Sinai has a robust commercialization arm that filed close to 400 patents last year. The incubator’s first participant is avoMD, which makes a mobile clinical decision support platform.

June 15, 2021

Vaccination disparities

Burlington-Vermont

Big vaccination milestones: An AMA survey finds that 96% of practicing physicians in the U.S. have been vaccinated, and Vermont is the first state to have 80% of its population age 12 and older at least partially vaccinated. But a report from Kaiser Family Foundation finds that vaccination rates in communities of color are still lagging, with only 63% of Hispanics and 51% of African-Americans expected to be vaccinated by July 4. As for when those communities will be 70% vaccinated, the report claims that will be the end of July for Hispanics and the beginning of September for Blacks. The report also notes that many states aren’t on track to achieve 70% vaccination rates with at least one shot by July 4.

June 14, 2021

Judge tosses anti-vaxx lawsuit brought by hospital workers

A federal judge this weekend threw out a lawsuit brought by more than 100 hospital workers who were suspended from Houston Methodist Hospital for refusing to be vaccinated against covid. The workers, who say they will appeal, claimed in their suit that they did not believe the vaccines were safe because they’d been issued only EUAs by the FDA, not full approvals. In his ruling, the judge rejected the argument that the hospital’s policy of mandatory covid vaccinations was forcing workers to take part in a “human trial”—and called “reprehensible” the plaintiffs’ complaint that the vaccine mandate was similar to medical experiments done during the Holocaust. USA Today reports that a growing number of hospitals around the country are beginning to require vaccination among their workers.

Link between second dose and heart inflammation in young people?

myocarditis-covid

It’s rare but higher than expected, according to CDC and FDA officials. While the data are still preliminary, the agencies are investigating 573 cases of myocarditis and pericarditis reported in younger patients after receiving the second dose of either mRNA vaccine. (After the first dose, 216 cases have been reported.) The cases appear to be more common in men than in women, and most cases are mild. STAT reports that Israeli officials are also investigating “a possible link” between myocarditis and a second vaccine dose among men ages 16 to 30. According to agency officials, most of the patients for whom cases have been reported have fully recovered.

June 11, 2021

The push to vaccinate teens

teen-covid-vaccination

Adults are more than 10 times more likely to be hospitalized for covid than patients under age 18. But a new report from the CDC points out that covid hospitalization rates among those ages 12 to 17 is twice that for seasonal flu, and that adolescents with chronic health issues are a big concern. Among teenagers hospitalized with covid from early January 2021 through April 2021, nearly one-third required ICU care and 5% needed to be on a ventilator, however none died. About 70% had underlying health issues, with obesity being the most common and chronic lung diseases, including asthma, and neurological conditions also occurring. As for vaccinations among teens, the Kaiser Family Foundation looked at state laws around needing parental consent. Most states—41 of them—require teens younger than 18 to get parental consent, while Nebraska mandates parental consent for those below age 19. But many states allow teens who are emancipated or homeless to self-consent, as do two cities: San Francisco and Philadelphia, where minors age 12 and older can themselves decide to be vaccinated.

Analysis argues for continued use of convalescent plasma

Hospitals’ use of convalescent plasma to treat covid dropped after several published studies found no apparent benefit. But new research from Johns Hopkins makes the case for clinicians taking another look. The authors compared data on both the number of plasma units distributed to hospitals and of covid hospital deaths, finding a strong negative correlation. According to the model that researchers devised, every 10% increase in the rate of plasma used in hospitals cut covid fatalities by 1.8%—while the decline in plasma use between November 2020 and February 2021 may have contributed to more than 29,000 excess covid deaths. As to why some studies found no therapeutic benefit, the authors note that in many of the negative trials, convalescent plasma was administered relatively late in the course of the illness when patients were too sick to benefit and their immune responses were driving their disease.

Urban-rural gap in death rates is getting worse

The good news is that mortality rates for both urban and rural Americans are falling. The bad news: A new JAMA research letter finds a widening gap in the rate of those declines. Looking at 1999-2019 data, the authors found that the mortality gap between those two areas grew by more than 170%. In 2019, the death rate was close to 665 deaths per 100,000 in urban America but 834 deaths per 100,000 in rural areas. While men had higher mortality rates than women, both men and women in rural areas died at higher rates than their urban counterparts. In related news, the CDC reports that U.S. death rates for nine conditions climbed last year during the pandemic. The AP reports that the common killers with spiking rates last year included diabetes, heart disease, Alzheimer’s, stroke and hypertension. Some experts chalk those increases up to patients delaying care for fear of becoming infected.

Did pandemic precautions kill off some flu strains?

Some possible positive fallout from all the masking and physical distancing: Certain flu strains may have become extinct that in turn could make it easier to develop a more effective flu shot. That’s according to a STAT article, which notes that certain strains of the flu haven’t been recorded in databases since March 2020. While flu shots typically are quadrivalent—targeting four separate flu viruses—trivalent ones may be OK going forward. But not all flu epidemiologists are convinced the strains are gone for good, and experts point out that very few cases actually undergo genetic sequencing. In a typical year, about 20,000 undergo such sequencing—but this year, only 200 were uploaded to a repository.

June 9, 2021

Hospitalizations jump in areas with low vaccination rates

The seven-day averages for both new covid cases and deaths have dropped, with most states seeing a 5% or greater decline in new cases. But vaccination rates have also fallen off dramatically, and the New York Times reports that covid hospitalizations are on the rise in areas with low vaccination rates. One Tennessee county where only 20% of the population is fully vaccinated, for instance, has seen a close to 700% increase in covid hospitalizations over the past two weeks. Part of the problem is the spread of variants, with the highly transmissible Delta strain from India now accounting for more than 6% of the cases sequenced in the U.S. Another part of the problem is highlighted in an article from The Center for Public Integrity: People who have established profitable businesses selling vaccine skepticism and conspiracies.

June 8, 2021

How does covid affect the brain?

That question still remains unanswered a year and a half into the pandemic. Autopsies of patients who’ve died of severe covid show acute damage in their brains, including clotting and “swarms of immune cells,” according to the Washington Post. And patients report a host of seeming neurological symptoms such as disturbances of vision and hearing, as well as vertigo. Experts quoted in the article, including UCSF’s S. Andrew Josephson, MD, editor in chief of JAMA Neurology, suspect the virus does attack the brain, but they’re not sure of the mechanism. Perhaps covid acts like herpes simplex, sometimes causing dangerous swelling of the brain that in turn triggers an autoimmune attack. Experts disagree on whether the virus invades the brain directly. The NYU Grossman School of Medicine has received federal funding for four years to develop a databank of neurological studies and a biobank of tissue samples.

Pandemic precautions may have killed off some flu strains

Some possible positive fallout from all the masking and physical distancing that’s taken place over the past 18 months: Certain flu strains may have become extinct, and that in turn could make it easier to develop a more effective flu shot. That’s according to a STAT article, which notes that certain strains of the flu haven’t been record in databases since March 2020. While flu shots typically are quadrivalent—targeting four separate flu viruses—trivalent ones may be OK going forward. However, not all flu epidemiologists are convinced the strains are gone for good, and experts point out that very few actually undergo genetic sequencing. In a typical year, about 20,000 undergo such sequencing—but this year, only 200 were uploaded to a repository.

June 4, 2021

Good riddance to the (in-person) med school interview

med school virtual interviewA new article in Slate highlights what may be positive fallout from the pandemic: the end of the expensive cycle of in-person interviews for those applying to medical schools. According to the article, candidates apply to an average of 17 medical schools; back in the day, applicants went in person to every interview they were able to get. That added up to a very expensive application process, discouraging those with lower incomes or those who couldn’t take time off work when applying. “It might be no surprise at all,” the article noted, “that 51 percent of medical students come from the wealthiest quintile of households, with 24 percent from the top 5 percent alone.” This year, however, the entire interview process went virtual, which some sources in the article believe may disadvantage newer and rural medical schools. However, the majority of candidates and admission officers quoted welcomed the change.

Study: Close to half of discharged patients suffer functional decline

A recent study from University of Michigan delivers this snapshot of what may be an underreported covid complication: Close to half—45%—of all covid patients discharged had significant functional decline. The study, published in PM&R, found that 20% of patients who experienced functional decline were no longer able to live independently after discharge and needed to either enter a post-acute facility or go live with a family member. Researchers looked at charts for close to 300 patients discharged between March and May 2020, the pandemic’s first wave. During that time, the study notes that clinicians were struggling to maintain hospital capacity and to minimize their own and colleagues’ exposure; as a result, 40% of the patients in the study didn’t receive a rehab evaluation while hospitalized. Among patients in the study who suffered functional decline, more than two-thirds (68%) needed to be discharged with some form of durable medical equipment.

