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 COVID transmission in schoolchildren, jobs and COVID mortality risk, and mental health during the pandemic.
:40 Transmission of COVID among schoolchildren
1:40 Almost 2200 contacts
2:37 Infection differences in younger versus older children
3:11 Occupations and COVID mortality risk
4:11 36% increase in Latinos
5:12 Treat their lives as essential
6:00 Mental health issues in the pandemic
7:01 Disorders highly prevalent in 18-24-year-olds
8:01 Need to be creative in providing services
9:01 First time with a disruption like the pandemic
10:00 Update on the AZ vaccine and interval
11:00 Initially was supposed to be a single dose
12:02 Antibodies against more of the spike protein
Elizabeth Tracey: Can we safely extend the interval between the first and second vaccine for COVID-19?
Rick Lange, MD: Mental health during the COVID crisis.
Elizabeth: What are the differences in COVID infection rates among different occupations?
Rick: And quarantining student contacts during COVID.
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 the Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, since there are so many school systems that are considering sending back their students or even have already done so, why don’t we turn first to this research letter that’s in JAMA?
Rick: All right. Elizabeth, you know, the U.S. Centers for Disease Control and Prevention — that is, CDC — recommended a 14-day quarantine period without testing for any close contacts of anyone diagnosed with coronavirus. We know, however that most individuals, if they’re going to develop COVID infection after a contact, do so within 5 days, but in children, 6 to 7 days. One of the counties in Florida implemented a SARS COVID testing on Day 9 and a return to school on Day 10 if it was negative for any individual that had been in contact with somebody having COVID.
So these are the results. They had 49 schools serving a population of over 26,000 kindergarten through 12 students. About half of the instruction was in person and half of it was hybrid. They identified any symptomatic COVID-positive kids — and there were about 257 of them — and then they traced their contacts. From that, there were almost 2,200 contacts of those kids.
Now, normally those kids would be sent home for 14 days, but they tested them at 9 days. What they found out was that about 5% were positive — by the way, more in high school than in elementary school, about 8% versus about 2% — and they kept those kids at home, but they allowed the other kids to come back to school.
The question is, how many of those ended up being COVID-positive? Well, of the 800 kids that came back to school after testing negative, only one developed COVID infection. Oh, by the way, it was genetically different than what they’d been in contact with, so they probably got it from somewhere else. What this suggests is, this is a really good strategy. It gets the kids to school faster, there’s less absenteeism, and it’s still safe for the rest of the school.
Elizabeth: And in view of the fact that we are seeing so many warning signs of increased mental health problems, and especially among school-aged populations, I think it’s super important. I thought it was really interesting, the difference between the infection rates among the elementary students and those among the teenagers or the adolescents, who seem to resemble adults a lot more in transmission rates.
Rick: Right. We worry a lot about the kids that are in elementary school and middle school because we think, “Yes, they’re probably more likely to be asymptomatic and more likely to spread it around.” But as we mentioned, only 2% of the elementary and middle school kids that had come in contact with somebody during that quarantine period actually developed infection, so I agree with you. I was surprised at that as well.
Elizabeth: Good news, then, and helps to support this idea that maybe it’s time for kids to go back to school.
Let’s turn to the preprint server medRxiv — this study, speaking about transmissions in these kinds of settings, is in an occupational setting. The study took place in California. They examined this issue of occupational differences in excess mortality. They used data — death records, actually — from the California Department of Public Health and they examined those among Californians 18 to 65 years of age by occupational sector and occupation, and also by race and ethnicity.
During the pandemic, overall working-age adults experienced a 22% increase in mortality compared to historical periods, but the relative excess mortality was highest among food and agricultural workers — that was a 39% increase — transportation and logistics workers 28%, facilities 27%, and manufacturing workers 23%.
Among Latinos, there was a 36% increase in mortality, 59% among Latino food and agricultural workers. Black Californians saw a 28% increase in their mortality. Among that group, 36% increase for Black retail workers, and finally, Asian Californians experienced an 18% increase with a 40% increase among Asian healthcare workers, who represent quite a large number of nurse’s aides and so forth in the state. Clearly, what these authors conclude is, “Hello, folks. Maybe what we ought to be doing is targeting vaccination to these populations.”
Rick: Elizabeth, these working groups you described, we describe as essential workers. Oftentimes, as we’ve noted before, there’s a disproportionate number of minority individuals that work in these essential groups. Therefore, as you said, they are more likely to develop COVID infection because they are essential. They can’t work at home.
The authors here really have some great suggestions. They say, “If they’re essential workers, we ought to treat their lives as essential as well.” Since we can’t keep them at home to work, we need to do extra precautions for them. We need to provide free personal protective equipment. We need to have clearly-defined and enforceable safety protocols for them. We need to make sure they have testing available. We need to have generous sick policies so they’re not coming to work. Obviously, if they do come to work and sick, be able to enforce that as well. I was surprised that it wasn’t healthcare workers that were high on the list. It was all these other workers and especially minority populations.
Elizabeth: So would you agree with the strategy that we ought to be targeting these folks for vaccination?
Rick: Absolutely, Elizabeth. I would certainly make sure we targeted those high-risk individuals, but specifically in these essential worker positions.
Elizabeth: Let’s turn, then, to JAMA Network Open. This is a very concerning aspect of the pandemic. This is a study taking a look at what’s going on with mental health issues.
Rick: We had talked before about this. Early on, there was a survey — that was between April and June of 2020 — that looked at the mental health issues. It was clear that there was an increased risk of mental health disorder, but these authors said, “Well, listen. It may just be due to the early effects, and now that we’re well into this, we’re over kind of the acute traumatic phase, are we still seeing many of the mental health issues that were previously reported?”
