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Two case reports identify Guillain-Barré variants after SARS-CoV-2 vaccination
Guillain-Barré syndrome, a rare peripheral nerve disorder that can occur after certain types of viral and bacterial infections, has not to date been definitively linked to infection by SARS-CoV-2 or with vaccination against the virus, despite surveillance searching for such associations.
Spikes in Guillain-Barré syndrome incidence have previously, but rarely, been associated with outbreaks of other viral diseases, including Zika, but not with vaccination, except for a 1976-1977 swine influenza vaccine campaign in the United States that was seen associated with a slight elevation in risk, and was halted when that risk became known. Since then, all sorts of vaccines in the European Union and United States have come with warnings about Guillain-Barré syndrome in their package inserts – a fact that some Guillain-Barré syndrome experts lament as perpetuating the notion that vaccines cause Guillain-Barré syndrome.
Epidemiologic studies in the United Kingdom and Singapore did not detect increases in Guillain-Barré syndrome incidence during the COVID-19 pandemic. And as mass vaccination against COVID-19 got underway early this year, experts cautioned against the temptation to attribute incident Guillain-Barré syndrome cases following vaccination to SARS-CoV-2 without careful statistical and epidemiological analysis. Until now reports of Guillain-Barré syndrome have been scant: clinical trials of a viral vector vaccine developed by Johnson & Johnson saw one in the placebo arm and another in the intervention arm, while another case was reported following administration of a Pfizer mRNA SARS-Cov-2 vaccine.
Recent case reports
None of the patients had evidence of current SARS-CoV-2 infection.
From India, Boby V. Maramattom, MD, of Aster Medcity in Kochi, India, and colleagues reported on seven severe cases of Guillain-Barré syndrome occurring between 10 and 14 days after a first dose of the AstraZeneca vaccine. All but one of the patients were women, all had bilateral facial paresis, all progressed to areflexic quadriplegia, and six required respiratory support. Patients’ ages ranged from 43 to 70. Four developed other cranial neuropathies, including abducens palsy and trigeminal sensory nerve involvement, which are rare in reports of Guillain-Barré syndrome from India, Dr. Maramattom and colleagues noted.
The authors argued that their findings “should prompt all physicians to be vigilant in recognizing Guillain-Barré syndrome in patients who have received the AstraZeneca vaccine. While the risk per patient (5.8 per million) may be relatively low, our observations suggest that this clinically distinct [Guillain-Barré syndrome] variant is more severe than usual and may require mechanical ventilation.”
The U.K. cases, reported by Christopher Martin Allen, MD, and colleagues at Nottingham (England) University Hospitals NHS Trust, describe bifacial weakness and normal facial sensation in four men between 11 and 22 days after their first doses of the Astra-Zeneca vaccine. This type of facial palsy, the authors wrote, was unusual Guillain-Barré syndrome variant that one rapid review found in 3 of 42 European patients diagnosed with Guillain-Barré syndrome following SARS-CoV-2 infection.
Dr. Allen and colleagues acknowledged that causality could not be assumed from the temporal relationship of immunization to onset of bifacial weakness in their report, but argued that their findings argued for “robust postvaccination surveillance” and that “the report of a similar syndrome in the setting of SARS-CoV-2 infection suggests an immunologic response to the spike protein.” If the link is casual, they wrote, “it could be due to a cross-reactive immune response to the SARS-CoV-2 spike protein and components of the peripheral immune system.”
‘The jury is still out’
Asked for comment, neurologist Anthony Amato, MD, of Brigham and Women’s Hospital, Boston, said that he did not see what the two new studies add to what is already known. “Guillain-Barré syndrome has already been reported temporally following COVID-19 along with accompanying editorials that such temporal occurrences do not imply causation and there is a need for surveillance and epidemiological studies.”
Robert Lisak, MD, of Wayne State University, Detroit, and a longtime adviser to the GBS-CIDP Foundation International, commented that “the relationship between vaccines and association with Guillain-Barré syndrome continues to be controversial in part because Guillain-Barré syndrome, a rare disorder, has many reported associated illnesses including infections. Many vaccines have been implicated but with the probable exception of the ‘swine flu’ vaccine in the 1970s, most have not stood up to scrutiny.”
With SARS-Cov-2 infection and vaccines, “the jury is still out,” Dr. Lisak said. “The report from the U.K. is intriguing since they report several cases of an uncommon variant, but the cases from India seem to be more of the usual forms of Guillain-Barré syndrome.”
Dr. Lisak noted that, even if an association turns out to be valid, “we are talking about a very low incidence of Guillain-Barré syndrome associated with COVID-19 vaccines,” one that would not justify avoiding them because of a possible association with Guillain-Barré syndrome.
The GBS-CIDP Foundation, which supports research into Guillain-Barré syndrome and related diseases, has likewise stressed the low risk presented by SARS-CoV-2 vaccines, noting on its website that “the risk of death or long-term complications from COVID in adults still far exceeds the risk of any possible risk of Guillain-Barré syndrome by several orders of magnitude.”
None of the study authors reported financial conflicts of interest related to their research. Dr. Amato is an adviser to the pharmaceutical firms Alexion and Argenx, while Dr. Lisak has received research support or honoraria from Alexion, Novartis, Hoffmann–La Roche, and others.
Guillain-Barré syndrome, a rare peripheral nerve disorder that can occur after certain types of viral and bacterial infections, has not to date been definitively linked to infection by SARS-CoV-2 or with vaccination against the virus, despite surveillance searching for such associations.
Spikes in Guillain-Barré syndrome incidence have previously, but rarely, been associated with outbreaks of other viral diseases, including Zika, but not with vaccination, except for a 1976-1977 swine influenza vaccine campaign in the United States that was seen associated with a slight elevation in risk, and was halted when that risk became known. Since then, all sorts of vaccines in the European Union and United States have come with warnings about Guillain-Barré syndrome in their package inserts – a fact that some Guillain-Barré syndrome experts lament as perpetuating the notion that vaccines cause Guillain-Barré syndrome.
Epidemiologic studies in the United Kingdom and Singapore did not detect increases in Guillain-Barré syndrome incidence during the COVID-19 pandemic. And as mass vaccination against COVID-19 got underway early this year, experts cautioned against the temptation to attribute incident Guillain-Barré syndrome cases following vaccination to SARS-CoV-2 without careful statistical and epidemiological analysis. Until now reports of Guillain-Barré syndrome have been scant: clinical trials of a viral vector vaccine developed by Johnson & Johnson saw one in the placebo arm and another in the intervention arm, while another case was reported following administration of a Pfizer mRNA SARS-Cov-2 vaccine.
Recent case reports
None of the patients had evidence of current SARS-CoV-2 infection.
From India, Boby V. Maramattom, MD, of Aster Medcity in Kochi, India, and colleagues reported on seven severe cases of Guillain-Barré syndrome occurring between 10 and 14 days after a first dose of the AstraZeneca vaccine. All but one of the patients were women, all had bilateral facial paresis, all progressed to areflexic quadriplegia, and six required respiratory support. Patients’ ages ranged from 43 to 70. Four developed other cranial neuropathies, including abducens palsy and trigeminal sensory nerve involvement, which are rare in reports of Guillain-Barré syndrome from India, Dr. Maramattom and colleagues noted.
The authors argued that their findings “should prompt all physicians to be vigilant in recognizing Guillain-Barré syndrome in patients who have received the AstraZeneca vaccine. While the risk per patient (5.8 per million) may be relatively low, our observations suggest that this clinically distinct [Guillain-Barré syndrome] variant is more severe than usual and may require mechanical ventilation.”
The U.K. cases, reported by Christopher Martin Allen, MD, and colleagues at Nottingham (England) University Hospitals NHS Trust, describe bifacial weakness and normal facial sensation in four men between 11 and 22 days after their first doses of the Astra-Zeneca vaccine. This type of facial palsy, the authors wrote, was unusual Guillain-Barré syndrome variant that one rapid review found in 3 of 42 European patients diagnosed with Guillain-Barré syndrome following SARS-CoV-2 infection.
Dr. Allen and colleagues acknowledged that causality could not be assumed from the temporal relationship of immunization to onset of bifacial weakness in their report, but argued that their findings argued for “robust postvaccination surveillance” and that “the report of a similar syndrome in the setting of SARS-CoV-2 infection suggests an immunologic response to the spike protein.” If the link is casual, they wrote, “it could be due to a cross-reactive immune response to the SARS-CoV-2 spike protein and components of the peripheral immune system.”
‘The jury is still out’
Asked for comment, neurologist Anthony Amato, MD, of Brigham and Women’s Hospital, Boston, said that he did not see what the two new studies add to what is already known. “Guillain-Barré syndrome has already been reported temporally following COVID-19 along with accompanying editorials that such temporal occurrences do not imply causation and there is a need for surveillance and epidemiological studies.”
Robert Lisak, MD, of Wayne State University, Detroit, and a longtime adviser to the GBS-CIDP Foundation International, commented that “the relationship between vaccines and association with Guillain-Barré syndrome continues to be controversial in part because Guillain-Barré syndrome, a rare disorder, has many reported associated illnesses including infections. Many vaccines have been implicated but with the probable exception of the ‘swine flu’ vaccine in the 1970s, most have not stood up to scrutiny.”
With SARS-Cov-2 infection and vaccines, “the jury is still out,” Dr. Lisak said. “The report from the U.K. is intriguing since they report several cases of an uncommon variant, but the cases from India seem to be more of the usual forms of Guillain-Barré syndrome.”
Dr. Lisak noted that, even if an association turns out to be valid, “we are talking about a very low incidence of Guillain-Barré syndrome associated with COVID-19 vaccines,” one that would not justify avoiding them because of a possible association with Guillain-Barré syndrome.
The GBS-CIDP Foundation, which supports research into Guillain-Barré syndrome and related diseases, has likewise stressed the low risk presented by SARS-CoV-2 vaccines, noting on its website that “the risk of death or long-term complications from COVID in adults still far exceeds the risk of any possible risk of Guillain-Barré syndrome by several orders of magnitude.”
None of the study authors reported financial conflicts of interest related to their research. Dr. Amato is an adviser to the pharmaceutical firms Alexion and Argenx, while Dr. Lisak has received research support or honoraria from Alexion, Novartis, Hoffmann–La Roche, and others.
Guillain-Barré syndrome, a rare peripheral nerve disorder that can occur after certain types of viral and bacterial infections, has not to date been definitively linked to infection by SARS-CoV-2 or with vaccination against the virus, despite surveillance searching for such associations.
Spikes in Guillain-Barré syndrome incidence have previously, but rarely, been associated with outbreaks of other viral diseases, including Zika, but not with vaccination, except for a 1976-1977 swine influenza vaccine campaign in the United States that was seen associated with a slight elevation in risk, and was halted when that risk became known. Since then, all sorts of vaccines in the European Union and United States have come with warnings about Guillain-Barré syndrome in their package inserts – a fact that some Guillain-Barré syndrome experts lament as perpetuating the notion that vaccines cause Guillain-Barré syndrome.