June 2, 2021

Hospital employees push back against vaccine mandate

vaccine mandateMore than 100 unvaccinated staff members at Houston Methodist Hospital signed onto a lawsuit filed late last week, pushing back against that hospital’s vaccine mandate. The Washington Post reports that the suit likens mandatory covid vaccination to medical experimentation without consent. The lawsuit states that the hospital—through compulsory vaccination—”is forcing its employees to be human ‘guinea pigs’ as a condition for continued employment.” Experts quoted in the article point out that the “experimentation” charge is absurd, given that the vaccines now in use went through rigorous clinical trials. Among staff members at the hospital, 99% have been vaccinated. According to the EEOC, companies can mandate vaccinations for employees within a workspace. However, employers must also meet a host of legal considerations, including accommodating employees’ health concerns—which encompass having disabilities as well as religious reasons against being vaccinated—and keeping vaccination information confidential. While most employers aren’t mandating vaccinations, many are offering incentives to encourage employees to get them.

Covid variants get new names

Can’t remember which variant is the B.1.1.7 or the B.1.671.2? While members of the medical community may be able to recognize the various variant designations, the World Health Organization has announced a new naming system for important variants, going with the Greek alphabet instead of the current system that relies on numbers and periods. The variant first identified in Britain (B.1.1.7) will now be known as Alpha because it was the first major one to be identified; the Indian variant (B.1.671.2), which was the fourth strain to be identified, will now be known as Delta. Once the number of variants exceeds the 24 letters in the Greek alphabet, a new naming system will be called for. STAT reports that the new nomenclature is a bid to make it easier for the public to keep important variants straight. It’s also a move to encourage reporting of new variants because the names of countries of origin now won’t be associated with an emerging mutation.

June 1, 2021

The ongoing search for effective treatments

covid research

Coronavirus spurred an unprecedented wave of targeted research into possible treatments. But according to a Wired writer looking at covid trials, most of those studies “were crap.” Despite a few standout trials, including those that showed the efficacy of steroids, most covid studies were either not randomized or were so small as to reach no solid conclusions. Now, however, large randomized trials being conducted in both the U.S. and Europe are looking at therapies with real potential: infliximab, an immune-suppressant; the anti-inflammatory imatinib; and artesunate, an antimalarial. In the U.S., another series of trials is gearing up to look at repurposed drugs that may be effective against mild or early covid. The chaos in covid trials might yield another important future change: master protocols to allow trials to test more than one drug at a time. During covid, the U.S. government spent $18 billion researching vaccines and only $8 billion on therapeutics. The article points out that the federal government needs to step up and sponsor more trials on repurposed drugs because such drugs don’t represent enough profit for Big Pharma to fund.

Study: Close to half of discharged patients suffer functional decline

A recent study from University of Michigan delivers this snapshot of what may be an underreported covid complication: Close to half—45%—of all covid patients discharged had significant functional decline. The study, published in PM&R, found that 20% of patients who experienced functional decline were no longer able to live independently after discharge and needed to either enter a post-acute facility or go live with a family member. Researchers looked at charts for close to 300 patients discharged between March and May 2020, the pandemic’s first wave. During that time, the study notes that clinicians were struggling to maintain hospital capacity and to minimize their own and colleagues’ exposure; as a result, 40% of the patients in the study didn’t receive a rehab evaluation while hospitalized. Among patients in the study who suffered functional decline, more than two-thirds (68%) needed to be discharged with some form of durable medical equipment.

May 28, 2021

How much delayed care wasn’t needed?

Will care delayed during the pandemic help researchers shine a light on low-value health care? A Kaiser Health News article examines the growing body of evidence on outcomes for people who delayed care during the pandemic to determine if that care is unnecessary. One study, for example, found that VA patients who had elective surgeries canceled because of covid showed no increased use of the ED compared to patients who had undergone the same surgeries two years before. A HealthAffairs article suggests that researchers could study differences in pre-pandemic and current outcomes for screening colonoscopy (particularly among older patients), regular measurements of hemoglobin A1c for diabetics and knee arthroscopy for articular cartilage repair. In related news, a recent study found that while routine preop testing before low-risk surgery is common, it adds little value. A study in JAMA Internal Medicine found that of people undergoing preop testing for three low-risk surgeries, half had one or more preop tests while 29% had two or more tests. Older patients were the most likely to receive testing, and the most common tests were CBC counts and electrocardiograms.

“Burnout” doesn’t really cover it

Before the pandemic, many health care workers were already struggling with burnout. But to be able to communicate and work through what health care professionals have experienced in the past 18 months, “leaders and organizations need expanded vocabularies, strategies and resources.” That’s according to a Becker’s Hospital Review editorial, which delves into the many facets of clinicians’ experience since the pandemic began. Labeling all of those reactions—fear, moral injury, invalidation, isolation, exhaustion—as “burnout” prevents groups and organizations from addressing specific factors that drive those different feelings. Making matters worse: Some organizations try to meet the current mental and emotional challenges with the same menu of strategies they used pre-pandemic, as if those experiences could be managed through yoga classes or more workouts. Instead, the editorial argues, health care organizations need to offer new kinds of resources for mental health and emotional support. They also shouldn’t expect the difficult effects of working through the pandemic to subside when covid patients stop being hospitalized. “Naming distinct emotions or experiences helps diffuse their charge and gives us a say in what we do with them,” the editorial concludes.

Lotteries, other incentives, drive vaccination rates

A recent college grad in Ohio is $1 million richer this week, the first of five winners to be named in Ohio’s “Vax-a-Million” lottery. Also named: The first of what will be five teenagers awarded a full scholarship to Ohio public colleges, all part of that state’s drive to boost vaccination rates among those age 16 and older. In the week after it was rolled out, Ohio’s lottery drive increased vaccinations in that state by more than 30%. Colorado, Oregon, New York and California have followed suit, announcing big-cash lotteries, while Maryland will hold drawings for 40 days straight, giving vaccinated state residents 18 and older a chance to win portions of a total $2 million pot. The lotteries are part of an array of vaccination incentives, ranging from new cars and sporting goods to a chance to win a year of free domestic airline travel. (All vaccinated members of United’s MileagePlus program can enter that travel lottery by June 22.) In other vaccination efforts, states and cities are switching from having only mass vaccination sites to mobile campaigns. The New York Times reports, for instance, that Los Angeles will move to mobile vaccine vans and trailers by Aug. 1, using mobile units to target communities with the lowest vaccination rates. Similar mobile clinics have been set up in Washington state, Delaware and Minnesota.

With breakthrough infections, the CDC courts controversy

The CDC continues to provide state-level data on breakthrough infections, which occur in people who are fully vaccinated. But the agency is drawing fire for its decision to, starting this month, collect data and report on only those breakthrough cases severe enough to result in hospitalizations or deaths. As of the end of April, the CDC had received reports on more than 10,200 breakthrough infections (out of more than 100 million full vaccinations), with 63% occurring in women. Based on preliminary data, 27% of those cases were asymptomatic, while 10% were hospitalized and 2% died. As for the CDC’s decision to stop collecting data on all breakthrough infections, those who support the change say that only cases that tax the health care system are worth monitoring. But critics believe the CDC is losing the opportunity to learn whether breakthrough infections are associated with a specific vaccine and whether mild or even asymptomatic cases produce long-term complications.

May 24, 2021

Huge health care meeting says only vaccinated can attend

speaker for continuing medical education in hospital medicineOne of the biggest medical meetings to return after the pandemic has announced that all attendees will need to provide proof that they’re vaccinated. The Healthcare Information and Management Systems Society (HIMSS), whose meetings before covid routinely drew 40,000-plus attendees, will host its next meeting this August in Las Vegas. An article in Heathcare Innovation says the meeting will consider attendees fully vaccinated if two weeks have passed since their last shot of the Moderna or Pfizer/BioNTech vaccines or if two weeks have passed since their single dose of the J&J vaccine. HIMSS says it is currently evaluating how it will require attendees to prove their vaccination status, but it will likely use digital technology that protects the privacy of attendees. Meeting organizers say they plan to keep an appropriate amount of space on the exhibit hall floor between exhibitors and to use social-distancing strategies during educational sessions.

Vaccines help vaccinated and unvaccinated nursing home residents

New data show that covid vaccines are slowing down spread of the virus in vaccinated and unvaccinated residents of nursing homes. A correspondence published in The New England Journal of Medicine found that in more than 13,000 nursing home residents vaccinated with the Moderna or Pfizer/BioNTech vaccine, cases of the virus dropped from 822 within two weeks of the first shot to 38 cases two weeks after the second shot. Among nearly 4,000 unvaccinated residents, cases of the virus dropped from 173 within 14 days of the vaccination clinic to 12 cases after the second vaccination clinic. There was more good news: 66% of cases were asymptomatic in the two weeks after the first vaccination clinic, and 83% were asymptomatic after the second vaccination clinic.

May 21, 2021

CDC details more cases of blood clots after J&J vaccine

Late last week, the CDC announced that it had found more cases of “potentially life-threatening” blood clots among people who received the J&J shot. A Medscape article says that the CDC has identified 28 cases of thrombosis with thrombocytopenia syndrome out of the nearly 3 million people who received the J&J vaccine. Three of those people died. The agency noted that the side effects resemble those found in a small number of Europeans who received the AstraZeneca vaccine. Both shots use adenovirus technology to deliver messages that instruct the body to make covid proteins to help the body fight the infection.

