TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.
This week’s topics include the benefits of stay-at-home orders, going to work when sick, mental health and coronaviruses, and proning patients with Covid-19.
0:36 Do you go to work when sick?
1:36 Most would work with minor symptoms
2:38 Don’t want to burden their colleagues
3:33 Need a pool of workers to fill in
4:02 Proning patients to improve lung function
5:02 Work of breathing went down
5:50 Impact of coronavirus infection and mental health
6:54 Range of mental health symptoms
7:50 No long term impact
8:51 Physical and social isolation
9:12 Impact of stay-at-home orders
10:13 Same incidence for all counties beforehand
11:13 Have enough PPE
Elizabeth Tracey: Do you go to work when you’re sick?
Rick Lange: Do stay-at-home orders decrease COVID infections?
Elizabeth: What are the mental health consequences of coronavirus infection?
Rick: And does prone positioning help breathing in individuals with COVID infection?
Elizabeth: That’s what we’re talking about this week on TT HealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: And I’m Rick Lange, President of Texas Tech University Health Sciences here in El Paso, where I’m also Dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, I’d like to turn first to the journal PLOS ONE, Public Library of Science ONE, the story that I served up as do you go to work when you’re sick? This is a study that took a look at whether people who had an influenza-like illness — both healthcare workers and non-healthcare workers — chose to go to work anyway. It’s an international study. But for an international study, it has a rather disappointingly small “n” as far as I’m concerned. They have 49 countries participating, a total of 533 respondents. Of that number, about half are healthcare workers and the other half are not healthcare workers.
They found that overall almost 60% of these folks would continue to work while sick with an influenza-like illness. There were about 27% of the healthcare workers and 16% of the non-healthcare workers would work with just a fever. Most of them would work with minor symptoms such as sore throat, a sinus cold, fatigue, sneezing, runny nose, mild cough, and reduced appetite — obviously, for those who’ve been paying attention, many of the symptoms that attend COVID-19 infection.
This study admittedly was done before the pandemic has enfolded the globe, if you will, and so the question is, with awareness today, would these people still be making the same kinds of responses to this inquiry? But it’s concerning that people still say, “I’m going to continue to work, even when I’m symptomatic.”
Rick: Elizabeth, as you mentioned, this was done prior to the COVID infection. It was done by a group that is trying to prevent infections after chemotherapy. You didn’t mention the many factors involved with why people would continue to work.
Some people don’t have enough allocated sick leave days. Some people feel the pressure to be at work with minimal symptoms. Some aren’t aware of how severe the problem could be, especially with older patients or patients immunocompromised. Some people feel like they don’t want to put a burden on their colleagues. How would you suggest we address it?
Elizabeth: I think that there are some things that are out there already. For example, there’s an app that’s called Emocha that many healthcare environments are employing now, where they ask people, “Hey, do you have any symptoms?” And self-report those and then hopefully bring that into awareness and potentially self-exclude from the workplace.
Many workplaces are also taking people’s temperatures when they come in, so one piece of objective data that might help inform that decision to send people home. I think, obviously, we need to protect people’s incomes if they choose to be at home. That’s something that is not global and that also has been blamed, or has been a factor, relative to the disproportionate impact of COVID-19 on service workers, for example.
Rick: The other thing I would also add is we need to have a pool of workers to fill in when those of us that are sick, or mildly sick, shouldn’t come to work. Elizabeth, I think the important thing you’ve mentioned is it’s not a single thing that’s going to fix this, but we need to address all the issues. Every healthcare provider who’s listening to this podcast, I want them to know if they have fever, or even mild symptoms suggestive of an influenza-like illness, it’s best not to go to work.
Elizabeth: We could even end right there, but we’re not going to. Let’s turn to the Journal of the American Medical Association. This issue of is it helpful to put patients in a prone position in order to improve their lung function when they have COVID-19 infection?
Rick: We’re going to limit that particular question to people that are spontaneously breathing. We know that there’s good evidence that if people are on a ventilator and have severe acute respiratory distress syndrome, especially related to COVID, that if they’re put in a prone position — that is face-down — and ventilated for a long period of time 16 hours or more, it improves their survival.
The next question is, “What if those individuals that are struggling with COVID infection, they’re not ventilated, if we put them in a prone position, does it decrease their work of breathing? Does it improve their oxygenation? Do they tolerate it?” Then, “Is it sustained when we put them back in a supine position?” Two studies published in JAMA address that.
These are both small studies. One had 15 patients. The other one had 24 patients. What they showed is that they could put people in prone position for 3 hours. A half and two thirds of patients tolerated it. When they were in the prone position, their respiratory rate went down. Their work of breathing went down. Their oxygenation oftentimes improved. But then when they put them back in the supine position, results really didn’t last. The groups were too small to assess whether it prevented intubation or whether it improved their survival, so we can’t really tell.
Elizabeth: I understand that there’s a relationship between obesity and this issue of supine versus prone. That in obese patients, putting them prone is better.
Rick: This particular study didn’t address it, but as we know, obesity is a risk factor for having complications, ventilation, and for death as well, and obesity impairs ventilation. The more impaired it is, the more likely the patient is to respond to a prone position. The patient with obesity, which may have the most severe respiratory difficulties, may improve even more.
Elizabeth: Let’s turn now to Lancet Psychiatry — many people talking about the impact of having been in an ICU with COVID infection, and surviving, thankfully, and what happens to you. Are there mental health issues relative to that?