Epidemiologic studies in the United Kingdom and Singapore did not detect increases in Guillain-Barré syndrome incidence during the COVID-19 pandemic. And as mass vaccination against COVID-19 got underway early this year, experts cautioned against the temptation to attribute incident Guillain-Barré syndrome cases following vaccination to SARS-CoV-2 without careful statistical and epidemiological analysis. Until now reports of Guillain-Barré syndrome have been scant: clinical trials of a viral vector vaccine developed by Johnson & Johnson saw one in the placebo arm and another in the intervention arm, while another case was reported following administration of a Pfizer mRNA SARS-Cov-2 vaccine.
Recent case reports
None of the patients had evidence of current SARS-CoV-2 infection.
From India, Boby V. Maramattom, MD, of Aster Medcity in Kochi, India, and colleagues reported on seven severe cases of Guillain-Barré syndrome occurring between 10 and 14 days after a first dose of the AstraZeneca vaccine. All but one of the patients were women, all had bilateral facial paresis, all progressed to areflexic quadriplegia, and six required respiratory support. Patients’ ages ranged from 43 to 70. Four developed other cranial neuropathies, including abducens palsy and trigeminal sensory nerve involvement, which are rare in reports of Guillain-Barré syndrome from India, Dr. Maramattom and colleagues noted.
The authors argued that their findings “should prompt all physicians to be vigilant in recognizing Guillain-Barré syndrome in patients who have received the AstraZeneca vaccine. While the risk per patient (5.8 per million) may be relatively low, our observations suggest that this clinically distinct [Guillain-Barré syndrome] variant is more severe than usual and may require mechanical ventilation.”
The U.K. cases, reported by Christopher Martin Allen, MD, and colleagues at Nottingham (England) University Hospitals NHS Trust, describe bifacial weakness and normal facial sensation in four men between 11 and 22 days after their first doses of the Astra-Zeneca vaccine. This type of facial palsy, the authors wrote, was unusual Guillain-Barré syndrome variant that one rapid review found in 3 of 42 European patients diagnosed with Guillain-Barré syndrome following SARS-CoV-2 infection.
Dr. Allen and colleagues acknowledged that causality could not be assumed from the temporal relationship of immunization to onset of bifacial weakness in their report, but argued that their findings argued for “robust postvaccination surveillance” and that “the report of a similar syndrome in the setting of SARS-CoV-2 infection suggests an immunologic response to the spike protein.” If the link is casual, they wrote, “it could be due to a cross-reactive immune response to the SARS-CoV-2 spike protein and components of the peripheral immune system.”
‘The jury is still out’
Asked for comment, neurologist Anthony Amato, MD, of Brigham and Women’s Hospital, Boston, said that he did not see what the two new studies add to what is already known. “Guillain-Barré syndrome has already been reported temporally following COVID-19 along with accompanying editorials that such temporal occurrences do not imply causation and there is a need for surveillance and epidemiological studies.”
Robert Lisak, MD, of Wayne State University, Detroit, and a longtime adviser to the GBS-CIDP Foundation International, commented that “the relationship between vaccines and association with Guillain-Barré syndrome continues to be controversial in part because Guillain-Barré syndrome, a rare disorder, has many reported associated illnesses including infections. Many vaccines have been implicated but with the probable exception of the ‘swine flu’ vaccine in the 1970s, most have not stood up to scrutiny.”
With SARS-Cov-2 infection and vaccines, “the jury is still out,” Dr. Lisak said. “The report from the U.K. is intriguing since they report several cases of an uncommon variant, but the cases from India seem to be more of the usual forms of Guillain-Barré syndrome.”
Dr. Lisak noted that, even if an association turns out to be valid, “we are talking about a very low incidence of Guillain-Barré syndrome associated with COVID-19 vaccines,” one that would not justify avoiding them because of a possible association with Guillain-Barré syndrome.
The GBS-CIDP Foundation, which supports research into Guillain-Barré syndrome and related diseases, has likewise stressed the low risk presented by SARS-CoV-2 vaccines, noting on its website that “the risk of death or long-term complications from COVID in adults still far exceeds the risk of any possible risk of Guillain-Barré syndrome by several orders of magnitude.”
None of the study authors reported financial conflicts of interest related to their research. Dr. Amato is an adviser to the pharmaceutical firms Alexion and Argenx, while Dr. Lisak has received research support or honoraria from Alexion, Novartis, Hoffmann–La Roche, and others.
FROM ANNALS OF NEUROLOGY
The pandemic hurt patients with liver disease in many ways
The COVID-19 pandemic has worsened the health of patients with liver disease worldwide, researchers say.
Not only does liver disease make people more vulnerable to the virus that causes COVID-19, precautions to prevent its spread have delayed health care and worsened alcohol abuse.
At this year’s virtual International Liver Congress (ILC) 2021, experts from around the world documented this toll on their patients.
Surgeons have seen a surge in patients needing transplants because of alcoholic liver disease, the campaign to snuff out hepatitis C slowed down, and procedures such as endoscopy and ultrasound exams postponed, said Mario Mondelli, MD, PhD, a professor and consultant physician of infectious diseases at the University of Pavia, Italy.
“We were able to ensure only emergency treatments, not routine surveillance,” he said in an interview.
Of 1,994 people with chronic liver disease who responded to a survey through the Global Liver Registry, 11% reported that the pandemic had affected their liver health.
This proportion was not statistically different for the 165 patients (8.2%) who had been diagnosed with COVID-19 compared with those who had not. But many of those who had been diagnosed with COVID-19 reported that it severely affected them. They reported worse overall heath, more mental illness, and greater need for supportive service than those who evaded the virus. Thirty-three respondents (20.8%) were hospitalized.
The global effort to eradicate hepatitis C slowed as a result of the pandemic. Already in 2019, the United States was behind the World Health Organization schedule for eliminating this virus. In 2020, it slipped further, with 25% fewer patients starting treatment for hepatitis C than in 2019, according to researchers at the U.S. Centers for Disease Control and Prevention.
Similar delays in eliminating hepatitis C occurred around the world, Dr. Mondelli said, noting that the majority of countries will not be able to reach the WHO objectives.
One striking result of the pandemic was an uptick of patients needing liver transplants as a result of alcoholic liver disease, said George Cholankeril, MD, a liver transplant surgeon at Baylor College of Medicine, Houston.
Before the pandemic, he and his colleagues had noted an increase in the number of people needing liver transplants because of alcohol abuse. During the pandemic, that trend accelerated.
They defined the pre-COVID era as June 1, 2019, to Feb. 29, 2020, and the COVID era as after April 1, 2020. In the COVID era, alcoholic liver disease accounted for 40% of patients whom the hospital put on its list for liver transplant. Hepatitis C and nonalcoholic fatty liver disease combined accounted for only 36%.
The change has resulted in part from the effectiveness of hepatitis C treatments, which have reduced the number of patients with livers damaged by that virus. But the change also resulted from the increased severity of illness in the patients with alcoholic liver disease, Dr. Cholankeril said in an interview. Overall, Model for End-Stage Liver Disease scores – which are used to predict survival – worsened for patients with alcoholic liver disease but remained the same for patients with nonalcoholic liver disease.
In the pre-COVID era, patients with alcoholic liver disease had a 10% higher chance for undergoing transplant, compared with patients with nonalcoholic liver disease. In the COVID era, they had a 50% higher chance, a statistically significant change (P < .001).
The finding parallels those of other studies that have shown a spike in consults for alcohol-related gastrointestinal and liver diseases, as reported by this news organization.
“We feel that the increase in alcoholic hepatitis is possibly from binge drinking and alcoholic consumption during the pandemic,” said Dr. Cholankeril. “Anecdotally, I can’t tell you how many patients say that the video meetings for Alcoholic Anonymous just don’t work. It’s not the same as in person. They don’t feel that they’re getting the support that they need.”
In Europe, fewer of the people who need liver transplants may be receiving them, said Dr. Mondelli.
“There are several papers indicating, particularly in Italy, in France, and in the United Kingdom, that during the pandemic, the offer for organs significantly declined,” he said.
Other studies have shown increases in mortality from liver disease during the pandemic, Dr. Mondelli said. The same is true of myocardial infarction, cancer, and most other life-threatening illnesses, he pointed out.
“Because of the enormous tsunami that has affected hospital services during the peaks of the pandemic, there has been an increase in deceased patients from a variety of other diseases, not only liver disease,” he said.
But Dr. Mondelli also added that physicians had improved in their ability to safely care for their patients while protecting themselves over the course of the pandemic.
Dr. Mondelli and Dr. Cholankeril have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
The COVID-19 pandemic has worsened the health of patients with liver disease worldwide, researchers say.
Not only does liver disease make people more vulnerable to the virus that causes COVID-19, precautions to prevent its spread have delayed health care and worsened alcohol abuse.
At this year’s virtual International Liver Congress (ILC) 2021, experts from around the world documented this toll on their patients.
Surgeons have seen a surge in patients needing transplants because of alcoholic liver disease, the campaign to snuff out hepatitis C slowed down, and procedures such as endoscopy and ultrasound exams postponed, said Mario Mondelli, MD, PhD, a professor and consultant physician of infectious diseases at the University of Pavia, Italy.
“We were able to ensure only emergency treatments, not routine surveillance,” he said in an interview.
Of 1,994 people with chronic liver disease who responded to a survey through the Global Liver Registry, 11% reported that the pandemic had affected their liver health.
This proportion was not statistically different for the 165 patients (8.2%) who had been diagnosed with COVID-19 compared with those who had not. But many of those who had been diagnosed with COVID-19 reported that it severely affected them. They reported worse overall heath, more mental illness, and greater need for supportive service than those who evaded the virus. Thirty-three respondents (20.8%) were hospitalized.
The global effort to eradicate hepatitis C slowed as a result of the pandemic. Already in 2019, the United States was behind the World Health Organization schedule for eliminating this virus. In 2020, it slipped further, with 25% fewer patients starting treatment for hepatitis C than in 2019, according to researchers at the U.S. Centers for Disease Control and Prevention.
Similar delays in eliminating hepatitis C occurred around the world, Dr. Mondelli said, noting that the majority of countries will not be able to reach the WHO objectives.
One striking result of the pandemic was an uptick of patients needing liver transplants as a result of alcoholic liver disease, said George Cholankeril, MD, a liver transplant surgeon at Baylor College of Medicine, Houston.
Before the pandemic, he and his colleagues had noted an increase in the number of people needing liver transplants because of alcohol abuse. During the pandemic, that trend accelerated.
They defined the pre-COVID era as June 1, 2019, to Feb. 29, 2020, and the COVID era as after April 1, 2020. In the COVID era, alcoholic liver disease accounted for 40% of patients whom the hospital put on its list for liver transplant. Hepatitis C and nonalcoholic fatty liver disease combined accounted for only 36%.
The change has resulted in part from the effectiveness of hepatitis C treatments, which have reduced the number of patients with livers damaged by that virus. But the change also resulted from the increased severity of illness in the patients with alcoholic liver disease, Dr. Cholankeril said in an interview. Overall, Model for End-Stage Liver Disease scores – which are used to predict survival – worsened for patients with alcoholic liver disease but remained the same for patients with nonalcoholic liver disease.