Fauci says vaccines offering “near-complete protection” against variants

During the keynote address before the American Thoracic Society meeting, Anthony Fauci, MD, said new data show the vaccines being used in the U.S. are offering “near-complete protection” against the U.K. and South African covid variants. According to a MedPage Today report, Dr. Fauci cited data from a research letter published in The New England Journal of Medicine. That letter found that that the Pfizer/BioNTech vaccine was 90% effective against the U.K. variant and 70% effective against the South Africa variant. The data come from a study of nearly 400,000 people in Qatar. Dr. Fauci added that preliminary data on the vaccines’ effectiveness against the Brazil and India variants are similarly promising, although he warned that the situation could change.

May 14, 2021

More data on vaccines’ effectiveness in protecting health care workers

protection-health-care-worker

If you have colleagues who are refusing to get a covid shot, you can point to a new study that shows the Pfizer/BioNTech vaccine will keep them safe. A JAMA study found that in a group of health care workers in Israel, only eight of 5,500 fully vaccinated workers got symptomatic covid, compared to 38 of nearly 760 unvaccinated workers. The study also found that asymptomatic infections occurred in 19 fully vaccinated health care workers and 17 unvaccinated workers. Because the group of vaccinated workers was so much larger than the number of unvaccinated workers, the data showed that unvaccinated workers were 14% more likely to have asymptomatic cases of covid. A research letter in the same issue of JAMA similarly found fewer symptomatic infections among vaccinated health care workers, but it also found more asymptomatic infections among the vaccinated.

CDC releases report on “stark differences” in vaccination rates

While nearly 80% of Americans 65 and over have received at least one dose of the covid vaccine, there are gaps in vaccine coverage that illustrate some of the geographic, racial and social disparities the country faces as it tries to reign in the pandemic. A CDC report says that vaccinated Americans are overwhelmingly white, although demographic data weren’t available for everyone in the study population. The report also found stark differences by geography. In Alabama, for example, fewer than 70% of seniors have received at least one dose of the vaccine, compared to nearly 100% of older adults in New Hampshire. Counties with lower vaccination rates tended to have higher numbers of older adults with “social vulnerabilities,” such as a lack of access to the Internet and living alone.

Most docs vaccinated, support mandatory vaccines for clinicians

A Medscape poll provides data on vaccination rates for physicians and what they think of mandatory vaccinations for health care workers. The survey of nearly 1,000 physicians found that 79% are partially vaccinated and that 75% are fully vaccinated. That leaves 16% who have no plans to get vaccinated and 5% who are planning on getting the shot. In the survey, 69% of physicians said they believe employers should require clinicians to get a shot. Seventy percent of those physicians said the shots should be required immediately; the other 30% advocated for waiting for full FDA approval before requiring vaccinations for health care workers. Seventy-five percent of female physicians supported the idea of mandatory vaccines for clinicians compared to 67% of male physicians, and support was highest among physicians 65 and older. Among nurses, 62% were already vaccinated, but only half supported the idea of mandatory vaccines for clinicians.

CDC’s messaging a mess, according to critics

While the CDC has made major announcements in the last week about the nature of how the covid virus spreads (via aerosolized particles) and the need—or lack thereof—for masks, critics are complaining that the agency’s messaging has been too conservative and is confusing the public. A STAT article outlines the issues the CDC has had with its messaging, pointing that its mask guidance a week or so ago was so conservative that it was lampooned on The Daily Show. A poll conducted by the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health found that only 52% of Americans said they have “a great deal of trust” in the CDC, and only 37% said the same thing about the NIH or FDA. An NPR article says those sentiments extend to state and local health agencies, which are trusted by just over 40% of Americans.

I hate myself on screens! The psychologic fallout of covid

One side effect of the pandemic appears to be a growing interest in cosmetic surgery. A MedPage Today article explains that as people have been staring at images of themselves on platforms like Zoom, many haven’t liked what they’ve seen. “Zoom dysmorphia” is a term dermatologists are using to describe the fallout, which one small study found was associated with a 57% increase in cosmetic consultations. In that study, 86% of patients cited video conferencing as the reason they were seeking a consult. The study found that the most common concerns cited by patients were wrinkles on their upper face, circles under the eyes, dark spots on the face, and sagging necks.

May 9, 2021

Can the J&J vaccine cause anxiety-related adverse events?

vaccination-anxietyThe pandemic has clearly challenged the mental health of many people, but can the stress of covid produce a physical response to a vaccine? Researchers claim that’s exactly what happened when dozens of Americans had post-vaccine symptoms this spring that included fainting or dizziness. According to a Modern Healthcare article, 64 people who received the J&J vaccine in five states experienced problems, but experts from the CDC say those issues were not caused directly by the vaccine. CDC researchers suspect that the people who experienced issues had specifically sought out the J&J’s one-dose shot because they were anxious about getting a vaccine. This anxiety, the researchers claim, likely made these people “more highly predisposed to anxiety-related events” when getting vaccinated. CDC researchers also discovered that about one-quarter of people who experienced problems after getting the covid shot said that they had experienced similar side effects after getting other vaccines. According to a MedPage Today article, data published this week in the MMWR found that there were 8.2 anxiety-related episodes for every 1,000 people who received the J&J vaccine, compared to 0.05 episodes per 1,000 people who received the flu vaccine. Concerns that people are anxious about the J&J vaccine are backed up by recent polling data, which found that about three in four Americans who haven’t yet been vaccinated said they won’t get the J&J vaccine. Those same Americans rated the J&J vaccine as less safe than the Moderna and Pfizer vaccines.

Report names hospitals performing the most unnecessary procedures

A group is naming what it says are the best and worst 50 hospitals when it comes to 12 procedures that are widely regarded as unnecessary. The report, which was issued by the Lown Institute, focuses on inappropriate procedures like the use of carotid artery imaging and head CTs/MRIs to examine patients who present after fainting but had no other risk factors. For those patients, carotid imaging was used by all hospitals on average 7% of the time; CTs/MRIs of the head were used on average 23% of the time. A MedPage Today article says that at the hospital designated the worst offender by the report, carotid imaging was used for 23% of the above patients and head CTs/MRIs were given to 75% of the above patients. Other inappropriately used procedures cited by the report include hysterectomy and vertebroplasty.

May 5, 2021

What do Leapfrog safety grades look like during a pandemic? (updated 5/7/2021)

hospital-safety-ratingNew safety ratings from the Leapfrog Group gave 906 hospitals its top rating and more than 1,000 hospitals a “C” grade or worse. While the ratings have been around for 20 years, the group says that its current ratings serve as a proxy for safety during the pandemic. The report ranks states with top-performing and low-performing hospitals, noting that four states—Idaho, Maine, Massachusetts and Virginia—had more than half of their hospitals scoring an “A” grade. The organization has also posted testimonials from hospitals explaining what they have done during the pandemic to keep patients safe. Fierce Healthcare notes that the Leapfrog Group’s reporting methods have been challenged by hospitals and researchers.

30-days post-diagnosis, covid patients face “excess” health issues, increased death

A study in Nature found that more than 30 days after being diagnosed with covid, patients face an “excess burden” of a variety of problems, and that even patients with mild infections face an increased risk of death within six months of a diagnosis. A Healio article says that researchers found that 30 days after a diagnosis, covid patients who were not hospitalized had a nearly 60% increased risk of death, with 8.39 excess deaths per 1,000 people. Patients hospitalized after 30 days faced a 51% increased risk of death, with excess deaths in this group estimated about 29 per 1,000 people. The researchers also found that beyond 30 days, covid patients faced a “substantial burden of health loss” involving nearly every organ in the body. The most common issues were respiratory conditions, but researchers also saw nervous system issues, cardiovascular problems and GI issues.

April 30, 2021

Real-world data confirm efficacy of covid vaccines

Real-world data from a small trial show that the Pfizer-BioNTech and Moderna vaccines are 94% effective in reducing hospitalization among Americans 65 and older who got both shots. A report in MMWR notes that in people who received only one shot, the vaccine was 64% effective. The study represents the first real-world data. While another Israeli study had come up with similar results, it looked at only the Pfizer-BioNTech vaccine. The MMWR study looked at 417 adults hospitalized with COVID-19–like illness in 14 states between January and March 2021.

Creative strategies to get more Americans vaccinated

money-incentiveAs vaccination rates in the U.S. begin to wane, a long list of organizations is coming up with creative strategies to vaccinate more Americans. A hospital in Jackson Hole, Wyo., for example, is giving its employees a $600 bonus if they’re fully vaccinated by May 31. A Houston health system is not only using a carrot to encourage vaccinations (by offering $500 payments), but it is also threatening to fire employees who can’t provide proof of vaccination by June 7. The giant insurer Cigna is offering U.S. employees $200 in their health savings accounts and paid time off to get vaccinated. And on the national level, President Biden has announced tax credits that businesses can take if they give employees paid time off to get vaccinated.