This is a retrospective study that is a meta-analysis of those studies that were related to SARS and MERS, and a little bit of the COVID-19 literature that’s out there. The outcome measures were psychiatric signs or symptoms, symptom severity, quality of life, and employment from this meta-analysis.
They identified 65 peer-reviewed studies and seven preprints — which I think is really interesting, the inclusion of the preprints. We’ve been talking about preprints, so it’s sort of this expanded criteria relative to COVID. The total number of coronavirus cases — so remember it’s all of these — was just above 3,500. Ages of these participants ranged from 12.2 years to 68 years of age.
In looking at the symptoms that people demonstrated relative to coronavirus infection, they saw confusion, depressed mood, anxiety, impaired memory, and insomnia. They also reported on steroid-induced mania and psychosis, which are not surprising for people who are in those ICU stays.
They also looked at this post-illness stage, and found depressed mood, insomnia, memory impairment, fatigue, and also, in one study, traumatic memories of their ICU stay. They calculated the point prevalence of post-traumatic stress disorder as 32%. They also found clear evidence for delirium in 65% of 40 intensive care unit patients. We’re seeing this, of course, in the COVID patients — a very high incidence of delirium in these folks.
The good news was that when they looked at long-term impact, though, they did not see that there was a long-term impact of increasing mental illness following convalescence.
Rick: That’s important because, as you said, this study looks at all coronaviruses. The reason why they did that is because we don’t have enough information, and certainly long-term information, just about the COVID-19 viral infections. There’s not much in the way of long-term psychiatric risks, which is important, because these viruses are neuroinvasive, neurotrophic, and neurovirulent as well.
The thing that was remarkable to me is the percentage of individuals that have confusion or delirium. When you take a step back, it shouldn’t be that surprising because these patients are oftentimes in the ICU for a week to 2 weeks. They are on a ventilator, they’re sedated, so to have experienced confusion and delirium… and they’re oftentimes older as well. All those are risk factors.
I would also add by the way that when these patients get out of the hospital, they’re oftentimes emaciated or wasted, and fatigued and tired. Secondly, they’re entering society that has an economic crisis, oftentimes with food insecurity, and their experience with their lockdowns. They have physical and social isolation as well. Even getting them out of the hospital, into this setting, it’s not surprising they have PTSD and you didn’t mention that about 15% have depression and anxiety. This is an important study to alert us that even when you get them out of the hospital, we’re not done treating the patient.
Elizabeth: That’s exactly right. I think there are all kinds of long-term sequelae that we still don’t know much about. Let’s turn to your final one. I think we’re going back to JAMA.
Rick: This is JAMA Network Open. It has to do with trying to assess do stay-at-home orders really benefit? Now you say, “Well, how would you do that?” You’d like to compare two states or two counties, one of which had a stay-at-home order and one of which didn’t. But there are so many geographic and differences in the populations, unless you did it as these authors did, which was really smart.
They compared two states that touch one another, Iowa and Illinois. Illinois had stay-at-home orders. Iowa did not. Now, Iowa did do other things. They have banned large gatherings, and social isolation, but they didn’t have a stay-at-home order. We have two states next to one another and they looked at 8 bordering counties that touched one another. Their only difference was one state had stay-at-home orders and the other one didn’t. They followed these individuals.
Here’s what they discovered. In the Iowa border counties, almost 500,000 individuals, in the Illinois border counties, about 250,000 individuals. Before there was a difference in how they treated their county population, the incidence of COVID infection was the same for all 8 counties.
What happened over the next 10, 20, and 30 days was there was a dramatic increase in the number of individuals in Iowa who developed COVID infection. Let me quantitate that. Again, they started with the same incidence. Over the next 10 days, there were 5 more persons per 1,000 in Iowa that got infected. At 20 days, there were 11 more patients, and then at the end of 30 days, 47 more patients per 1,000. They estimated there was an excess of 217 cases in Iowa, just as a result of the fact they didn’t have shelter-in-home. That accounted for 30% of their new cases that particular month.
Elizabeth: Hmm, this is some pretty impressive data. This issue of stay-at-home, of course, we’re seeing this nationally and internationally, and lots of folks bucking this particular mandate.
Rick: The coronavirus is here to stay for a while. We’re not going to outrun it. We’re not going to outlast it. We have to learn to exist with it. What we want to do is we want to make sure we don’t overwhelm the healthcare system, we try to protect our vulnerable population, and we have enough PPE [personal protective equipment] when we need it.
Knowing that measures like this are important so that if we get to a point in a geographic area where we’re running out of PPE or we’re running out of hospital resources, knowing that shelter-at-home can decrease additional new cases is pretty important.
Elizabeth: Yes, and so I saw just today this model where they were talking about maybe we should sort of pulse — stay at home, don’t stay at home, stay at home, don’t stay at home — as a means of kind of interrupting this.
Rick: There are a lot of different ways to address it. Obviously, we have to have adequate testing and adequate contact and isolation. But if we follow things very rigorously, we can gauge how restrictive we need to be or don’t need to be based upon it because there are obviously economic things we need to consider as well. To have a fourth of Americans out of work means they don’t have access to food, or shelter, or healthcare, that’s a serious problem. That’s also a health problem as well. Finding that balance between protecting individuals and protecting their economic situations, that’s what we’ll be addressing.
Elizabeth: OK. On that note, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.