In the pre-COVID era, patients with alcoholic liver disease had a 10% higher chance for undergoing transplant, compared with patients with nonalcoholic liver disease. In the COVID era, they had a 50% higher chance, a statistically significant change (P < .001).
The finding parallels those of other studies that have shown a spike in consults for alcohol-related gastrointestinal and liver diseases, as reported by this news organization.
“We feel that the increase in alcoholic hepatitis is possibly from binge drinking and alcoholic consumption during the pandemic,” said Dr. Cholankeril. “Anecdotally, I can’t tell you how many patients say that the video meetings for Alcoholic Anonymous just don’t work. It’s not the same as in person. They don’t feel that they’re getting the support that they need.”
In Europe, fewer of the people who need liver transplants may be receiving them, said Dr. Mondelli.
“There are several papers indicating, particularly in Italy, in France, and in the United Kingdom, that during the pandemic, the offer for organs significantly declined,” he said.
Other studies have shown increases in mortality from liver disease during the pandemic, Dr. Mondelli said. The same is true of myocardial infarction, cancer, and most other life-threatening illnesses, he pointed out.
“Because of the enormous tsunami that has affected hospital services during the peaks of the pandemic, there has been an increase in deceased patients from a variety of other diseases, not only liver disease,” he said.
But Dr. Mondelli also added that physicians had improved in their ability to safely care for their patients while protecting themselves over the course of the pandemic.
Dr. Mondelli and Dr. Cholankeril have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
The COVID-19 pandemic has worsened the health of patients with liver disease worldwide, researchers say.
Not only does liver disease make people more vulnerable to the virus that causes COVID-19, precautions to prevent its spread have delayed health care and worsened alcohol abuse.
At this year’s virtual International Liver Congress (ILC) 2021, experts from around the world documented this toll on their patients.
Surgeons have seen a surge in patients needing transplants because of alcoholic liver disease, the campaign to snuff out hepatitis C slowed down, and procedures such as endoscopy and ultrasound exams postponed, said Mario Mondelli, MD, PhD, a professor and consultant physician of infectious diseases at the University of Pavia, Italy.
“We were able to ensure only emergency treatments, not routine surveillance,” he said in an interview.
Of 1,994 people with chronic liver disease who responded to a survey through the Global Liver Registry, 11% reported that the pandemic had affected their liver health.
This proportion was not statistically different for the 165 patients (8.2%) who had been diagnosed with COVID-19 compared with those who had not. But many of those who had been diagnosed with COVID-19 reported that it severely affected them. They reported worse overall heath, more mental illness, and greater need for supportive service than those who evaded the virus. Thirty-three respondents (20.8%) were hospitalized.
The global effort to eradicate hepatitis C slowed as a result of the pandemic. Already in 2019, the United States was behind the World Health Organization schedule for eliminating this virus. In 2020, it slipped further, with 25% fewer patients starting treatment for hepatitis C than in 2019, according to researchers at the U.S. Centers for Disease Control and Prevention.
Similar delays in eliminating hepatitis C occurred around the world, Dr. Mondelli said, noting that the majority of countries will not be able to reach the WHO objectives.
One striking result of the pandemic was an uptick of patients needing liver transplants as a result of alcoholic liver disease, said George Cholankeril, MD, a liver transplant surgeon at Baylor College of Medicine, Houston.
Before the pandemic, he and his colleagues had noted an increase in the number of people needing liver transplants because of alcohol abuse. During the pandemic, that trend accelerated.
They defined the pre-COVID era as June 1, 2019, to Feb. 29, 2020, and the COVID era as after April 1, 2020. In the COVID era, alcoholic liver disease accounted for 40% of patients whom the hospital put on its list for liver transplant. Hepatitis C and nonalcoholic fatty liver disease combined accounted for only 36%.
The change has resulted in part from the effectiveness of hepatitis C treatments, which have reduced the number of patients with livers damaged by that virus. But the change also resulted from the increased severity of illness in the patients with alcoholic liver disease, Dr. Cholankeril said in an interview. Overall, Model for End-Stage Liver Disease scores – which are used to predict survival – worsened for patients with alcoholic liver disease but remained the same for patients with nonalcoholic liver disease.
In the pre-COVID era, patients with alcoholic liver disease had a 10% higher chance for undergoing transplant, compared with patients with nonalcoholic liver disease. In the COVID era, they had a 50% higher chance, a statistically significant change (P < .001).
The finding parallels those of other studies that have shown a spike in consults for alcohol-related gastrointestinal and liver diseases, as reported by this news organization.
“We feel that the increase in alcoholic hepatitis is possibly from binge drinking and alcoholic consumption during the pandemic,” said Dr. Cholankeril. “Anecdotally, I can’t tell you how many patients say that the video meetings for Alcoholic Anonymous just don’t work. It’s not the same as in person. They don’t feel that they’re getting the support that they need.”
In Europe, fewer of the people who need liver transplants may be receiving them, said Dr. Mondelli.
“There are several papers indicating, particularly in Italy, in France, and in the United Kingdom, that during the pandemic, the offer for organs significantly declined,” he said.
Other studies have shown increases in mortality from liver disease during the pandemic, Dr. Mondelli said. The same is true of myocardial infarction, cancer, and most other life-threatening illnesses, he pointed out.
“Because of the enormous tsunami that has affected hospital services during the peaks of the pandemic, there has been an increase in deceased patients from a variety of other diseases, not only liver disease,” he said.
But Dr. Mondelli also added that physicians had improved in their ability to safely care for their patients while protecting themselves over the course of the pandemic.
Dr. Mondelli and Dr. Cholankeril have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Almost all U.S. COVID-19 deaths now in the unvaccinated
If you, a friend, or a loved one remain unvaccinated against COVID-19 at this point – for whatever reason – you are at higher risk of dying if you become infected.
That’s the conclusion of a new report released by the Associated Press looking at COVID-19 deaths during May 2021.
Of more than 18,000 people who died from COVID-19, for example, only about 150 were fully vaccinated. That’s less than 1%.
“Recently, I was working in the emergency room [and] I saw a 21-year-old African American who came in with shortness of breath,” said Vino K. Palli, MD, MPH, a physician specializing in emergency medicine, internal medicine, and urgent care.
The patient rapidly deteriorated and required intubation and ventilation. She was transferred to a specialized hospital for possible extracorporeal membrane oxygenation (ECMO) treatment.
“This patient was unvaccinated, along with her entire family. This would have been easily preventable,” added Dr. Palli, who is also founder and CEO of MiDoctor Urgent Care in New York City.
“Vaccine misinformation, compounded with vaccine inertia and vaccine access, have contributed to this,” he added. “Even though we have a surplus amount of vaccines at this time, we are only seeing 50% to 55% of completely vaccinated patients.”
Authors of the Associated Press report also acknowledge that some people who are fully vaccinated can get a breakthrough infection. These occurred in fewer than 1,200 of more than 853,000 people hospitalized for COVID-19 in May, or about 0.1%.
The Associated Press came up with these numbers using data from the Centers for Disease Control and Prevention. The CDC tracks the numbers of cases, hospitalizations, and deaths but does not breakdown rates by vaccination status.
Stronger argument for vaccination?
“The fact that only 0.8% of COVID-19 deaths are in the fully vaccinated should persuade those people still hesitant about vaccination,” said Hugh Cassiere, MD, medical director of Respiratory Therapy Services at North Shore University Hospital in Manhasset, New York.
Stuart C. Ray, MD, professor of medicine and oncology in the Division of Infectious Diseases at Johns Hopkins University, Baltimore, agreed. “It seems compelling, even for skeptics, that unvaccinated people represent 99% of those now dying from COVID-19 when they represent less than 50% of the adult population in the United States.”
The findings from the study could be more persuasive than previous arguments made in favor of immunization, Dr. Ray said. “These recent findings of striking reductions in risk of death in the vaccinated are more directly attributable and harder to ignore or dismiss.”
Brian Labus, PhD, MPH, of the University of Nevada Las Vegas (UNLV) is less convinced. “While this might change some peoples’ minds, it probably won’t make a major difference. People have many different reasons for not getting vaccinated, and this is only one of the things they consider.”
The study adds information that was not available before, said Dr. Labus, assistant professor in the Department of Epidemiology and Biostatistics at the UNLV School of Public Health. “We study the vaccine under tightly controlled, ideal conditions. This is the evidence that it works as well in the real world as it did in the trials, and that is what is most important in implementing a vaccination program,” added Dr. Labus.
“The scientific data has honed in on one thing: Vaccines are effective in preventing hospitalizations, ICU admissions, ventilations, and deaths,” agreed Dr. Palli.
“We now know that almost all deaths occurred in patients who were not vaccinated. We also know that all vaccines are effective against various strains that are in circulation right now, including the Delta variant, which is rapidly spreading,” Dr. Palli said.
Dr. Cassiere pointed out that the unvaccinated are not only at higher risk of developing COVID-19 but also of spreading, being hospitalized for, and dying from the infection. Avoiding “long hauler” symptoms is another argument in favor of immunization, he added.
As of June 28, the CDC reports that 63% of Americans 12 years and older have received at least one dose of a COVID-19 vaccine, and 54% are fully vaccinated.
Worldwide worry?
Although overall rates of U.S. COVID-19 hospitalizations and deaths are down, the outlook may not remain as encouraging. “I hope I’m wrong about this, but I anticipate that the coming fall and winter will bring increasingly localized versions of similar findings – severe disease and death due to SARS-CoV-2 infection in regions or groups with lower vaccination rates,” Dr. Ray said.
There could be a silver lining, he added: “If this unfortunate surge occurs, the health and economic consequences seem likely to erode much of the remaining hesitancy regarding vaccination.”
The rise of more infectious SARS-CoV-2 variants, such as the Delta variant, could also throw a wrench in controlling COVID-19. “This isn’t just a domestic issue,” Dr. Ray said. “We have learned that the world is a small place in pandemic times.”
The Associated Press investigators state that their findings support the high efficacy of the vaccine. Also, given the current widespread availability of COVID-19 vaccines in the United States, they believe many of the COVID-19 deaths now occurring are preventable.
Public health measures should have continued longer to protect unvaccinated individuals, especially Black Americans, Hispanic Americans, and other minorities, Dr. Palli said. “Only time will tell if re-opening and abandoning all public health measures by the CDC was premature.”
A version of this article first appeared on Medscape.com.
If you, a friend, or a loved one remain unvaccinated against COVID-19 at this point – for whatever reason – you are at higher risk of dying if you become infected.
That’s the conclusion of a new report released by the Associated Press looking at COVID-19 deaths during May 2021.
Of more than 18,000 people who died from COVID-19, for example, only about 150 were fully vaccinated. That’s less than 1%.
“Recently, I was working in the emergency room [and] I saw a 21-year-old African American who came in with shortness of breath,” said Vino K. Palli, MD, MPH, a physician specializing in emergency medicine, internal medicine, and urgent care.
The patient rapidly deteriorated and required intubation and ventilation. She was transferred to a specialized hospital for possible extracorporeal membrane oxygenation (ECMO) treatment.
“This patient was unvaccinated, along with her entire family. This would have been easily preventable,” added Dr. Palli, who is also founder and CEO of MiDoctor Urgent Care in New York City.