FDA “encourages” hospitals to return to one-and-done for N95s

In another sign that some signs of normalcy are on the horizon, the FDA is encouraging health care workers to return to the pre-pandemic policy of using N95 masks once and then discarding them. While hospitals are still legally allowed to sterilize and re-use N95s, the FDA is currently recommending a one-use policy and in the coming weeks is expected to begin requiring health care facilities to discard masks after one use. A Modern Healthcare article says that the announcement comes on the heels of word that U.S. manufacturers have surpluses of PPE for sale. Many hospitals say they have three to 12 months of PPE stockpiled.

Rules for buprenorphine relaxed as opioid use rises in long haulers

The Biden administration will make it easier for physicians to prescribe buprenorphine to treat opioid disorder. A Fierce Healthcare article says that the HHS has released new guidelines that exempt physicians and other clinicians from some certification requirements to prescribe the drug that were viewed as onerous. The Trump administration had announced the changes earlier this year, but the current administration put them on hold until now. The change is significant given the rise in overdose deaths during the pandemic. A Kaiser Health News article notes that a new study found “alarmingly high rates” of opioid use among covid long haulers at VA hospitals around the country. The study is raising alarms about a new epidemic of opioid addiction.

April 28, 2021

Good, bad news about your chances of getting covid

First, the good news: Health care providers rarely get covid on the job. In a study published this month in Clinical Infectious Diseases, researchers performed viral sequencing to determine the origins of covid in health care workers. They found no signs of healthcare-associated transmission in “the majority” of infections they evaluated. A Medscape article says that 11% of the infections studied in health care workers could be attributed to one of their coworkers and 4% could be attributed to one of their patients.

The not-so-good news is for health care professionals who work a lot of nights. A study in the journal Thorax found that people who worked some shifts outside of a traditional 9-5 schedule were more than twice as likely to get covid as people who work during the day. People who only worked nontraditional shifts were 2.5 times more likely to be diagnosed with covid. Researchers found these risks persisted even after controlling for known risk factors like BMI and smoking. They hypothesized that shift work’s effects on the circadian rhythm may alter the body’s response to the covid virus.

April 26, 2021

One unvaccinated nursing home worker; dozens of infections and three deaths

nursing-home-importance-vaccinationA covid outbreak in March in a nursing home in Kentucky is a stark reminder of the consequences of continuing to work with vulnerable patients while not being vaccinated. The New York Times reports that while 90% of the residents in that home had been vaccinated, that was the case for only half the staff. One unvaccinated worker who became infected caused 26 infections among residents (including 18 among those vaccinated) and 20 infections among other staff members. Three of the infected residents died, including one who’d had vaccine. A CDC write-up of the outbreak notes that the infections were “a newly introduced variant to the region.” The New York Times points out that resistance to being vaccinated has been high around the country among nursing home staff.

Even mild covid cases are linked to higher mortality risk

New VA data deliver this bad news: Being infected with covid—even without needing to be hospitalized—leads to a 59% greater risk of death within six months than among those who don’t become infected. Further, six-month mortality risk is also high among covid patients who are hospitalized, running 51% more than among patients with seasonal flu. Published in Nature, the study is based on data from more than 70,000 VA patients; fewer than 20% of those patients were women, and most were over age 60, according to Forbes. The study is one of the largest to look at “long covid,” those symptoms patients suffer long after their acute infection. And speaking of seasonal flu, here’s a New York Times headline from last week: “The Flu Vanished During Covid.” While recent flu seasons in the U.S. have each produced more than 200,000 recorded cases a year, the 2020-21 season saw only 2,000.

Bamlanivimab is out as a monotherapy

Earlier this month, the FDA revoked its EUA for bamlanivimab when administered alone, saying that the covid variants that are on the rise are resistant to being treated with the monoclonal antibody alone. As a result, Medicare will pay for bamlanivimab as a monotherapy only if administered between Nov. 10, 2020, and April 16, 2021. But there’s good news: The FDA also indicated that alternative therapies consisting of combined monoclonal antibodies are still appropriate. Those include casirivimab/imdevimab as well as bamlanivimab/etesevimab, and fact sheets about the use of those combinations can be found here and here. The FDA has issued EUAs for those combinations for the same indications that bamlanivimab alone used to have: for adult and certain pediatric patients with mild to moderate covid.

 April 23, 2021

More younger people are being hospitalized

young-adult-covid-hospitalA handful of states—many of them hard hit with covid a year ago—are once again the country’s hotspots, according to the Wall Street Journal (subscription required). About three-quarters of all new cases last week were reported in five states: Michigan, Florida, New York, Pennsylvania and New Jersey. CNN reports that, due to the U.K. variant being more contagious and more older patients being vaccinated, hospitalizations are on the rise among younger patients, who are suffering more severe complications than expected. Last month, for instance, New Jersey saw a 31% jump in covid hospitalizations among patients ages 20 to 29 and a 48% increase in covid hospitalizations among ages 40 to 49. An article in The Atlantic posits a future in which adults stop worrying about their elder parents becoming infected and start worrying about their children under age 12, who will be the last group vaccinated. Around the world, India is in crisis, setting global records for new daily cases (more than 300,000). The CDC is warning against traveling to India, saying that if a trip in unavoidable, only fully vaccinated people should travel there. The U.K. is now banning all travelers from India.

How soon will vaccine supply in the U.S. catch up to demand?

As of Monday, all adults in all states are eligible for vaccine and vaccine supplies have bumped up significantly from just a month ago. Kaiser Family Foundation now predicts that within the next two to four weeks, the U.S. will likely hit a tipping point where finding Americans who want to be vaccinated will become much harder. “Federal, state, and local officials, and the private sector,” the foundation writes in a policy statement, “will face the challenge of having to figure out how to increase willingness to get vaccinated among those still on the fence.” In addition to those hesitating to get vaccine, 20% of Americans polled claim they won’t be vaccinated or will only if required. The Cleveland Clinic is partnering with Mayo and more than 50 other hospitals and health systems on the “Get the Vaccine to Save Lives” campaign, producing public service announcements to convince those who haven’t yet been vaccinated to step up. And to entice employees to be vaccinated, one hospital in Wyoming—St. John’s Health in Jackson Hole—is giving each full-time vaccinated employee a $600 bonus—and offering the same to those who’ve held off, as long as they’re fully vaccinated by May 31. The goal is to have as many employees vaccinated as possible before summer tourists start to arrive. Meanwhile, while the FDA and CDC may decide later today whether to end the pause in using the J&J vaccine, phase 3 trial results for that vaccine have been published in the NEJM. The results: 75% efficacy at more than 28 days, and 85% against severe or critical disease.

April 22, 2021

Nursing vacancies grow, and burnout is widespread

covid-icuHospitals are reporting a spike in unfilled nursing positions, a dilemma that hospitals have increasingly tried to meet with growing numbers of (expensive) traveling nurses. In a survey of 100 hospital executives, 36% said they expect to have more than 25 nursing positions open this year, a rate more than twice what it was in 2020 (17%). Among respondents, 70% reported losing between 5% and 30% of their nursing staff as a result of covid. In other news, a Washington Post-Kaiser Family Foundation poll found that three out of every 10 health care workers are considering leaving the profession, due to burnout and stress. While 55% of all health care workers surveyed reported burnout, younger people had higher levels: 69% among those age 18 to 29 and 61% among those age 30 to 39. Mona Masood, DO, a Philadelphia psychiatrist, started the Physician Support Line (1-888-409-0141) a year ago, staffing it with hundreds of volunteer psychiatrists and fielding more than 2,500 calls. Dr. Masood told the Washington Post that she is most concerned about health care workers when the pandemic ends, likening them to soldiers returning from war.

April 19, 2021

New variant tracking system will target biological threats

biological-threat-protectionThe White House last week announced a $1.7 billion federal program to track covid mutations. As proposed, the program would establish the first permanent national infrastructure to tackle biological threats. AP reports that the network has three components: directing the CDC and state health departments to map genetic samples (to be funded with $1 billion); partnering with universities to create six research and development centers to identify emerging pathogens ($400 million); and creating a national data-sharing network ($300 million). According to the AP, the funds are part of the recently approved coronavirus relief package and are designed to “break what experts say is a feast-or-famine cycle in U.S. preparedness for disease threats.”

Why are vaccinated people getting infected?

Their numbers are tiny, which is reassuring. But a very few cases are being recorded of fully vaccinated patients coming down with what are being called “breakthrough infections” and testing positive for covid. In rare cases, some even have been hospitalized and a few deaths have occurred, according to ProPublica. Experts don’t know why; further, they are concerned that many cases of breakthrough infections aren’t being sampled and analyzed to find out which variants, if any, may be driving the very few reported cases. Another problem: Some states aren’t reporting the level of symptoms that patients with breakthrough infections are having. South Carolina’s health department has reported 155 cases of breakthrough infections out of 950,500 full vaccinated patients, an infection rate of 0.02%. MedPage Today coverage points out that the number of breakthrough cases are as expected.

