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 face masks in Kansas, WHO recommendations on remdesivir, rate of HIV-related death, and delirium in older folks with COVID.
Program notes:
0:44 Face masks in Kansas and COVID
1:44 Seven day average decreased 6%
2:45 This study seems unlikely to change behavior
3:44 Rate of delirium in older patients with COVID in the ED
4:41 Increased odds of ICU admission and death
5:41 May be only symptom
6:48 WHO recommendations about remdesivir
7:48 Does it improve survival?
8:42 Resource rich areas
9:45 Data from AstraZeneca vaccine
10:44 mRNA vaccines more expensive
11:15 Rates of death in those with HIV
12:15 Rate decreased by 37%
13:10 End
Transcript:
Elizabeth Tracey: How often does delirium happen in older people who come to the ED with COVID-19?
Rick Lange: What’s the World Health Organization’s recommendation for remdesivir?
Elizabeth: Good news about HIV-related death.
Rick: And what can Kansas teach us about wearing masks to prevent 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 Center in El Paso, where I’m also the Dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, since you’re pretty close to Kansas out there in Texas, why don’t we start with what can they teach us about face masks? That’s in Morbidity and Mortality Weekly Report.
Rick: Right. This is a report from the Centers for Disease Control and Prevention that talks about the trends in the county-level COVID-19 incidence in counties with and without a mask mandate in Kansas between June 1st and August 23rd.
What happened was on July 2nd, the governor of Kansas issued an executive order — this is a state mandate — that was effective the next day that required masks or other face coverings in public spaces. But in Kansas, as a result of a rule that was passed earlier, the counties can either opt in to follow the governor’s mandate or decide not to.
As of August 11th, 24 of Kansas’ 105 counties did not opt out of the state mandate, whereas the rest of them did. What happens to COVID infection in the counties that did use the mask mandate and those that didn’t? Those that opted to follow the governor’s recommendation — and by the way, that accounted for about two-thirds of the state’s population — the 7-day average number of new daily cases decreased a net 6%. What happened in the counties that didn’t do it? Well, they had an increase of 100%.
Now, the nice thing about this particular trial is they didn’t have to adjust for various things like whether it was urban or rural. It’s just an observational study in a state that otherwise didn’t do anything significantly different other than either opt in or opt out of a mask mandate.
Elizabeth: Of course, they had the other recommendations in place also with regard to physical distancing and crowd size, and all the rest of that, right?
Rick: Absolutely. Now, one could argue that maybe the places that followed the mask mandate were more vigilant about the other things. But actually, when you look at the data from June until July, until the mask mandate, the numbers increased substantially in all the counties, but it even increased more in those counties that later adopted the mask mandate. None of those things changed at all, the prevention measures that you describe. What primarily changed was the use or the non-use of masks.
Elizabeth: I’m sorry to wax cynical here. However, I am going to comment that this study seems a lot like preaching to the choir to me. I think that everybody who is even peripherally involved with medicine is pretty convinced that masks are the right thing to do. I’m not sure that this is going to motivate those who are convicted that they are not going to wear a mask to change their behavior.
Rick: And I agree with you. You might say, “Well, this is kind of a no-brainer.” But obviously three-fourths of the counties in Kansas didn’t believe it was a no-brainer and we still have a lot of people around the United States that really question the value of masks, especially if you’re not using an N95.
So apropos to this particular report, they’ve also put out recommendations and data regarding mask use across the United States in various places, because some people are unconvinced. I know you’re convinced and I’m convinced, but there are still many people around the United States — many of them leading legislative bodies in the United States — that really don’t believe in it. Believe it or not, some of them even live in Texas.
Elizabeth: On that note, let’s turn to JAMA Network Open. This is a study taking a look at how often does delirium occur in older patients with COVID-19 when they present to the ED? Delirium, of course, we know is a really huge problem in older people and this study — it’s a retrospective study, really, looking at 817 older patients with COVID-19 who came to EDs spread throughout the whole country, and their average age was 77.7 years. Of those, 28% had delirium at presentation. It was the sixth most common of all presenting symptoms and signs in this population.
Among those with delirium, 16% had delirium as a primary symptom and 37% had no typical COVID-19 symptoms or signs such as fever or shortness of breath. To me, that’s really important. They also noticed that delirium was associated with increased odds of being admitted to the intensive care unit and dying. So clearly, when older people come to the ED, even if their only presentation is delirium, COVID-19 is really an important thing to be looking for.
Rick: Elizabeth, several things about this study that I found were kind of interesting. This data has geographic importance. When you look at the COVID data, even though people over the age of 65 only make up about 16% of the population, they represent 80% of the COVID-related deaths in the United States, so identifying these individuals early and establishing treatment is important. What you don’t want to do is you don’t want to miss a diagnosis, and usually we think about things like fever and shortness of breath and fatigue as being major symptoms. But as you described, about one in eight of these individuals presented with just delirium, and nothing but delirium.
By the way, in this study, many of those individuals had delirium for a protracted period of time, even up to as long as a week when they recognized they were sick. In older individuals, as you noted, this may be the only symptom because their immune system is somewhat suppressed and their baseline temperature is lower than younger individuals, so they don’t manifest the usual symptoms.
Elizabeth: They also note in here that this rate of delirium in this cohort is higher than has been reported in ED studies that were done before COVID, where they assessed that rate of delirium. The other thing that they note is that there’s a high occurrence of delirium and other neuropsychiatric manifestations with COVID-19 even among younger people.