“Vaccine misinformation, compounded with vaccine inertia and vaccine access, have contributed to this,” he added. “Even though we have a surplus amount of vaccines at this time, we are only seeing 50% to 55% of completely vaccinated patients.”
Authors of the Associated Press report also acknowledge that some people who are fully vaccinated can get a breakthrough infection. These occurred in fewer than 1,200 of more than 853,000 people hospitalized for COVID-19 in May, or about 0.1%.
The Associated Press came up with these numbers using data from the Centers for Disease Control and Prevention. The CDC tracks the numbers of cases, hospitalizations, and deaths but does not breakdown rates by vaccination status.
Stronger argument for vaccination?
“The fact that only 0.8% of COVID-19 deaths are in the fully vaccinated should persuade those people still hesitant about vaccination,” said Hugh Cassiere, MD, medical director of Respiratory Therapy Services at North Shore University Hospital in Manhasset, New York.
Stuart C. Ray, MD, professor of medicine and oncology in the Division of Infectious Diseases at Johns Hopkins University, Baltimore, agreed. “It seems compelling, even for skeptics, that unvaccinated people represent 99% of those now dying from COVID-19 when they represent less than 50% of the adult population in the United States.”
The findings from the study could be more persuasive than previous arguments made in favor of immunization, Dr. Ray said. “These recent findings of striking reductions in risk of death in the vaccinated are more directly attributable and harder to ignore or dismiss.”
Brian Labus, PhD, MPH, of the University of Nevada Las Vegas (UNLV) is less convinced. “While this might change some peoples’ minds, it probably won’t make a major difference. People have many different reasons for not getting vaccinated, and this is only one of the things they consider.”
The study adds information that was not available before, said Dr. Labus, assistant professor in the Department of Epidemiology and Biostatistics at the UNLV School of Public Health. “We study the vaccine under tightly controlled, ideal conditions. This is the evidence that it works as well in the real world as it did in the trials, and that is what is most important in implementing a vaccination program,” added Dr. Labus.
“The scientific data has honed in on one thing: Vaccines are effective in preventing hospitalizations, ICU admissions, ventilations, and deaths,” agreed Dr. Palli.
“We now know that almost all deaths occurred in patients who were not vaccinated. We also know that all vaccines are effective against various strains that are in circulation right now, including the Delta variant, which is rapidly spreading,” Dr. Palli said.
Dr. Cassiere pointed out that the unvaccinated are not only at higher risk of developing COVID-19 but also of spreading, being hospitalized for, and dying from the infection. Avoiding “long hauler” symptoms is another argument in favor of immunization, he added.
As of June 28, the CDC reports that 63% of Americans 12 years and older have received at least one dose of a COVID-19 vaccine, and 54% are fully vaccinated.
Worldwide worry?
Although overall rates of U.S. COVID-19 hospitalizations and deaths are down, the outlook may not remain as encouraging. “I hope I’m wrong about this, but I anticipate that the coming fall and winter will bring increasingly localized versions of similar findings – severe disease and death due to SARS-CoV-2 infection in regions or groups with lower vaccination rates,” Dr. Ray said.
There could be a silver lining, he added: “If this unfortunate surge occurs, the health and economic consequences seem likely to erode much of the remaining hesitancy regarding vaccination.”
The rise of more infectious SARS-CoV-2 variants, such as the Delta variant, could also throw a wrench in controlling COVID-19. “This isn’t just a domestic issue,” Dr. Ray said. “We have learned that the world is a small place in pandemic times.”
The Associated Press investigators state that their findings support the high efficacy of the vaccine. Also, given the current widespread availability of COVID-19 vaccines in the United States, they believe many of the COVID-19 deaths now occurring are preventable.
Public health measures should have continued longer to protect unvaccinated individuals, especially Black Americans, Hispanic Americans, and other minorities, Dr. Palli said. “Only time will tell if re-opening and abandoning all public health measures by the CDC was premature.”
A version of this article first appeared on Medscape.com.
If you, a friend, or a loved one remain unvaccinated against COVID-19 at this point – for whatever reason – you are at higher risk of dying if you become infected.
That’s the conclusion of a new report released by the Associated Press looking at COVID-19 deaths during May 2021.
Of more than 18,000 people who died from COVID-19, for example, only about 150 were fully vaccinated. That’s less than 1%.
“Recently, I was working in the emergency room [and] I saw a 21-year-old African American who came in with shortness of breath,” said Vino K. Palli, MD, MPH, a physician specializing in emergency medicine, internal medicine, and urgent care.
The patient rapidly deteriorated and required intubation and ventilation. She was transferred to a specialized hospital for possible extracorporeal membrane oxygenation (ECMO) treatment.
“This patient was unvaccinated, along with her entire family. This would have been easily preventable,” added Dr. Palli, who is also founder and CEO of MiDoctor Urgent Care in New York City.
“Vaccine misinformation, compounded with vaccine inertia and vaccine access, have contributed to this,” he added. “Even though we have a surplus amount of vaccines at this time, we are only seeing 50% to 55% of completely vaccinated patients.”
Authors of the Associated Press report also acknowledge that some people who are fully vaccinated can get a breakthrough infection. These occurred in fewer than 1,200 of more than 853,000 people hospitalized for COVID-19 in May, or about 0.1%.
The Associated Press came up with these numbers using data from the Centers for Disease Control and Prevention. The CDC tracks the numbers of cases, hospitalizations, and deaths but does not breakdown rates by vaccination status.
Stronger argument for vaccination?
“The fact that only 0.8% of COVID-19 deaths are in the fully vaccinated should persuade those people still hesitant about vaccination,” said Hugh Cassiere, MD, medical director of Respiratory Therapy Services at North Shore University Hospital in Manhasset, New York.
Stuart C. Ray, MD, professor of medicine and oncology in the Division of Infectious Diseases at Johns Hopkins University, Baltimore, agreed. “It seems compelling, even for skeptics, that unvaccinated people represent 99% of those now dying from COVID-19 when they represent less than 50% of the adult population in the United States.”
The findings from the study could be more persuasive than previous arguments made in favor of immunization, Dr. Ray said. “These recent findings of striking reductions in risk of death in the vaccinated are more directly attributable and harder to ignore or dismiss.”
Brian Labus, PhD, MPH, of the University of Nevada Las Vegas (UNLV) is less convinced. “While this might change some peoples’ minds, it probably won’t make a major difference. People have many different reasons for not getting vaccinated, and this is only one of the things they consider.”
The study adds information that was not available before, said Dr. Labus, assistant professor in the Department of Epidemiology and Biostatistics at the UNLV School of Public Health. “We study the vaccine under tightly controlled, ideal conditions. This is the evidence that it works as well in the real world as it did in the trials, and that is what is most important in implementing a vaccination program,” added Dr. Labus.
“The scientific data has honed in on one thing: Vaccines are effective in preventing hospitalizations, ICU admissions, ventilations, and deaths,” agreed Dr. Palli.
“We now know that almost all deaths occurred in patients who were not vaccinated. We also know that all vaccines are effective against various strains that are in circulation right now, including the Delta variant, which is rapidly spreading,” Dr. Palli said.
Dr. Cassiere pointed out that the unvaccinated are not only at higher risk of developing COVID-19 but also of spreading, being hospitalized for, and dying from the infection. Avoiding “long hauler” symptoms is another argument in favor of immunization, he added.
As of June 28, the CDC reports that 63% of Americans 12 years and older have received at least one dose of a COVID-19 vaccine, and 54% are fully vaccinated.
Worldwide worry?
Although overall rates of U.S. COVID-19 hospitalizations and deaths are down, the outlook may not remain as encouraging. “I hope I’m wrong about this, but I anticipate that the coming fall and winter will bring increasingly localized versions of similar findings – severe disease and death due to SARS-CoV-2 infection in regions or groups with lower vaccination rates,” Dr. Ray said.
There could be a silver lining, he added: “If this unfortunate surge occurs, the health and economic consequences seem likely to erode much of the remaining hesitancy regarding vaccination.”
The rise of more infectious SARS-CoV-2 variants, such as the Delta variant, could also throw a wrench in controlling COVID-19. “This isn’t just a domestic issue,” Dr. Ray said. “We have learned that the world is a small place in pandemic times.”
The Associated Press investigators state that their findings support the high efficacy of the vaccine. Also, given the current widespread availability of COVID-19 vaccines in the United States, they believe many of the COVID-19 deaths now occurring are preventable.
Public health measures should have continued longer to protect unvaccinated individuals, especially Black Americans, Hispanic Americans, and other minorities, Dr. Palli said. “Only time will tell if re-opening and abandoning all public health measures by the CDC was premature.”
A version of this article first appeared on Medscape.com.
New COVID-19 vaccinations decline again in 12- to 15-year-olds
Even though less than 21% of all children aged 12-15 years are fully vaccinated against COVID-19, the number seeking first vaccinations continues to decline, according to data from the Centers for Disease Control and Prevention.
and 462,000 during the week ending June 14. Collectively, 30.2% of 12- to 15-year-olds have gotten at least one dose of vaccine so far and 20.7% are now fully vaccinated, the CDC said on its COVID Data Tracker site.
Among children aged 16-17 years, who were able to start the vaccination process earlier, 42.9% have received at least one dose and 34.0% have completed the COVID-19 vaccine regimen. Vaccine initiation – measured as the proportion of all individuals getting a first shot over the previous 2 weeks – has been consistently around 4.8% during the month of June for this age group but has dropped from 17.9% on June 7 to 14.3% on June 28 for those aged 12-15, the CDC data show.
Looking at the same measure for vaccine completion, 16.7% of all those who reached full vaccination status in the 14 days ending June 28 were 12- to 15-years-olds, down from 21.5% on June 21 and 19.6% on June 14. The numbers for those aged 15-16 were, respectively, 4.6%, 4.5%, and 4.2%, the CDC reported.
Fortunately, in the wake of recent vaccination trends, new cases of COVID-19 in children were down to their lowest level – just 8,447 for the week ending June 24 – since May of 2020, according to a new report from the American Academy of Pediatrics and the Children’s Hospital Association.
New cases had been well over 15,000 the previous week (June 17), following weeks of 14,000 (June 10) and 16,000 (June 3) new cases, so the latest drop down to just four digits represents a 1-week decline of over 46% in the 49 states (excluding New York) that are reporting age distribution, along with the District of Columbia, New York City, Puerto Rico, and Guam.
The cumulative number of child COVID-19 cases in those jurisdictions is about 4.03 million since the beginning of the pandemic, which represents 14.2% of all cases in the United States. At the state level, the cumulative rate of cases in children is highest in Vermont (22.7%) and lowest in Florida (8.9%), which uses an age range of 0-14 years for children, compared with 0-17 or 0-19 for most states, the AAP and CHA said.
Severe illness has been rare in children, which is reflected in the proportion of children among all hospitalizations, 2.2% in 24 jurisdictions, and the proportion of deaths, 0.06% in 46 jurisdictions, since the start of the pandemic, the AAP and CHA said, with a total of 336 COVID-19–related deaths reported.