April 16, 2021

Working nights alters your genetic “circadian rhythmicity”

how nocturnists manage difficult night admissions?We all know that working nights stinks, but new research yields data on how night work may increase your risk for cancer. An MDedge article says that researchers have found that a simulation of night work changed “the normal circadian rhythmicity of genes,” which can lead to hallmarks of cancer. The study, which appeared in the Journal of Pineal Research, concluded that night work reduces the ability of the body’s RNA to repair genes affected by working at night. During the simulation, some of the genes of participants lost their normal day-shift rhythmicity. The study also found that night work increases endogenous and exogenous DNA damage. The next step, researchers say, is to test real-world night-shift workers to see if the damage from unrepaired DNA builds up over time, increasing cancer risk.

Pandemic spurs rapid evolution of chief wellness officer role

survey done last summer at University of Utah Health about the pandemic came to this conclusion: “a substantial number of employees and trainees experienced major stress and work disruptions.” In fact, one in five reported considering leaving the health care workforce because of covid-related challenges, particularly around child care, and 30% considered cutting their work hours. It’s results like these that underscore the importance of wellness efforts in health care, while a new NEJM article highlights the evolving role of chief wellness officers during the pandemic. The authors, who are chief wellness officers from health systems and academic centers around the country, say that support services in many of their institutions were underutilized even during the pandemic, due in part to the ongoing stigma over using mental health resources. Successful outreach deployed during the pandemic included in-person wellness rounds. Importantly, the authors note that the intensity of treating covid patients hasn’t allowed clinicians to process their experiences.

April 13, 2021

FDA, CDC recommend a pause on the J&J vaccine

pause-buttonU.S. agencies are recommending halting the use of Johnson & Johnson’s one-dose covid vaccine pending the results of an investigation into six cases of clotting among recipients. STAT reports that the recommendation stops short of pulling the vaccine off the market, even temporarily. The clotting incidents, which all occurred in women, are similar to those found with AstraZeneca’s vaccine. All six cases were rare cerebral venous sinus thromboses in combination with thrombocytopenia. The six women affected were between the ages of 18 and 48, and their symptoms occurred between six and 13 days after they received the vaccine. As of this week, more than 6.8 J&J doses have been administered in the U.S. Two studies in NEJM—one looking at 11 patients in Germany and Austria, the other on five patients in Norway—delved into the clotting problems with AstraZeneca’s vaccine. The authors of both studies implicate platelet-activating antibodies targeting platelet factor 4 (PF4)-heparin, and they speculate that the antibodies are triggered by free DNA in the vaccine.

Prophylactic monoclonal antibodies?

A monoclonal antibody combination developed by Regeneron is being touted as a prophylaxis for household members of infected covid patients. According to a company press release, phase 3 trial results indicate that giving household contacts the casirivimab-imdevimab cocktail cut their risk of developing symptoms 72% during the first week and 93% in subsequent weeks. By day 29, only 1.5% of those who received the monoclonal antibodies had developed symptomatic infection vs. 7.8% of those given placebo. In addition, among those receiving the cocktail who developed symptoms, those symptoms lasted only one week vs. three weeks among those on placebo who became symptomatic.

April 12, 2021

OK to ease up on conserving N95s?

n95-face-maskThe FDA last week issued guidance that says it is now OK for health care personnel and facilities to transition away from conservation strategies with N95s and other filtering respirators. Included in the recommendations: Facilities can move away from using a crisis capacity strategy of conservation, and they can limit their decontamination of disposable respirators. They can also increase their inventory of available NIOSH-approved respirators and PAPRs. According to a press release, both the FDA and the CDC believe U.S. hospitals now have an adequate respirator supply. At the same time, the FDA made it clear that the agency is not revoking its current authorization of decontamination and bioburden reduction systems.

Covid pneumonia: Researchers find good results with home oxygen

According to a recent study, researchers in southern California got good results—low all-cause mortality and 30-day readmission rates—by discharging patients with covid pneumonia home with supplemental oxygen. Writing in JAMA Network Open, the authors detail the retrospective results of a program launched by the Los Angeles health department that included more than 620 patients. All needed at least 3L per minute of supplemental oxygen, and all were stable without any other indication for inpatient care. (Nurses followed up with patients within 12 to 18 hours of discharge from either the hospital or ED, and that back-up continued if indicated.) Followed for close to 30 days, patients had a mortality rate of 1.3% and a readmission rate of 8.5%. The authors point out that the intervention helped preserve inpatient beds for sicker patients, had an adequate safety profile and “may help optimize outcomes.”

April 9, 2021

Video games to treat brain fog?

A Boston-based startup made news last summer as the first company to get FDA clearance to market a video game as a prescription therapeutic. While that indication was for children with ADHD, Fierce Healthcare reports that the same company is now working with several major academic centers to test whether that digital treatment can improve covid “brain fog,” cognitive and mental effects that linger in some covid patients months after respiratory symptoms resolve. The company, Akili Interactive, is working with Vanderbilt University Medical Center, NewYork-Presbyterian Hospital and Well Cornell Medicine to design randomized trials. Those trials will test the ability of the video game which is marketed as EndeavorRx—to improve cognitive functioning. “The software,” according to the coverage, “provides challenges and stimuli that target the brain’s neural systems linked to focus, cognitive function and multitasking.” The academic centers plan to begin enrolling patients in the studies next month. A study published this February in Neuropsychopharmacology found that among patients with severe covid and prolonged hospitalizations, 81% had cognitive impairment that ranged from mild to severe.

U.K. variant: spiking cases, vaccine strategies, hospital testing

The spring’s steady downtick of cases is long over, with close to 65,000 cases a day now being reported. Many are occurring in cities in Michigan and New York, and experts say that most are being caused by the U. K. variant, although a variant first identified in New York City is behind outbreaks in Connecticut, New Jersey and Pennsylvania. Hospitalizations in areas with spiking cases are also rising, particularly among middle aged patients under age 50—a group that’s not close to being vaccinated. Some public health officials are urging the administration to divert vaccine supplies to Michigan, a move the Biden administration so far has rebuffed. Other experts have renewed calls made earlier this year to switch for now to a one-dose vaccine strategy, delaying second doses of both the Pfizer-BioNTech and Moderna vaccines for 12 weeks to allow more people to receive at least one dose. In other variant news, MedPage Today reports that the FDA is cautioning about possible problems with a molecular test brand popular in hospitals. Three Cepheid PCR tests (Xpert Xpress, Xpert Xpress DoD and Xpert Omni) pinpoint the N2 and E targets within viral RNA, according to the coverage, but the U.K. variant may reduce test sensitivity for the N2 target. Microbiologists quoted in the article, however, say they’re not worried about the accuracy of test results because the tests have multiple targets.

More setbacks for AstraZeneca

Another week, more AstraZeneca drama: A European agency now says that blood clots should be listed among the very rare side effects of that company’s covid vaccine. According to the European Medicines Agency, its members investigated more than 80 cases of thrombosis (out of 25 million doses administered) among patients given the AstraZeneca vaccine, 18 of which were fatal. Most of those cases were in women under age 60, and they occurred within two weeks of being vaccinated. While the agency noted “a possible link,” it did not recommend limiting the use of that vaccine, which is the go-to in European vaccination efforts. The WHO, meanwhile, notes that no causal relationship between the vaccine and clotting has yet been confirmed, although such a relationship is plausible. CNN reports that U.K. officials now recommend that people under age 30 look for alternative vaccines. While the AstraZeneca vaccine isn’t approved for use in the U.S., experts worry that concerns here about side effects, even when very rare, could spur vaccine hesitancy.

April 7, 2021

Up to 43,000 children in the U.S. have lost a parent to covid

shadow-parent-childrenA new research letter delivers this heartbreaking statistic: Tens of thousands of American children had lost at least one parent to coronavirus as of February 2021. Depending on the estimation model used by the authors, the number of children in the U.S. who have lost a parent ranges between 37,300 and 43,000. About three-quarters of them are adolescents, while 20,600 were non-Hispanic White and 7,600 were Black. Black children represent 20% of those who have lost a parent although they make up only 14% of the pediatric population. Due to covid, the tally indicates a 17.5%-20.2% increase in expected parental deaths. The letter, which was published by JAMA Pediatrics, estimated the number of affected children based on demographic simulation of several mortality scenarios, and the authors point out that the estimates don’t account for nonparental primary caregivers. “Sweeping national reforms,” they write, “are needed to address the health, educational, and economic fallout affecting children.”

Excess deaths last year jumped more than 20%

Another grim tally of coronavirus in 2020: All-cause mortality rates in the U.S. last year jumped 23%, with close to three-quarters of those deaths chalked up to covid. The number of excess deaths from March 2020 through the beginning of January this year was 522,000, according to a JAMA research letter. The authors found that death rates for Alzheimer’s, diabetes and heart disease also rose over the course of last year, particularly during covid surges. They also pointed out the racial disparities they uncovered in their analysis: While Blacks make up only 12.5% of the U.S. population, they account for close to 17% of the excess deaths recorded. An accompanying editorial points out that covid—despite the advances over the past century in public health, medicine and science—will likely contribute to almost as many deaths in the U.S. as the 1918 influenza pandemic.