Rick: You’re right. We’ve talked before about brain fog that occurs with COVID infection even afterwards. We’ve looked at delirium in the hospital, and in fact, we estimated that about 25% to 33% of hospitalized patients with COVID have delirium, and even 65% of those in the intensive care unit. But this is a unique population — these are older individuals that haven’t been hospitalized. We’re talking about how often is delirium their initial and sometimes only manifestation. This is a unique study and the data are really pretty important for caring for older individuals that may be COVID-infected.
Elizabeth: Let’s turn to the British Medical Journal, where you served this up, about what is the WHO saying about remdesivir?
Rick: The World Health Organization is providing a living guidance that focuses on different treatments for COVID. This is their second version; the first version looked at the use of steroids. This particular one looked at the use of remdesivir.
The panel emphasized that the evidence suggests that there is no important effect on mortality, need for mechanical ventilation, time to clinical improvement, or other what they called “patient-important outcomes.” Based upon the low certainty that it was beneficial and the fact that it could possibly have some harm, the panel said that the current evidence doesn’t support patient-important outcomes.
Let me take a step back because we’re obviously using it in our hospital setting and many places around the United States. I want to focus on what they called patient-important outcomes. Because you and I would both agree that if we have a disease, things that may be important to us are: does the treatment improve survival, or does it make me feel better, or do I improve quicker? The data with remdesivir doesn’t necessarily show that, but what it did show was it decreased hospital stays for individuals.
Now, that may not be an important patient outcome, but I can tell you, especially in our setting in El Paso and other places around the United States, it’s a very important outcome because as the number of cases increases, it overwhelms our system — that is, our facilities and staff as well.
While this may not be an important patient-centered outcome, it’s an important community outcome, even though the WHO says, “Listen, based upon how the patient feels and availability and cost, is the evidence strong for it?” They said, “Well, we can’t exclude that it’s beneficial, but the data aren’t very supportive.” From our standpoint, remdesivir does have an important role. The important role is freeing up hospital facilities and staff for other individuals that may have COVID infection.
Elizabeth: Clearly, we are in a resource-rich environment, and so the fact that remdesivir is utilized here in the United States is not surprising, and I think part of the WHO’s reluctance to say, “Yeah, we’re going to say this is good stuff” is because of the cost.
Rick: You’re right, Elizabeth. It’s due to the cost of the medication. It is due to availability as well. It does require an intravenous infusion and it’s limited to hospitalized patients, those that aren’t sick enough to need steroids, but it’s not used on an outpatient basis. So, you’re right. By the way, they came down pretty salty and said we can’t rule out a benefit, but we can’t prove it as well.
Now, we call ourselves resource-rich, and that’s true, but the resources are finite. Again, in El Paso we happen to be at the epicenter of the pandemic and we’ve overwhelmed our hospital facilities and our staff. We’ve had to bring in mobile units and bring in outside staff as well. So if we can get people out of the hospital quicker, then any therapy that does that’s beneficial.
Elizabeth: Let’s just mention, because this seems like an appropriate time to do so, that we’re recording on Monday because of the Thanksgiving holiday. We have data from the AstraZeneca vaccine that was published in the British Medical Journal also, I believe, that shows that it’s 90.9% effective. Now, I thought that was really interesting.
They had two vaccine regimens, both requiring two doses of the vaccine. One regimen was less effective; that was two full doses of the vaccine. The one that was more effective was half dose followed by a full dose, so I thought that was a real curiosity and I’m going to be very interested to see what happens in post-marketing surveillance.
Rick: A couple of things about these vaccines. The Pfizer vaccine, obviously mRNA vaccine, it has to be stored in super cold facilities and it will have limited access worldwide. The AstraZeneca vaccine is a chimpanzee adenovirus — inactivated virus — vaccine. It doesn’t require the extreme cold. It can be stored in a refrigerator and it will be available globally, and it will be substantially cheaper. That will be about $4 to $5 per dose, whereas the other vaccines, the Pfizer and Moderna vaccines, will probably range between $20 and $35 per dose. Again, all these vaccines require two doses, so you can double that cost per person.
So stay tuned. The Pfizer vaccines should be available for distribution in the United States the second week in December. The AstraZeneca dose, first of all, it hasn’t received EUA designation by the FDA or been approved worldwide yet, but it should be available fairly soon because there are more than ten countries that will be manufacturing the AstraZeneca Oxford vaccine.
Elizabeth: Good news, and we’re going to end with some good news. This is back to Morbidity and Mortality Weekly Report. This is taking a look at trends regarding death among people with diagnosed HIV infection in the United States between 2010 and 2018. Those HIV-related deaths have decreased almost 49% — 48.4%, which is really fabulous, fabulous news.
The bad news, of course, is that that rate of decrease was highest in the Northeast — so more people are getting diagnosed, getting treated, getting on medicines, staying on them and so forth — and unfortunately was lowest in the South. It’s clearly pointing to places where we need to make sure that people get tested, they find out their status, and then they get on these medicines, which we know really do suppress HIV and render people who have the virus almost able to have a normal lifespan.
Rick: Elizabeth, as you mentioned, this is great news and since 2010 we’ve seen the death rate among these individuals in the U.S. decrease by 37%. We targeted 33%, by the way, so this is even better than we expected.
There are still some disparities, as you mentioned. More deaths in the South than the North and more among African-Americans than other ethnicities. That gap is closing over the years, and again, it’s due to early identification, early testing, and early treatment as well. For those of us who trained in the era where there was no treatment and this was a death sentence, knowing that these individuals can have a nearly normal lifespan — that’s terrific news.
Elizabeth: It is indeed. On that note, Happy Thanksgiving to all. This is definitely something to be thankful for, hopefully a model for how we’re going to manage with COVID. That’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: So stay safe and y’all listen up make healthy choices.
Source: MedicalNewsToday.com