Even though less than 21% of all children aged 12-15 years are fully vaccinated against COVID-19, the number seeking first vaccinations continues to decline, according to data from the Centers for Disease Control and Prevention.
and 462,000 during the week ending June 14. Collectively, 30.2% of 12- to 15-year-olds have gotten at least one dose of vaccine so far and 20.7% are now fully vaccinated, the CDC said on its COVID Data Tracker site.
Among children aged 16-17 years, who were able to start the vaccination process earlier, 42.9% have received at least one dose and 34.0% have completed the COVID-19 vaccine regimen. Vaccine initiation – measured as the proportion of all individuals getting a first shot over the previous 2 weeks – has been consistently around 4.8% during the month of June for this age group but has dropped from 17.9% on June 7 to 14.3% on June 28 for those aged 12-15, the CDC data show.
Looking at the same measure for vaccine completion, 16.7% of all those who reached full vaccination status in the 14 days ending June 28 were 12- to 15-years-olds, down from 21.5% on June 21 and 19.6% on June 14. The numbers for those aged 15-16 were, respectively, 4.6%, 4.5%, and 4.2%, the CDC reported.
Fortunately, in the wake of recent vaccination trends, new cases of COVID-19 in children were down to their lowest level – just 8,447 for the week ending June 24 – since May of 2020, according to a new report from the American Academy of Pediatrics and the Children’s Hospital Association.
New cases had been well over 15,000 the previous week (June 17), following weeks of 14,000 (June 10) and 16,000 (June 3) new cases, so the latest drop down to just four digits represents a 1-week decline of over 46% in the 49 states (excluding New York) that are reporting age distribution, along with the District of Columbia, New York City, Puerto Rico, and Guam.
The cumulative number of child COVID-19 cases in those jurisdictions is about 4.03 million since the beginning of the pandemic, which represents 14.2% of all cases in the United States. At the state level, the cumulative rate of cases in children is highest in Vermont (22.7%) and lowest in Florida (8.9%), which uses an age range of 0-14 years for children, compared with 0-17 or 0-19 for most states, the AAP and CHA said.
Severe illness has been rare in children, which is reflected in the proportion of children among all hospitalizations, 2.2% in 24 jurisdictions, and the proportion of deaths, 0.06% in 46 jurisdictions, since the start of the pandemic, the AAP and CHA said, with a total of 336 COVID-19–related deaths reported.
Even though less than 21% of all children aged 12-15 years are fully vaccinated against COVID-19, the number seeking first vaccinations continues to decline, according to data from the Centers for Disease Control and Prevention.
and 462,000 during the week ending June 14. Collectively, 30.2% of 12- to 15-year-olds have gotten at least one dose of vaccine so far and 20.7% are now fully vaccinated, the CDC said on its COVID Data Tracker site.
Among children aged 16-17 years, who were able to start the vaccination process earlier, 42.9% have received at least one dose and 34.0% have completed the COVID-19 vaccine regimen. Vaccine initiation – measured as the proportion of all individuals getting a first shot over the previous 2 weeks – has been consistently around 4.8% during the month of June for this age group but has dropped from 17.9% on June 7 to 14.3% on June 28 for those aged 12-15, the CDC data show.
Looking at the same measure for vaccine completion, 16.7% of all those who reached full vaccination status in the 14 days ending June 28 were 12- to 15-years-olds, down from 21.5% on June 21 and 19.6% on June 14. The numbers for those aged 15-16 were, respectively, 4.6%, 4.5%, and 4.2%, the CDC reported.
Fortunately, in the wake of recent vaccination trends, new cases of COVID-19 in children were down to their lowest level – just 8,447 for the week ending June 24 – since May of 2020, according to a new report from the American Academy of Pediatrics and the Children’s Hospital Association.
New cases had been well over 15,000 the previous week (June 17), following weeks of 14,000 (June 10) and 16,000 (June 3) new cases, so the latest drop down to just four digits represents a 1-week decline of over 46% in the 49 states (excluding New York) that are reporting age distribution, along with the District of Columbia, New York City, Puerto Rico, and Guam.
The cumulative number of child COVID-19 cases in those jurisdictions is about 4.03 million since the beginning of the pandemic, which represents 14.2% of all cases in the United States. At the state level, the cumulative rate of cases in children is highest in Vermont (22.7%) and lowest in Florida (8.9%), which uses an age range of 0-14 years for children, compared with 0-17 or 0-19 for most states, the AAP and CHA said.
Severe illness has been rare in children, which is reflected in the proportion of children among all hospitalizations, 2.2% in 24 jurisdictions, and the proportion of deaths, 0.06% in 46 jurisdictions, since the start of the pandemic, the AAP and CHA said, with a total of 336 COVID-19–related deaths reported.
Disturbing number of hospital workers still unvaccinated
Tim Oswalt had been in a Fort Worth, Texas, hospital for over a month, receiving treatment for a grapefruit-sized tumor in his chest that was pressing on his heart and lungs. It turned out to be stage 3 non-Hodgkin lymphoma.
Then one day in January, he was moved from his semi-private room to an isolated one with special ventilation. The staff explained he had been infected by the virus that was once again surging in many areas of the country, including Texas.
“How the hell did I catch COVID?” he asked the staff, who now approached him in full moon-suit personal protective equipment (PPE).
The hospital was locked down, and Mr. Oswalt hadn’t had any visitors in weeks. Neither of his two roommates tested positive. He’d been tested for COVID several times over the course of his nearly 5-week stay and was always negative.
“‘Well, you know, it’s easy to [catch it] in a hospital,’” Mr. Oswalt said he was told by hospital staff. “‘We’re having a bad outbreak. So you were just exposed somehow.’”
Officials at John Peter Smith Hospital, where Mr. Oswalt was treated, said they are puzzled by his case. According to their infection prevention team, none of his caregivers tested positive for COVID-19, nor did Mr. Oswalt share space with any other COVID-positive patients. And yet, local media reported a surge in cases among JPS hospital staff in December.
“Infection of any kind is a constant battle within hospitals and one that we all take seriously,” said Rob Stephenson, MD, chief quality officer at JPS Health Network. “Anyone in a vulnerable health condition at the height of the pandemic would have been at greater risk for contracting COVID-19 inside – or even more so, outside – the hospital.”
Mr. Oswalt was diagnosed with COVID in early January. JPS Hospital began vaccinating its health care workers about 2 weeks earlier, so there had not yet been enough time for any of them to develop full protection against catching or spreading the virus.
Today, the hospital said 74% of its staff – 5,300 of 7,200 workers – are now vaccinated.
against the SARS-CoV2 virus.
Refusing vaccinations
In fact, nationwide, 1 in 4 hospital workers who have direct contact with patients had not yet received a single dose of a COVID vaccine by the end of May, according to a WebMD and Medscape Medical News analysis of data collected by the U.S. Department of Health and Human Services (HHS) from 2,500 hospitals across the United States.
Among the nation’s 50 largest hospitals, the percentage of unvaccinated health care workers appears to be even larger, about 1 in 3. Vaccination rates range from a high of 99% at Houston Methodist Hospital, which was the first in the nation to mandate the shots for its workers, to a low between 30% and 40% at some hospitals in Florida.
Memorial Hermann Texas Medical Center in Houston has 1,180 beds and sits less than half a mile from Houston Methodist Hospital. But in terms of worker vaccinations, it is farther away.
Memorial Hermann reported to HHS that about 32% of its 28,000 workers haven’t been inoculated. The hospital’s PR office contests that figure, putting it closer to 25% unvaccinated across their health system. The hospital said it is boosting participation by offering a $300 “shot of hope” bonus to workers who start their vaccination series by the end of June.
Lakeland Regional Medical Center in Lakeland, Fla., reported to HHS that 63% of its health care personnel are still unvaccinated. The hospital did not return a call to verify that number.
To boost vaccination rates, more hospitals are starting to require the shots, after the Equal Employment Opportunity Commission gave its green light to mandates in May.
“It’s a real problem that you have such high levels of unvaccinated individuals in hospitals,” said Lawrence Gostin, JD, director of the O’Neill Institute for National and Global Health Law at Georgetown University, Washington.
“We have to protect our health workforce, and we have to protect our patients. Hospitals should be the safest places in the country, and the only way to make them safe is to have a fully vaccinated workforce,” Mr. Gostin said.
Is the data misleading?
The HHS system designed to amass hospital data was set up quickly, to respond to an emergency. For that reason, experts say the information hasn’t been as carefully collected or vetted as it normally would have been. Some hospitals may have misunderstood how to report their vaccination numbers.
In addition, reporting data on worker vaccinations is voluntary. Only about half of hospitals have chosen to share their numbers. In other cases, like Texas, states have blocked the public release of these statistics.
AdventHealth Orlando, a 1,300-bed hospital in Florida, reported to HHS that 56% of its staff have not started their shots. But spokesman Jeff Grainger said the figures probably overstate the number of unvaccinated workers because the hospital doesn’t always know when people get vaccinated outside of its campus, at a local pharmacy, for example.
For those reasons, the picture of health care worker vaccinations across the country is incomplete.
Where hospitals fall behind
Even if the data are flawed, the vaccination rates from hospitals mirror the general population. A May Gallup poll, for example, found 24% of Americans said they definitely won’t get the vaccine. Another 12% say they plan to get it but are waiting.
The data also align with recent studies. A review of 35 studies by researchers at New Mexico State University that assessed hesitancy in more than 76,000 health care workers around the world found about 23% of them were reluctant to get the shots.
An ongoing monthly survey of more than 1.9 million U.S. Facebook users led by researchers at Carnegie Mellon University, Pittsburgh recently looked at vaccine hesitancy by occupation. It revealed a spectrum of hesitancy among health care workers corresponding to income and education, ranging from a low of 9% among pharmacists to highs of 20%-23% among nursing aides and emergency medical technicians. About 12% of registered nurses and doctors admitted to being hesitant to get a shot.
“Health care workers are not monolithic,” said study author Jagdish Khubchandani, professor of public health sciences at New Mexico State.
“There’s a big divide between males, doctoral degree holders, older people and the younger low-income, low-education frontline, female, health care workers. They are the most hesitant,” he said. Support staff typically outnumbers doctors at hospitals about 3 to 1.
“There is outreach work to be done there,” said Robin Mejia, PhD, director of the Statistics and Human Rights Program at Carnegie Mellon, who is leading the study on Facebook’s survey data. “These are also high-contact professions. These are people who are seeing patients on a regular basis.”
That’s why, when the Centers for Disease Control and Prevention was planning the national vaccine rollout, they prioritized health care workers for the initially scarce first doses. The intent was to protect vulnerable workers and their patients who are at high risk of infection. But the CDC had another reason for putting health care workers first: After they were safely vaccinated, the hope was that they would encourage wary patients to do the same.
Hospitals were supposed to be hubs of education to help build trust within less confident communities. But not all hospitals have risen to that challenge.
Political affiliation seems to be one contributing factor in vaccine hesitancy. Take for example Calhoun, Ga., the seat of Gordon County, where residents voted for Donald Trump over Joe Biden by a 67-point margin in the 2020 general election. Studies have found that Republicans are more likely to decline vaccines than Democrats.