April 6, 2021

Pfizer vaccine effective against South Africa, New York variants

In the fight against the South Africa variant, data show that the Pfizer-BioNTech vaccine is effective. Pfizer-BioNTech released data last week showing that its vaccine appeared to be 100% effective in preventing the South Africa variant of covid from spreading in a trial of 800 people. In addition, a MedPage Today article notes that data from a larger study showed that the vaccine had 91.3% efficacy in preventing symptomatic illness after a second dose was administered. In other variant news, data also show that both the Pfizer-BioNTech and Moderna vaccines appear to be effective against a New York variant of covid. A Medscape article says that a team of New York researchers exposed replicas of the New York variant to blood from people who had been vaccinated (and also to the Regeneron antibody therapy used to treat infected patients) to determine whether the variant could be “neutralized.” The study, which has not been peer-reviewed, found that antibodies induced by the vaccines were effective in blocking the variant. Finally, an Axios article offers an excellent overview of covid variants and strategies to stop them.

Videos help educate minorities about the basics of covid

covid-education-videoAn Annals of Internal Medicine study has found that giving basic information about pandemic protocols via video “modestly improved” knowledge among Black and Latino patients regardless of the race of the clinicians presenting information in the videos. A JAMA Network article says that when 15,000 participants viewed three videos covering pandemic basics like social distancing, hygiene and face masks, the control group did better on a short questionnaire. While 80% of people in the intervention group answered all questions correctly, 73% of people in the control group got all answers right. Researchers also found that Black participants who spoke via video to a Black physician were more likely to request more information about covid.

April 5, 2021

Vaccines: Calls grow in the U.S. for a dose-sparing strategy

Using a one-dose strategy—and delaying a second dose of either the Moderna or Pfizer-BioNTech vaccine so more people would receive a single dose—is now getting a renewed push. While advocates for such an approach went public earlier this year, the Biden administration along with the FDA and Anthony Fauci, MD, decided to stay the course, ensuring second doses for those who’d already received one dose three or four weeks earlier. But new daily cases are up 18% over the last two weeks, with alarming outbreaks reminiscent of July 2020 and December 2020 taking place around the country, including in Michigan. STAT reports that the U.K. has had a great deal of success by delaying second doses of both the Pfizer-BioNTech and AstraZeneca vaccines, and 47% of that population has received at least one dose amid falling caseloads. (By contrast, only 31% of the U.S. population has received at least one dose.) Advocates for the one-dose strategy in the U.S. include former Biden advisory board members Atul Gawande, MD; Zeke Emanuel, MD. PhD; and Michael Osterholm, PhD, MPH.

CDC issues new travel guidance for the vaccinated

Good news for those who are desperate to get away: The CDC last week issued updated guidance, saying that fully vaccinated travelers inside the U.S. don’t need to get tested before or after their trip, unless such testing is required by their travel destination. (People are considered to be fully vaccinated two weeks after their last required dose.) Those with full vaccinations also don’t need to quarantine in the U.S. after they travel. As for international trips, fully vaccinated travelers don’t need to be tested before travel (unless required to do so by their destination). But they do need a negative test result within three to five days after returning to the U.S. They do not, however, need to quarantine upon their return. All travelers, including those who are fully vaccinated, should continue to mask, stay physically distanced and wash their hands frequently.

April 2, 2021

J1 visas: Make convoluted process more simple

foreign-medical-doctor-conceptIn a new JAMA perspective, a urology fellow with a J-1 waiver points out that, as a resident, he worked in the trenches with his colleagues during last spring’s covid crisis in New York. But as that surge subsided and other residents could take time off to visit family, that wasn’t available to him. Instead, both colleagues and the ECGME warned J-1s to not travel outside the country because re-entry couldn’t be guaranteed, making homesickness a hallmark of his pandemic experience as well. Complicating matters: U.S. immigration and customs has proposed having doctors extend their visas either through that agency—a process that can take up to 19 months—or at a consulate in their home country. The author calls on health care workers and institutions to advocate with lawmakers to make the visa renewal process easier, not more difficult. He writes that the French government is fast-tracking citizenship applications from front-line health care workers to show its appreciation for care rendered during the pandemic. The author also calls on hospitals to reach out to their IMG physicians proactively to offer mental health and emotional support. The number of J-1 physicians working in the U.S. has grown 62% over the last decade.

What’s hot, what’s not in covid spending

report from MarketWatch details how the pandemic has changed Americans’ shopping habits, with televisions flying off shelves and pet, plant and cleaning supplies in high demand. At the same time, movie theaters saw their revenue tank from $12.2 billion in January 2020 to just over $825 million this February, while spending on cold and flu medications fell so hard that chain pharmacies saw a drop in profits last year. Spending on beer is up as is that for specialty cheeses—and also for kidney beans, an indication that many households are strapped for cash. Spending on sunscreen and cosmetics declined over the past year, while sales of books and musical instruments have grown.

April 1, 2021

One in five Americans polled isn’t interested in vaccine

As the number of covid cases rose 10% this week, more states are rapidly expanding vaccine eligibility, with all 50 states announcing plans to offer vaccine to anyone eligible for vaccine under FDA authorizations. That comes as Kaiser Health News reports that vaccine hesitancy continues to shrink in the U.S., with the “I’ll wait and see group” falling from 39% of those polled in December 2020 to 17% in March 2021. But the “definitely not” group that doesn’t intend to be vaccinated at all was 13% in March, with another 7% saying they’ll get vaccine only if it’s required. Hesitancy levels were high among white evangelicals and rural populations. Between December and March, 32% of all those polled had received at least one dose. Experts say the vaccination gap is particularly troubling among Hispanic patients, who are running into barriers to vaccine access. Often, communications about vaccine availability and registration are in English only, and many older people in the Hispanic community don’t have access to computers.

In vaccine development, good news for parents: Pfizer-BioNTech reports that its vaccine has been found to be 100% effective in adolescents ages 12 through 15. The randomized trial the results were based on—which have not yet been peer-reviewed—included more than 2,200 adolescents. None in the vaccine arm developed symptomatic disease nor had side effects. The two companies have started testing its vaccine in children under 12. (Moderna is also testing its vaccine in children of all ages.) Pfizer-BioNTech expects to ask the FDA to amend their EUA to have the vaccine available to older children before school starts in September.

Covid and post-discharge dysfunction

A new JAMA article spells out the troubling long-term neuropsychiatric toll of covid, with long-term symptoms among patients “suggesting brain involvement persists,” the authors write. Symptoms range from loss of taste and smell and brain fog to psychosis, seizures and thoughts of suicide. While experts still aren’t sure if the virus invades the brain, the article discusses several possible mechanisms that could be at play including crossing the brain-blood barrier or having inflammation and clots combine to cause microstrokes and other damage. Another study, this one out of Britain and published in The BMJ, describes other types of longer-term multiorgan dysfunction after discharge. Among close to 48,000 patients in NHS hospitals followed for more than four months, close to one-third were readmitted while more than 10% died, much higher rates than among non-covid controls. Those who developed multiorgan dysfunction post-discharge weren’t limited to the elderly. Becker’s Hospital Review reports that at least 24 hospitals and health systems around the U.S. have launched covid recovery programs for covid patients who have been discharged but need longer-term treatment. Most of those programs involve an initial evaluation and specialist referral including to neurologists, pulmonologists and cardiologists.

March 31, 2021

What did the pandemic do to hospital finances?

A new report from HHS’ OIG paints a gloomy picture of hospitals struggling after their plague year, saying that hospitals now are in “survival mode.” HealthLeaders notes that the report is based on survey responses gathered in February from more than 300 hospital administrators across 45 states. According to many of those administrators, hospitals are suffering financial instability due to higher expenses as well as staffing shortages and exhaustion. Particularly trying for hospitals, the report says, is how to balance ongoing covid treatment with regular hospital care. At the same time, some hospital systems seem to be doing fine. In a new podcast, two Modern Healthcare finance reporters point out that some large health systems—both for-profit and not-for-profit—actually saw their margins grow in 2020. Factors driving that increased profit (other than government grants) include higher acuity patients translating into more revenue and effective cost-cutting. The speakers also believe one pandemic-driven trend may become permanent: less ED traffic. Patients afraid of coming to EDs sought care in other settings, including urgent care, a shift that may persist.

March 30, 2021

Can an extra hour of sleep help prevent covid?

doctor-sleepA new study says that getting an extra hour of sleep a night could go a long way to helping health care workers fight off covid. A study published in BMJ Nutrition, Prevention & Health found that a one-hour longer duration of sleep among health care workers was associated with a 12% reduction in the odds of getting covid. In individuals who reported three kinds of issues with sleeping (difficulty sleeping at night, poor continuity of sleep, and frequent use of sleeping pills), there was a nearly twofold increased risk of getting covid when compared with people who had no sleep issues. And in some countries in which health workers were studied, researchers found that daytime napping was associated with a 6% increase in the chance of getting covid. A MedPage Today article notes that the study also found health care workers who reported feeling daily burnout at work had not only a higher risk of covid, but a longer duration of infection and greater severity.