They looked at a survey of adults aged 18 years and older, over 5,200 respondents. And what’s alarming is still the very high prevalence of mental health disorders. Overall, about 33% expressed anxiety or depression, about 30% had post-traumatic stress disorders, 15% indicated an increased use of substance abuse, and 12% had suicide ideation, that is, they thought seriously about killing themselves. Overall, 43% of individuals had one or more of these.
Now, the really alarming thing to me, Elizabeth? These disorders were extremely highly prevalent in those ages 18 to 24. Specifically, two-thirds of them had anxiety or depression, over 50% had traumatic stress disorder, about 20% really thought seriously about killing themselves, and that means 74% had one or more of these. That’s the population that seems particularly hard-hit, as opposed to individuals over the age of 65.
Elizabeth: Right, and I thought that was really interesting, was the mental health of those over 65 appears to be pretty robust.
Rick: Right. In fact, just 15% of those individuals over the age of 65 had one or more of these disorders, so this is a serious issue. It didn’t go away and it’s something that obviously we need to pay attention to.
Elizabeth: Our big issue, of course, is that we don’t have adequate populations of qualified mental healthcare workers to help to provide any interventions for these folks in spite of the fact that we’ve got telemedicine, which works pretty well in this circumstance.
Rick: As you’re aware, we’re straining the entire system and we need to be creative. Obviously, we can extend telehealth. We can do group therapy. We need to be screening for these individuals, especially in that high-risk group between the ages of 18 and 24, whether they’re in school — that is, in high school, or in college, or in junior college — or even in the workplace.
Elizabeth: If you were speculating on this, why would you say that it’s proven to be so particularly problematic for this 18 to 24-year-old-age group?
Rick: There are a lot of hypotheses. The older you are, the more tools you have in your tool chest with dealing with adversity, and younger individuals really haven’t had time to develop this; they have fewer life experiences, fewer cumulative issues they’ve had to deal with. What are your thoughts?
Elizabeth: I would agree with that. One thing we know is that life promises adversity, and that one of the things that is possible as a result of that is building resilience, is building coping strategies for those times that will happen. I guess that for many of these young adults this very well may be their first time that they’ve had to confront something as disruptive as the pandemic has been.
Rick: Elizabeth, for those of us that are older, this represents a shorter period of our lifespan. A year, it’s a significant amount but it’s one out of 50 or 60 or 70 years. But if they’re individuals that are 18 or 19 or 20 years old, this is still a major portion of their life. Again, without the resilience and the coping skills, it becomes particularly problematic.
Elizabeth: I guess the last thing I would add about that is that also, among that cohort, those interactions one to another, they’re still developing. They’re still establishing themselves as independent adults from their families and whatever their circumstances were when they were growing up. They’re also in that period of neuronal pruning.
Rick: All of that, and at a time where they ought to be establishing what they’re going to be for the next several decades, and for many of them that rug’s been pulled out from underneath them. I think the important thing is, it wasn’t just during the initial part. It’s still ongoing, and we need to be aware of it, and we need to address and try to meet those needs.
Elizabeth: Finally, let’s turn to The Lancet’s preprint server. We have looked at this particular vaccine before — that’s the AstraZeneca vaccine, and, in fact, we’ve looked at the data from this study before. What is noteworthy about looking at it this time is that what it clearly establishes — they had had that natural experiment where some people didn’t receive the second dose until further down the line, or even didn’t, and they have more data relative to that. They basically say if you get a longer prime boost interval they increase their vaccine efficacy to 82.4%, so that’s pretty good.
It also gives a window and I think that’s the important thing. One of my big concerns right now is getting as many people vaccinated as possible, and if this particular vaccine allows us to give so many more people that first dose without worrying too much that that second interval’s going to be longer, or even find out that it may be better, then that turns out to be a pretty important thing.
Rick: The AZ vaccination was initially just supposed to be a single dose, so the people that initially signed up for the study signed up for one dose. Then they realized that a second dose could help boost that. Well, there were some in that first dose that said, “Well, I’m not getting the second dose. That’s not what I agreed to.”
Then they recommended the second dose be given 4 weeks after the first dose. Unfortunately, they didn’t have enough vaccine available, so people received it between 4 and 12 weeks after the first dose. What they realized, as you said, is that you get about 70% efficacy with the first dose, but it boosted to about 84% with the second dose, but it’s even more effective if you do it at 12 weeks.
That means that when we have limited availability of the AstraZeneca vaccine, so we can give the first dose, but we don’t have to give the second dose until 12 weeks later. That allows the manufacturer to provide enough vaccine and for us to distribute it to more of the population initially and then following with their second dose later.
Elizabeth: One of the things that attracts me about this vaccine is that it’s an adenovirus vector and it replicates, and it produces antibodies against more than just the spike protein. I think that that’s a really important thing, especially now that we’ve got these variants popping up all over the place.
Rick: Right, and I’m sure we’ll report later on the efficacy with these variants. It looks like the Moderna and Pfizer vaccine are not quite as efficacious. But whether that translates into less effectiveness with regard to protecting against the variant viruses, we just don’t know at this particular point.
Elizabeth: OK. Why don’t we end, then, with the good news, that at least the AstraZeneca vaccine we could extend that interval and actually have greater efficacy and increased protection. I like that. How about you?
Rick: I agree. Wait a little bit longer and get a better response, that’s great news.
Elizabeth: On that note then, 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.