People who live in rural areas are less likely to be vaccinated than those who live in cities, and that’s true in Gordon County too. Vaccinations are lagging in this northwest corner of Georgia where factory jobs in chicken processing plants and carpet manufacturing energize the local economy. Just 24% of Gordon County residents are fully vaccinated, according to the Georgia Department of Public Health.
At AdventHealth Gordon, a 112-bed hospital in Calhoun, just 35% of the 1,723 workers that serve the hospital are at least partially vaccinated, according to data reported to HHS.
‘I am not vaccinated’
One reason some hospital staff say they are resisting COVID vaccination is because it’s so new and not yet fully approved by the FDA.
“I am not vaccinated,” said a social services worker for AdventHealth Gordon who asked that her name not be used because she was unauthorized to speak to this news organization and Georgia Health News (who collaborated on this project). “I just have not felt the need to do that at this time.”
The woman said she doesn’t have a problem with vaccines. She gets the flu shot every year. “I’ve been vaccinated all my life,” she said. But she doesn’t view COVID-19 vaccination in the same way.
“I want to see more testing done,” she said. “It took a long time to get a flu vaccine, and we made a COVID vaccine in 6 months. I want to know, before I start putting something into my body, that the testing is done.”
Staff at her hospital were given the option to be vaccinated or wear a mask. She chose the mask.
Many of her coworkers share her feelings, she said.
Mask expert Linsey Marr, PhD, a professor of civil and environmental engineering at Virginia Tech University, Blacksburg, Va., said N95 masks and vaccines are both highly effective, but the protection from the vaccine is superior because it is continuous.
“It’s hard to wear an N95 at all times. You have to take it off to eat, for example, in a break room in a hospital. I should point out that you can be exposed to the virus in other buildings besides a hospital – restaurants, stores, people’s homes – and because someone can be infected without symptoms, you could easily be around an infected person without knowing it,” she said.
Eventually, staff at AdventHealth Gordon may get a stronger nudge to get the shots. Chief Medical Officer Joseph Joyave, MD, said AdventHealth asks workers to get flu vaccines or provide the hospital with a reason why they won’t. He expects a similar policy will be adopted for COVID vaccines once they are fully licensed by the FDA.
In the meantime, he does not believe that the hospital is putting patients at risk with its low vaccination rate. “We continue to use PPE, masking in all clinical areas, and continue to screen daily all employees and visitors,” he said.
AdventHealth, the 12th largest hospital system in the nation with 49 hospitals, has at least 20 hospitals with vaccination rates lower than 50%, according to HHS data.
Other hospital systems have approached hesitation around the COVID vaccines differently.
When infectious disease experts at Vanderbilt Hospital in Nashville realized early on that many of their workers felt unsure about the vaccines, they set out to provide a wealth of information.
“There was a lot of hesitancy and skepticism,” said William Schaffner, MD, a professor of preventive medicine and infectious disease at Vanderbilt. So the infectious disease division put together a multifaceted program including Q&As, educational sessions, and one-on-one visits with employees “from the custodians all the way up to the C-Suite,” he said.
Today, HHS data shows the hospital is 83% vaccinated. Dr. Schaffner thinks the true number is probably higher, about 90%. “We’re very pleased with that,” he said.
In his experience with flu vaccinations, it was extremely difficult in the first year to get workers to take flu shots. The second year it was easier. By the third year it was humdrum, he said, because it had become a cultural norm.
Dr. Schaffner expects winning people over to the COVID vaccines will follow a similar course, but “we’re not there yet,” he said.
Protecting patients and caregivers
There is no question that health care workers carried a heavy load through the worst months of the pandemic. Many of them worked to the point of exhaustion and burnout. Some were the only conduits between isolated patients and their families, holding hands and mobile phones so distanced loved ones could video chat. Many were left inadequately protected because of shortages of masks, gowns, gloves, and other gear.
An investigation by Kaiser Health News and The Guardian recently revealed that more than 3,600 health care workers died in COVID’s first year in the United States.
Vaccination of health care workers is important to protect these frontline workers and their families who will continue to be at risk of coming into contact with the infection, even as the number of cases falls.
Hesitancy in health care is also dangerous because these clinicians and allied health workers – who may not show any symptoms – can also carry the virus to someone who wouldn’t survive an infection, including patients with organ transplants, those with autoimmune diseases, premature infants, and the elderly.
It is not known how often patients in the United States are infected with COVID in health care settings, but case reports reveal that hospitals are still experiencing outbreaks.
On June 1, Northern Lights A.R. Gould Hospital in Presque Isle, Maine, announced a COVID outbreak on its medical-surgical unit. As of June 22, 13 residents and staff have caught the virus, according to the Maine Centers for Disease Control, which is investigating. Four of the first five staff members to test positive had not been fully vaccinated.
According to HHS data, about 20% of the health care workers at that hospital are still unvaccinated.
Oregon Health & Science University experienced a COVID outbreak connected to the hospital’s cardiovascular care unit from April to mid-May of this year. According to hospital spokesperson Tracy Brawley, a patient visitor brought the infection to campus, where it ultimately spread to 14 others, including “patients, visitors, employees, and learners.”
In a written statement, the hospital said “nearly all” health care workers who tested positive were previously vaccinated and experienced no symptoms or only minor ones. The hospital said it hasn’t identified any onward transmission from health care workers to patients, and also stated: “It is not yet understood how transmission may have occurred between patients, visitors, and health care workers.”
In March, an unvaccinated health care worker in Kentucky carried a SARS-CoV-2 variant back to the nursing home where the person worked. Some 90% of the residents were fully vaccinated. Ultimately, 26 patients were infected; 18 of them were fully vaccinated. And 20 health care workers, four of whom were vaccinated, were infected.
Vaccines slowed the virus down and made infections less severe, but in this fragile population, they couldn’t stop it completely. One resident, who had survived a bout of COVID almost a year earlier, died. According to the CDC’s Morbidity and Mortality Weekly Report, 47% of the workers in that facility were unvaccinated.
In the United Kingdom, statistics collected through that country’s National Health Service also suggest a heavy toll. More than 32,300 patients caught COVID in English hospitals since March 2020. Up to 8,700 of them died, according to a recent analysis by The Guardian. The U.K. government recently made COVID vaccinations mandatory for health care workers.
COVID delays cancer care
When Mr. Oswalt, the Fort Worth, Texas man with non-Hodgkin lymphoma, contracted COVID-19, the virus took down his kidneys first. Toxins were building up in his blood, so doctors prescribed dialysis to support his body and buy his kidneys time to heal.
He was in one of these dialysis treatments when his lungs succumbed.
“Look, I can’t breathe,” he told the nurse who was supervising his treatment. The nurse gestured to an oxygen tank already hanging by his side, and said, “You should be OK.”
But he wasn’t.
“I can’t breathe,” Mr. Oswalt said again. Then the air hunger hit. Mr. Oswalt began gasping and couldn’t stop. Today, his voice breaks when he describes this moment. “A lot of it becomes a blur.”
When Mr. Oswalt, 61, regained consciousness, he was hooked up to a ventilator to ease his breathing.
For days, Mr. Oswalt clung to the edge of life. His wife, Molly, who wasn’t allowed to see him in the hospital, got a call that he might not make it through the night. She made frantic phone calls to her brother and sister and prayed.
Mr. Oswalt was on a ventilator for about a week. His kidneys and lungs healed enough so that he could restart his chemotherapy. He was eventually discharged home on January 22.
The last time he was scanned, the large tumor in his chest had shrunk from the size of a grapefruit to the size of a dime.
But having COVID on top of cancer has had a devastating effect on his life. Before he got sick, Molly said, he couldn’t stay still. He was busy all the time. After spending months in the hospital, his energy was depleted. He couldn’t keep his swimming pool installation business going.
He and Molly had to give up their house in Fort Worth and move in with family in Amarillo. He has had to pause his cancer treatments while doctors wait for his kidneys to heal. Relatives have been raising money on GoFundMe to pay their bills.
Months after moving across the state to Amarillo and hoping for better days, Tim said he got good news this week: He no longer needs dialysis. A new round of tests found no signs of cancer. His white blood cell count is back to normal. His lymph nodes are no longer swollen.
He goes back for another scan in a few weeks, but the doctor told him she isn’t going to recommend any further chemo at this point.
“It was shocking, to tell you the truth. It still is. When I talk about it, I get kind of emotional” about his recovery, he said.
Tim said he was really dreading more chemotherapy. His hair has just started growing back. He can finally taste food again. He wasn’t ready to face more side effects from the treatments, or the COVID – he no longer knows exactly which diagnosis led to his most debilitating symptoms.
He said his ordeal has left him with no patience for health care workers who don’t think they need to be vaccinated.
The way he sees it, it’s no different than the electrical training he had to get before he could wire the lights and pumps in a swimming pool.
“You know, if I don’t certify and keep my license, I can’t work on anything electrical. So, if I’ve made the choice not to go down and take the test and get a license, then I made the choice not to work on electrical stuff,” he said.
He supports the growing number of hospitals that have made vaccination mandatory for their workers.
“They don’t let electricians put people at risk. And they shouldn’t let health care workers for sure,” he said.
A version of this article first appeared on Medscape.com.
Tim Oswalt had been in a Fort Worth, Texas, hospital for over a month, receiving treatment for a grapefruit-sized tumor in his chest that was pressing on his heart and lungs. It turned out to be stage 3 non-Hodgkin lymphoma.
Then one day in January, he was moved from his semi-private room to an isolated one with special ventilation. The staff explained he had been infected by the virus that was once again surging in many areas of the country, including Texas.
“How the hell did I catch COVID?” he asked the staff, who now approached him in full moon-suit personal protective equipment (PPE).
The hospital was locked down, and Mr. Oswalt hadn’t had any visitors in weeks. Neither of his two roommates tested positive. He’d been tested for COVID several times over the course of his nearly 5-week stay and was always negative.
“‘Well, you know, it’s easy to [catch it] in a hospital,’” Mr. Oswalt said he was told by hospital staff. “‘We’re having a bad outbreak. So you were just exposed somehow.’”
Officials at John Peter Smith Hospital, where Mr. Oswalt was treated, said they are puzzled by his case. According to their infection prevention team, none of his caregivers tested positive for COVID-19, nor did Mr. Oswalt share space with any other COVID-positive patients. And yet, local media reported a surge in cases among JPS hospital staff in December.
“Infection of any kind is a constant battle within hospitals and one that we all take seriously,” said Rob Stephenson, MD, chief quality officer at JPS Health Network. “Anyone in a vulnerable health condition at the height of the pandemic would have been at greater risk for contracting COVID-19 inside – or even more so, outside – the hospital.”
Mr. Oswalt was diagnosed with COVID in early January. JPS Hospital began vaccinating its health care workers about 2 weeks earlier, so there had not yet been enough time for any of them to develop full protection against catching or spreading the virus.
Today, the hospital said 74% of its staff – 5,300 of 7,200 workers – are now vaccinated.
against the SARS-CoV2 virus.
Refusing vaccinations
In fact, nationwide, 1 in 4 hospital workers who have direct contact with patients had not yet received a single dose of a COVID vaccine by the end of May, according to a WebMD and Medscape Medical News analysis of data collected by the U.S. Department of Health and Human Services (HHS) from 2,500 hospitals across the United States.