March 29, 2021

New data: Vaccines prevent 90% of covid infections (updated 3/30/2020)

New data found that the vaccine was 90% effective in preventing covid infection in people who were fully vaccinated (they had received two shots at least 14 days before) and 80% effective in people who were partially vaccinated (they had received one of two shots at least 14 days before). A CDC study looked at nearly 4,000 health care workers who received either the Pfizer or Moderna vaccines who had not previously been infected with covid. Nearly two-thirds of the group received two shots. For every 1,000 subjects who were fully vaccinated, researchers found 0.04 infections, compared to 1.38 infections per 1,000 people who had not been vaccinated. Among subjects who had received only one vaccine, researchers found 0.19 infections per 1,000 people.

A Medscape article says that more data may soon be available looking at how well vaccines prevent the transmission of covid. A trial that began last week is examining transmission of the virus among 12,000 college students. Half will receive the Moderna vaccine immediately, while the other half will receive the vaccine in four months.

March 26, 2021

Deaths are down, but case numbers are on the rise

According to the New York Times, the number of covid deaths over the past two weeks has fallen 31% while hospitalizations have dropped 10%. At the same time, officials note that case numbers are on the rise for the first time since January. Reuters this week reports that cases are trending up in 30 out of 50 states, with health officials hoping the increase in vaccinations will prevent a corresponding rise in covid deaths. A growing number of states have lowered the age of vaccine eligibility, with Alaska the first to offer vaccine to every resident 16 and older.

Covid burden linked to mortality in hospitals

What effect does “covid burden”—the number of covid patients in a given hospital, divided by that hospital’s number of beds—have on patient mortality? Writing in the Journal of Hospital Medicine, UCSF researchers looked at data on more than 14,200 covid patients admitted last April across 117 U.S. hospitals. They found that individual hospitals’ covid burden increased the odds of patients dying of covid, suggesting “that patient surges may be an independent risk factor for in-hospital death among patients with COVID-19.” In coverage of the study, Fierce Healthcare notes that the research adds to literature linking heavy covid surges to poor outcomes. The study authors also point out that their results could underscore the impact of a strained health care workforce on patient outcomes.

Surgeon general deja vu

surgeon-general-vivek-murthyFor the second time in his career, former hospitalist Vivek Murthy, MD, MBA, has been confirmed and sworn in as the nation’s top doctor. Dr. Murthy, who previously filled the post of surgeon general during the Obama administration, proved to be a more controversial nominee this time around. During his confirmation hearings, some senators disapproved of Dr. Murthy’s support for gun reform (as they did during his first confirmation hearings), while other critics—including some in the medical community—questioned how much he’d earned from corporations as a consultant during the pandemic. The son of immigrant physicians, Dr. Murthy noted in a Twitter post that he has lost members of his own family to the pandemic. Once a hospitalist at Boston’s Brigham and Women’s, Dr. Murthy dealt with the Zika pandemic in 2016 and the opioid crisis during his first stint as surgeon general.

March 23, 2021

Good news for AstraZeneca? Not so fast

Yesterday’s announcement from AstraZeneca—that interim trial results of its vaccine indicate 79% efficacy against symptomatic covid, 100% efficacy against severe covid and hospitalization—was welcomed news. But in what news coverage claims is an unprecedented step, an NIH panel has weighed in with a “not so fast.” The problem, according to a NIH letter released late yesterday, is that those interim results may be based on “outdated and potentially misleading” data. But according to the Washington Post, the NIH panel has been working with AstraZeneca and has found the vaccine to be between 69% and 74% effective. Anthony Fauci, MD, is quoted as saying that the problem is probably not with the vaccine—”very likely a very good vaccine”—but with the rollout of trial data.

Almost half of all health care workers have not been vaccinated

While health care workers have been at the front of the line to receive vaccine, a new poll indicates that more than four out of 10 health care workers have not been vaccinated. The poll, which was put out by both the Kaiser Family Foundation and the Washington Post, finds that just a bare majority (52%) of health care workers across the country have received at least one dose of covid vaccine. While an additional 19% were either scheduled to be vaccinated or planned to, 18% did not plan on being vaccinated while another 12% remained undecided. More than one in three surveyed health care workers reported not being confident that the vaccines were safe and effective. The survey, which was held mid-February to early-March, gathered responses from more than 1,300 health care workers. In related news, Kaiser Health News reports that new covid cases among nursing home staff members have plummeted by more than 80%. That’s despite the vaccine hesitancy felt by many staff members, with some nursing homes reporting that only half their staff have been vaccinated so far.

Yes, there are covid stamps

https://jamanetwork.com/journals/jama/fullarticle/2777922
Image from JAMA

None of them, unfortunately, have yet been issued in the U.S. But a piece in JAMA written by French researchers points out that 21 countries as well as the U.N. have issued dozens of different stamps commemorating the pandemic. Iran was the first to do so last March. Many of the stamps depict clinicians, scientists or first responders, while a few contain public health messages about hand-washing and social distancing. Some also show patients being ventilated and attended to by health care workers. One in a series of covid-related stamps issued by the Isle of Man has an illustration of a clinician in scrubs and a red cape.

 

March 22, 2021

A drive-in Match?

It was once again a remote Match Day last Friday for more than 33,000 medical students and the more than 2,600 candidates around the world looking for residency slots. It was also an historic one that offered the most positions in Match history, with the number of slots up 3% from last year. MedPage Today reports that the need to hold a virtual Match Day led many medical schools to become creative, with at least one school holding a drive-in Match ceremony while another sent bottles of champagne or cookies to students’ homes. As for remote matching, students noted that not being able to travel to in-person interviews allowed them to apply to more programs. Internal medicine drew one-quarter of all applicants, with the number of internal medicine positions up 25% over five years ago. Over that same time frame, the number of family medicine positions increased 44%.

Study: Good news for the AstraZeneca vaccine (updated above)

After a tough week last week, the AstraZeneca vaccine has garnered some good news, showing 79% efficacy against symptomatic covid and 100% efficacy against severe covid and hospitalization. The vaccine’s manufacturer delivered the interim results of its phase 3 trial in a press release, saying the data were based on results from more than 32,000 participants. The two-dose vaccine was found to be just as efficacious in patients over age 65. STAT reports that the study also uncovered no safety problems, including any with blood clots; concerns about clotting led the AstraZeneca vaccine rollout being suspended in several European countries. Based on the results, the vaccine manufacturer intends to ask the FDA for emergency use authorization in the U.S.

March 19, 2021

Getting covid helps prevent reinfection for about six months

fight-covid-reinfectionResearch published in The Lancet found that most people who get covid have some protection from the virus for at least six months, although older people saw less immunity from becoming re-infected. The study found that being infected with covid reduced subjects’ chances of being infected again by 80%, but that figure fell to 50% for people over 65. A New York Times article says that the study is unique because it has been difficult to study reinfection rates, which require access to testing and genetic sequencing to confirm reinfections. The study was also conducted on a small population, and because researchers weren’t able to talk to the study’s subjects, it’s possible that people who became infected were asymptomatic and didn’t feel any ill effects of covid. The study also doesn’t take into account the possibility that people who have had covid and have some immunity can get reinfected in less than six months if they’re exposed to a different variant of the virus. A Newsweek article notes that Anthony Fauci, MD, warned of this scenario this week during congressional testimony.

Patients prefer clear (not cloth) masks when talking to docs

study published in JAMA Open Network found that surgeons who talked to their patients wearing clear masks, not standard cloth masks, saw better patient ratings. Researchers studied 200 patients from 15 surgery clinics in seven different subspecialties. When it came to providing clear explanations, surgeons with clear masks received a score of 95% compared to 78% for surgeons wearing cloth masks. Patients rated surgeons wearing clear masks higher on empathy (99% vs. 85%) and on building trust (94% vs. 72%). While patients said they preferred clear masks, 53% of surgeons said they were unlikely to replace their traditional masks with clear masks.

March 17, 2021

It’s been a tough week for the AstraZeneca vaccine (updated)

empty-vaccination-centerAstraZeneca’s covid vaccine took a beating this week on multiple fronts. The week began with European countries banning AstraZeneca’s vaccine because of concerns about blood clots, claims that an article in Science examines. Europe’s equivalent of the FDA offered its support for the vaccine later in the week, but much of the damage had already been done. Things got worse when a study concluded that the vaccine doesn’t do very well in preventing infection from the South African (B.1.351) variant of corona. Data published in the New England Journal of Medicine found that more than 90% of the cases in the study were caused by the variant, and that the vaccine’s efficacy against that variant was only about 10%. The study found that the AstraZeneca vaccine had an overall efficacy of 22% for all cases (not just cases caused by the variant) of mild to moderate covid. Finally, the U.S. announced yesterday that it is planning to send millions of doses of the AstraZeneca vaccine to Mexico and Canada. Federal officials have been sitting on a stockpile of the shots while awaiting FDA approval of the vaccine.

March 16, 2021

Are we giving the best PPE to the wrong people?

doctor-hospital-roomNew data show that we may be giving the best PPE to the wrong health care workers. An article from Kaiser Health News notes that while “aerosol-generating procedures” (think intubating patients) have been viewed as the most dangerous in terms of spreading covid, recent data say that a basic cough produces 20 times as many particles as an intubation. As a result, health care workers wearing a surgical mask (as recommended by the CDC) have a higher risk of infection by being in the same room as a covid patient than being near a patient during an intubation. While the thinking on covid risk is slowly shifting, a group of health care experts has stuck to the position that it’s safe for front-line workers to be around covid patients wearing only a surgical mask, while N95s be reserved for covid ICUs. One source in the Kaiser article said that the thinking about PPE during covid has been “upside down.”

Nurses exhausted and stressed, but staying in health care

A new survey of 22,000 nurses has found that younger workers seem to be bearing the emotional brunt of the pandemic. The survey found that among early-career nurses (those under 34), 81% reported exhaustion, 71% reported feeling overwhelmed, 65% were anxious or unable to react, and 47% felt sad. Among older nurses (those over 55), by comparison, about half (47%) reported exhaustion and 37% reported feeling overwhelmed. A Health Leaders article notes the survey also found that nearly 20% of nurses indicated they are financially worse off since the beginning of the pandemic, but most said they don’t plan to leave their current job or the profession. About 30% of surveyed nurses haven’t received a vaccine, and about 25% say they are undecided about getting vaccinated. Finally, only 73% say they have adequate PPE.

March 13, 2021

 Are you giving covid patients too many antibiotics?

Prescribing prophylactic antibiotics and surgeryNew data show that while more than half of covid patients last spring received antibiotics, only a “fraction” of them had bacterial infections. A MedPage Today article said that data show that most antibiotics were given within 48 hours of admission, before most physicians know their patients’ infection status. The data from a Pew Charitable Trusts project found that 36% of covid patients received more than one antibiotic and that only 20% of admissions had suspected or confirmed bacterial pneumonia. The MedPage Today article notes that a study found that VA hospitals used more antibiotics in the first five months of 2020 than in any year since 2016.

March 11, 2021

Study: Working at the hospital doesn’t increase your covid risk

New data claim that hospital workers don’t have a higher risk of getting covid at work,
proof that infection prevention practices are working. The study, which was published by JAMA Network Open, found that even nurses, who have the most direct contact with patients, don’t face a greater risk of getting the virus at work as shown by the presence of covid antibodies.

Among the 25,000 hospital workers studied, the overall positivity rate for covid antibodies was 4%. Physicians had a positivity rate of 3.7%, nurses had a positivity rate of 4.8%, and NPs/PAs had a positivity rate of 3.5%. Nonclinical staff had a positivity rate of 3.9%, but the highest rates were found among environmental service workers (7.4%). The study came out at about the same time as the release of a database of more than 3,500 U.S. health care workers who have died of covid. The list, compiled by a partnership between the Guardian and Kaiser Health News, analyzes the deaths by demographics including occupation, state and race/ethnicity.

March 10, 2021

Colchicine lacks mortality benefit

A trial looking at covid treatments has dropped an arm testing the drug colchicine, which is widely used to treat gout and other inflammatory conditions, because of a lack of a mortality benefit. The RECOVERY trial, which is evaluating potential covid treatments at hospitals in the UK, Indonesia and Nepal, found colchicine produced no 28-day mortality benefit when compared to usual care. An article on MDedge notes that the RECOVERY trial has already identified two anti-inflammatory drugs, dexamethasone and tocilizumab, that can help the survival rates of covid patients. A statement is online.

March 8, 2021

A look at whether vaccines can help long haulers

With the U.S. now giving 2 million vaccines a day, limited evidence suggests that the vaccines may be offering covid long haulers relief from their symptoms. A MedPage Today article cites anecdotal evidence of the recently vaccinated getting some relief from long-term effects of covid, but it also points out that the data are preliminary. A survey of nearly 500 covid long haulers found that 27% of respondents reported feeling “slightly better,” while 16% said their symptoms were “much better” and 5% said they were back to normal. Several experts interviewed for the article endorsed the idea of further studying the impact that the vaccine may be having on long haulers, noting that there are multiple reasons that a vaccine would provide those patients with relief. One recent study on long haulers found that up to one-third of covid patients with severe infections may suffer from post-traumatic stress disorder.

Is delaying second dose of vaccine a good idea?

Health experts are batting down the idea of delaying a second covid vaccine in order to get at least one vaccine into a bigger group of people. The CDC’s Advisory Committee on Immunization Practices recently ruled that there’s not enough evidence to delay a second vaccine or to give only one dose to people who have already had covid. A MedPage Today article says that members of that committee worried that estimates of the effectiveness of the protection offered by one dose are imprecise, and also that one dose may not sufficiently protect people from emerging variants. Last week, Anthony Fauci, MD, warned that delaying a second dose puts Americans at risk and urged health officials to continue with a two-dose schedule. A Medscape article says that while Dr. Fauci has spoken to health officials from the U.K. about their strategy of delaying second doses of the vaccine, he said he didn’t believe the strategy was a good choice for the U.S.

March 4, 2021

Asthma doesn’t increase hospitalizations, serious illness in covid

asthma patientData from patients tested for covid in California earlier this year found that asthma is not an independent risk factor for developing a severe case of the infection or increased risk hospitalization. Researchers at Stanford University found that out of nearly 170,000 people who received a covid test between March and September of 2000, there were no differences in hospitalization rates based on whether people had asthma. An article in MDedge said that 28% of patients with asthma had asymptomatic covid compared to 36% of people without asthma. While 53% of people with asthma had severe or critical cases of covid, so did 51% of people without asthma. The data were released as part of a poster presentation at the American Academy of Allergy, Asthma and Immunology’s virtual meeting this year.

Do lockdowns lead to more alcohol withdrawals?

Covid lockdowns seem to be leading to more cases of alcohol withdrawal. Data from a single-center study of hospitalized patients found that between March and September of 2020, rates of alcohol withdrawal jumped by 34% when compared to 2019. A MedPage Today article says that while rates of withdrawal were higher in all of 2020, they were higher immediately after lockdown periods. Researchers accounted for seasonal fluctuations in rates of alcohol withdrawal by comparing data from the same biweekly periods in 2019 and 2020. The data come from a sample size of 340 patients and were published in JAMA Network Open.

March 3, 2021

A look at pandemic-related violence against health care workers

health-worker-covid-confrontationOut of more than 1,000 reported attacks on health care workers in 2020, more than 400 were directly related to the covid pandemic. Incidents included arson at testing facilities, health care workers targeted on their way home after work because of fears that they would spread the virus, and violent responses to workers trying to enforce mask requirements. Individual health care workers were also arrested and assaulted after going public with concerns about the safety of PPE or criticizing government policies about the pandemic. The report, published by Data from Safeguarding Health in Conflict, found that health care workers “frequently” reported being attacked on their way to and from work. The report notes that hotspots for violence included India and Mexico, but violence against health care workers was reported in 79 countries.

WHO issues “strong recommendation” against hydroxychloroquine

The World Health Organization has made a strong recommendation against using hydroxychloroquine to prevent covid. An article in New England Journal says that the recommendation, which was published in the BMJ, is based on a meta-analysis of six clinical trials. The analysis found that hydroxychloroquine had “little to no effect” on covid patients’ mortality or admission rates. Researchers also found that hydroxychloroquine didn’t reduce rates of covid as confirmed by lab results.

March 2, 2021

The five diseases that are associated with covid hospitalizations

heavy-woman-covid-vaccinationA new study found that about one-third of covid hospitalizations were attributable to obesity. Researchers examining a little more than 900,000 U.S. covid hospitalizations found that 30.2% were attributable to obesity/severe obesity, followed by hypertension (26.2%), diabetes (20.5%), chronic kidney disease (12.9%), and heart failure (11.7%). Researchers also looked at the impact that combinations of disease had on covid hospitalizations and found that 40.7% of admissions were attributable to diabetes/hypertension, followed by diabetes/obesity (44.%), diabetes/hypertension/obesity (58.7%), and diabetes/hypertension/obesity/heart failure (63.5%). The study was published by the Journal of the American Heart Association.

Can vaccines in older people prevent the need for ventilators?

New data from Israel have found that older people given a covid vaccine were less likely to require mechanical ventilation to treat the virus than younger people who haven’t been vaccinated. Data from Israel found that Israelis 70 and older who had received the Pfizer vaccine were 67% less likely to need a ventilator than Israelis under 50. The study, which was published in MMWR, compared ventilation rates from February 2021 with rates from October-December of 2020. A Medscape article says that researchers found 80% of older Israelis had received the vaccine compared to only about 10% of people under 50.

 

Today’s Hospitalist has been reporting on covid-19 since January 2020. Click here for earlier updates. 

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