Among the nation’s 50 largest hospitals, the percentage of unvaccinated health care workers appears to be even larger, about 1 in 3. Vaccination rates range from a high of 99% at Houston Methodist Hospital, which was the first in the nation to mandate the shots for its workers, to a low between 30% and 40% at some hospitals in Florida.
Memorial Hermann Texas Medical Center in Houston has 1,180 beds and sits less than half a mile from Houston Methodist Hospital. But in terms of worker vaccinations, it is farther away.
Memorial Hermann reported to HHS that about 32% of its 28,000 workers haven’t been inoculated. The hospital’s PR office contests that figure, putting it closer to 25% unvaccinated across their health system. The hospital said it is boosting participation by offering a $300 “shot of hope” bonus to workers who start their vaccination series by the end of June.
Lakeland Regional Medical Center in Lakeland, Fla., reported to HHS that 63% of its health care personnel are still unvaccinated. The hospital did not return a call to verify that number.
To boost vaccination rates, more hospitals are starting to require the shots, after the Equal Employment Opportunity Commission gave its green light to mandates in May.
“It’s a real problem that you have such high levels of unvaccinated individuals in hospitals,” said Lawrence Gostin, JD, director of the O’Neill Institute for National and Global Health Law at Georgetown University, Washington.
“We have to protect our health workforce, and we have to protect our patients. Hospitals should be the safest places in the country, and the only way to make them safe is to have a fully vaccinated workforce,” Mr. Gostin said.
Is the data misleading?
The HHS system designed to amass hospital data was set up quickly, to respond to an emergency. For that reason, experts say the information hasn’t been as carefully collected or vetted as it normally would have been. Some hospitals may have misunderstood how to report their vaccination numbers.
In addition, reporting data on worker vaccinations is voluntary. Only about half of hospitals have chosen to share their numbers. In other cases, like Texas, states have blocked the public release of these statistics.
AdventHealth Orlando, a 1,300-bed hospital in Florida, reported to HHS that 56% of its staff have not started their shots. But spokesman Jeff Grainger said the figures probably overstate the number of unvaccinated workers because the hospital doesn’t always know when people get vaccinated outside of its campus, at a local pharmacy, for example.
For those reasons, the picture of health care worker vaccinations across the country is incomplete.
Where hospitals fall behind
Even if the data are flawed, the vaccination rates from hospitals mirror the general population. A May Gallup poll, for example, found 24% of Americans said they definitely won’t get the vaccine. Another 12% say they plan to get it but are waiting.
The data also align with recent studies. A review of 35 studies by researchers at New Mexico State University that assessed hesitancy in more than 76,000 health care workers around the world found about 23% of them were reluctant to get the shots.
An ongoing monthly survey of more than 1.9 million U.S. Facebook users led by researchers at Carnegie Mellon University, Pittsburgh recently looked at vaccine hesitancy by occupation. It revealed a spectrum of hesitancy among health care workers corresponding to income and education, ranging from a low of 9% among pharmacists to highs of 20%-23% among nursing aides and emergency medical technicians. About 12% of registered nurses and doctors admitted to being hesitant to get a shot.
“Health care workers are not monolithic,” said study author Jagdish Khubchandani, professor of public health sciences at New Mexico State.
“There’s a big divide between males, doctoral degree holders, older people and the younger low-income, low-education frontline, female, health care workers. They are the most hesitant,” he said. Support staff typically outnumbers doctors at hospitals about 3 to 1.
“There is outreach work to be done there,” said Robin Mejia, PhD, director of the Statistics and Human Rights Program at Carnegie Mellon, who is leading the study on Facebook’s survey data. “These are also high-contact professions. These are people who are seeing patients on a regular basis.”
That’s why, when the Centers for Disease Control and Prevention was planning the national vaccine rollout, they prioritized health care workers for the initially scarce first doses. The intent was to protect vulnerable workers and their patients who are at high risk of infection. But the CDC had another reason for putting health care workers first: After they were safely vaccinated, the hope was that they would encourage wary patients to do the same.
Hospitals were supposed to be hubs of education to help build trust within less confident communities. But not all hospitals have risen to that challenge.
Political affiliation seems to be one contributing factor in vaccine hesitancy. Take for example Calhoun, Ga., the seat of Gordon County, where residents voted for Donald Trump over Joe Biden by a 67-point margin in the 2020 general election. Studies have found that Republicans are more likely to decline vaccines than Democrats.
People who live in rural areas are less likely to be vaccinated than those who live in cities, and that’s true in Gordon County too. Vaccinations are lagging in this northwest corner of Georgia where factory jobs in chicken processing plants and carpet manufacturing energize the local economy. Just 24% of Gordon County residents are fully vaccinated, according to the Georgia Department of Public Health.
At AdventHealth Gordon, a 112-bed hospital in Calhoun, just 35% of the 1,723 workers that serve the hospital are at least partially vaccinated, according to data reported to HHS.
‘I am not vaccinated’
One reason some hospital staff say they are resisting COVID vaccination is because it’s so new and not yet fully approved by the FDA.
“I am not vaccinated,” said a social services worker for AdventHealth Gordon who asked that her name not be used because she was unauthorized to speak to this news organization and Georgia Health News (who collaborated on this project). “I just have not felt the need to do that at this time.”
The woman said she doesn’t have a problem with vaccines. She gets the flu shot every year. “I’ve been vaccinated all my life,” she said. But she doesn’t view COVID-19 vaccination in the same way.
“I want to see more testing done,” she said. “It took a long time to get a flu vaccine, and we made a COVID vaccine in 6 months. I want to know, before I start putting something into my body, that the testing is done.”
Staff at her hospital were given the option to be vaccinated or wear a mask. She chose the mask.
Many of her coworkers share her feelings, she said.
Mask expert Linsey Marr, PhD, a professor of civil and environmental engineering at Virginia Tech University, Blacksburg, Va., said N95 masks and vaccines are both highly effective, but the protection from the vaccine is superior because it is continuous.
“It’s hard to wear an N95 at all times. You have to take it off to eat, for example, in a break room in a hospital. I should point out that you can be exposed to the virus in other buildings besides a hospital – restaurants, stores, people’s homes – and because someone can be infected without symptoms, you could easily be around an infected person without knowing it,” she said.
Eventually, staff at AdventHealth Gordon may get a stronger nudge to get the shots. Chief Medical Officer Joseph Joyave, MD, said AdventHealth asks workers to get flu vaccines or provide the hospital with a reason why they won’t. He expects a similar policy will be adopted for COVID vaccines once they are fully licensed by the FDA.
In the meantime, he does not believe that the hospital is putting patients at risk with its low vaccination rate. “We continue to use PPE, masking in all clinical areas, and continue to screen daily all employees and visitors,” he said.
AdventHealth, the 12th largest hospital system in the nation with 49 hospitals, has at least 20 hospitals with vaccination rates lower than 50%, according to HHS data.
Other hospital systems have approached hesitation around the COVID vaccines differently.
When infectious disease experts at Vanderbilt Hospital in Nashville realized early on that many of their workers felt unsure about the vaccines, they set out to provide a wealth of information.
“There was a lot of hesitancy and skepticism,” said William Schaffner, MD, a professor of preventive medicine and infectious disease at Vanderbilt. So the infectious disease division put together a multifaceted program including Q&As, educational sessions, and one-on-one visits with employees “from the custodians all the way up to the C-Suite,” he said.
Today, HHS data shows the hospital is 83% vaccinated. Dr. Schaffner thinks the true number is probably higher, about 90%. “We’re very pleased with that,” he said.
In his experience with flu vaccinations, it was extremely difficult in the first year to get workers to take flu shots. The second year it was easier. By the third year it was humdrum, he said, because it had become a cultural norm.
Dr. Schaffner expects winning people over to the COVID vaccines will follow a similar course, but “we’re not there yet,” he said.
Protecting patients and caregivers
There is no question that health care workers carried a heavy load through the worst months of the pandemic. Many of them worked to the point of exhaustion and burnout. Some were the only conduits between isolated patients and their families, holding hands and mobile phones so distanced loved ones could video chat. Many were left inadequately protected because of shortages of masks, gowns, gloves, and other gear.
An investigation by Kaiser Health News and The Guardian recently revealed that more than 3,600 health care workers died in COVID’s first year in the United States.
Vaccination of health care workers is important to protect these frontline workers and their families who will continue to be at risk of coming into contact with the infection, even as the number of cases falls.
Hesitancy in health care is also dangerous because these clinicians and allied health workers – who may not show any symptoms – can also carry the virus to someone who wouldn’t survive an infection, including patients with organ transplants, those with autoimmune diseases, premature infants, and the elderly.
It is not known how often patients in the United States are infected with COVID in health care settings, but case reports reveal that hospitals are still experiencing outbreaks.
On June 1, Northern Lights A.R. Gould Hospital in Presque Isle, Maine, announced a COVID outbreak on its medical-surgical unit. As of June 22, 13 residents and staff have caught the virus, according to the Maine Centers for Disease Control, which is investigating. Four of the first five staff members to test positive had not been fully vaccinated.
According to HHS data, about 20% of the health care workers at that hospital are still unvaccinated.
Oregon Health & Science University experienced a COVID outbreak connected to the hospital’s cardiovascular care unit from April to mid-May of this year. According to hospital spokesperson Tracy Brawley, a patient visitor brought the infection to campus, where it ultimately spread to 14 others, including “patients, visitors, employees, and learners.”
In a written statement, the hospital said “nearly all” health care workers who tested positive were previously vaccinated and experienced no symptoms or only minor ones. The hospital said it hasn’t identified any onward transmission from health care workers to patients, and also stated: “It is not yet understood how transmission may have occurred between patients, visitors, and health care workers.”
In March, an unvaccinated health care worker in Kentucky carried a SARS-CoV-2 variant back to the nursing home where the person worked. Some 90% of the residents were fully vaccinated. Ultimately, 26 patients were infected; 18 of them were fully vaccinated. And 20 health care workers, four of whom were vaccinated, were infected.
Vaccines slowed the virus down and made infections less severe, but in this fragile population, they couldn’t stop it completely. One resident, who had survived a bout of COVID almost a year earlier, died. According to the CDC’s Morbidity and Mortality Weekly Report, 47% of the workers in that facility were unvaccinated.
In the United Kingdom, statistics collected through that country’s National Health Service also suggest a heavy toll. More than 32,300 patients caught COVID in English hospitals since March 2020. Up to 8,700 of them died, according to a recent analysis by The Guardian. The U.K. government recently made COVID vaccinations mandatory for health care workers.
COVID delays cancer care
When Mr. Oswalt, the Fort Worth, Texas man with non-Hodgkin lymphoma, contracted COVID-19, the virus took down his kidneys first. Toxins were building up in his blood, so doctors prescribed dialysis to support his body and buy his kidneys time to heal.
He was in one of these dialysis treatments when his lungs succumbed.
“Look, I can’t breathe,” he told the nurse who was supervising his treatment. The nurse gestured to an oxygen tank already hanging by his side, and said, “You should be OK.”
But he wasn’t.
“I can’t breathe,” Mr. Oswalt said again. Then the air hunger hit. Mr. Oswalt began gasping and couldn’t stop. Today, his voice breaks when he describes this moment. “A lot of it becomes a blur.”
When Mr. Oswalt, 61, regained consciousness, he was hooked up to a ventilator to ease his breathing.
For days, Mr. Oswalt clung to the edge of life. His wife, Molly, who wasn’t allowed to see him in the hospital, got a call that he might not make it through the night. She made frantic phone calls to her brother and sister and prayed.
Mr. Oswalt was on a ventilator for about a week. His kidneys and lungs healed enough so that he could restart his chemotherapy. He was eventually discharged home on January 22.
The last time he was scanned, the large tumor in his chest had shrunk from the size of a grapefruit to the size of a dime.
But having COVID on top of cancer has had a devastating effect on his life. Before he got sick, Molly said, he couldn’t stay still. He was busy all the time. After spending months in the hospital, his energy was depleted. He couldn’t keep his swimming pool installation business going.
He and Molly had to give up their house in Fort Worth and move in with family in Amarillo. He has had to pause his cancer treatments while doctors wait for his kidneys to heal. Relatives have been raising money on GoFundMe to pay their bills.
Months after moving across the state to Amarillo and hoping for better days, Tim said he got good news this week: He no longer needs dialysis. A new round of tests found no signs of cancer. His white blood cell count is back to normal. His lymph nodes are no longer swollen.
He goes back for another scan in a few weeks, but the doctor told him she isn’t going to recommend any further chemo at this point.
“It was shocking, to tell you the truth. It still is. When I talk about it, I get kind of emotional” about his recovery, he said.
Tim said he was really dreading more chemotherapy. His hair has just started growing back. He can finally taste food again. He wasn’t ready to face more side effects from the treatments, or the COVID – he no longer knows exactly which diagnosis led to his most debilitating symptoms.
He said his ordeal has left him with no patience for health care workers who don’t think they need to be vaccinated.
The way he sees it, it’s no different than the electrical training he had to get before he could wire the lights and pumps in a swimming pool.
“You know, if I don’t certify and keep my license, I can’t work on anything electrical. So, if I’ve made the choice not to go down and take the test and get a license, then I made the choice not to work on electrical stuff,” he said.
He supports the growing number of hospitals that have made vaccination mandatory for their workers.
“They don’t let electricians put people at risk. And they shouldn’t let health care workers for sure,” he said.
A version of this article first appeared on Medscape.com.
Tim Oswalt had been in a Fort Worth, Texas, hospital for over a month, receiving treatment for a grapefruit-sized tumor in his chest that was pressing on his heart and lungs. It turned out to be stage 3 non-Hodgkin lymphoma.
Then one day in January, he was moved from his semi-private room to an isolated one with special ventilation. The staff explained he had been infected by the virus that was once again surging in many areas of the country, including Texas.
“How the hell did I catch COVID?” he asked the staff, who now approached him in full moon-suit personal protective equipment (PPE).
The hospital was locked down, and Mr. Oswalt hadn’t had any visitors in weeks. Neither of his two roommates tested positive. He’d been tested for COVID several times over the course of his nearly 5-week stay and was always negative.
“‘Well, you know, it’s easy to [catch it] in a hospital,’” Mr. Oswalt said he was told by hospital staff. “‘We’re having a bad outbreak. So you were just exposed somehow.’”
Officials at John Peter Smith Hospital, where Mr. Oswalt was treated, said they are puzzled by his case. According to their infection prevention team, none of his caregivers tested positive for COVID-19, nor did Mr. Oswalt share space with any other COVID-positive patients. And yet, local media reported a surge in cases among JPS hospital staff in December.
“Infection of any kind is a constant battle within hospitals and one that we all take seriously,” said Rob Stephenson, MD, chief quality officer at JPS Health Network. “Anyone in a vulnerable health condition at the height of the pandemic would have been at greater risk for contracting COVID-19 inside – or even more so, outside – the hospital.”
Mr. Oswalt was diagnosed with COVID in early January. JPS Hospital began vaccinating its health care workers about 2 weeks earlier, so there had not yet been enough time for any of them to develop full protection against catching or spreading the virus.
Today, the hospital said 74% of its staff – 5,300 of 7,200 workers – are now vaccinated.
against the SARS-CoV2 virus.
Refusing vaccinations
In fact, nationwide, 1 in 4 hospital workers who have direct contact with patients had not yet received a single dose of a COVID vaccine by the end of May, according to a WebMD and Medscape Medical News analysis of data collected by the U.S. Department of Health and Human Services (HHS) from 2,500 hospitals across the United States.
Among the nation’s 50 largest hospitals, the percentage of unvaccinated health care workers appears to be even larger, about 1 in 3. Vaccination rates range from a high of 99% at Houston Methodist Hospital, which was the first in the nation to mandate the shots for its workers, to a low between 30% and 40% at some hospitals in Florida.
Memorial Hermann Texas Medical Center in Houston has 1,180 beds and sits less than half a mile from Houston Methodist Hospital. But in terms of worker vaccinations, it is farther away.
Memorial Hermann reported to HHS that about 32% of its 28,000 workers haven’t been inoculated. The hospital’s PR office contests that figure, putting it closer to 25% unvaccinated across their health system. The hospital said it is boosting participation by offering a $300 “shot of hope” bonus to workers who start their vaccination series by the end of June.
Lakeland Regional Medical Center in Lakeland, Fla., reported to HHS that 63% of its health care personnel are still unvaccinated. The hospital did not return a call to verify that number.
To boost vaccination rates, more hospitals are starting to require the shots, after the Equal Employment Opportunity Commission gave its green light to mandates in May.
“It’s a real problem that you have such high levels of unvaccinated individuals in hospitals,” said Lawrence Gostin, JD, director of the O’Neill Institute for National and Global Health Law at Georgetown University, Washington.
“We have to protect our health workforce, and we have to protect our patients. Hospitals should be the safest places in the country, and the only way to make them safe is to have a fully vaccinated workforce,” Mr. Gostin said.
Is the data misleading?
The HHS system designed to amass hospital data was set up quickly, to respond to an emergency. For that reason, experts say the information hasn’t been as carefully collected or vetted as it normally would have been. Some hospitals may have misunderstood how to report their vaccination numbers.
In addition, reporting data on worker vaccinations is voluntary. Only about half of hospitals have chosen to share their numbers. In other cases, like Texas, states have blocked the public release of these statistics.
AdventHealth Orlando, a 1,300-bed hospital in Florida, reported to HHS that 56% of its staff have not started their shots. But spokesman Jeff Grainger said the figures probably overstate the number of unvaccinated workers because the hospital doesn’t always know when people get vaccinated outside of its campus, at a local pharmacy, for example.
For those reasons, the picture of health care worker vaccinations across the country is incomplete.
Where hospitals fall behind
Even if the data are flawed, the vaccination rates from hospitals mirror the general population. A May Gallup poll, for example, found 24% of Americans said they definitely won’t get the vaccine. Another 12% say they plan to get it but are waiting.
The data also align with recent studies. A review of 35 studies by researchers at New Mexico State University that assessed hesitancy in more than 76,000 health care workers around the world found about 23% of them were reluctant to get the shots.
An ongoing monthly survey of more than 1.9 million U.S. Facebook users led by researchers at Carnegie Mellon University, Pittsburgh recently looked at vaccine hesitancy by occupation. It revealed a spectrum of hesitancy among health care workers corresponding to income and education, ranging from a low of 9% among pharmacists to highs of 20%-23% among nursing aides and emergency medical technicians. About 12% of registered nurses and doctors admitted to being hesitant to get a shot.
“Health care workers are not monolithic,” said study author Jagdish Khubchandani, professor of public health sciences at New Mexico State.
“There’s a big divide between males, doctoral degree holders, older people and the younger low-income, low-education frontline, female, health care workers. They are the most hesitant,” he said. Support staff typically outnumbers doctors at hospitals about 3 to 1.
“There is outreach work to be done there,” said Robin Mejia, PhD, director of the Statistics and Human Rights Program at Carnegie Mellon, who is leading the study on Facebook’s survey data. “These are also high-contact professions. These are people who are seeing patients on a regular basis.”
That’s why, when the Centers for Disease Control and Prevention was planning the national vaccine rollout, they prioritized health care workers for the initially scarce first doses. The intent was to protect vulnerable workers and their patients who are at high risk of infection. But the CDC had another reason for putting health care workers first: After they were safely vaccinated, the hope was that they would encourage wary patients to do the same.
Hospitals were supposed to be hubs of education to help build trust within less confident communities. But not all hospitals have risen to that challenge.
Political affiliation seems to be one contributing factor in vaccine hesitancy. Take for example Calhoun, Ga., the seat of Gordon County, where residents voted for Donald Trump over Joe Biden by a 67-point margin in the 2020 general election. Studies have found that Republicans are more likely to decline vaccines than Democrats.
People who live in rural areas are less likely to be vaccinated than those who live in cities, and that’s true in Gordon County too. Vaccinations are lagging in this northwest corner of Georgia where factory jobs in chicken processing plants and carpet manufacturing energize the local economy. Just 24% of Gordon County residents are fully vaccinated, according to the Georgia Department of Public Health.
At AdventHealth Gordon, a 112-bed hospital in Calhoun, just 35% of the 1,723 workers that serve the hospital are at least partially vaccinated, according to data reported to HHS.
‘I am not vaccinated’
One reason some hospital staff say they are resisting COVID vaccination is because it’s so new and not yet fully approved by the FDA.
“I am not vaccinated,” said a social services worker for AdventHealth Gordon who asked that her name not be used because she was unauthorized to speak to this news organization and Georgia Health News (who collaborated on this project). “I just have not felt the need to do that at this time.”
The woman said she doesn’t have a problem with vaccines. She gets the flu shot every year. “I’ve been vaccinated all my life,” she said. But she doesn’t view COVID-19 vaccination in the same way.
“I want to see more testing done,” she said. “It took a long time to get a flu vaccine, and we made a COVID vaccine in 6 months. I want to know, before I start putting something into my body, that the testing is done.”
Staff at her hospital were given the option to be vaccinated or wear a mask. She chose the mask.
Many of her coworkers share her feelings, she said.
Mask expert Linsey Marr, PhD, a professor of civil and environmental engineering at Virginia Tech University, Blacksburg, Va., said N95 masks and vaccines are both highly effective, but the protection from the vaccine is superior because it is continuous.
“It’s hard to wear an N95 at all times. You have to take it off to eat, for example, in a break room in a hospital. I should point out that you can be exposed to the virus in other buildings besides a hospital – restaurants, stores, people’s homes – and because someone can be infected without symptoms, you could easily be around an infected person without knowing it,” she said.
Eventually, staff at AdventHealth Gordon may get a stronger nudge to get the shots. Chief Medical Officer Joseph Joyave, MD, said AdventHealth asks workers to get flu vaccines or provide the hospital with a reason why they won’t. He expects a similar policy will be adopted for COVID vaccines once they are fully licensed by the FDA.
In the meantime, he does not believe that the hospital is putting patients at risk with its low vaccination rate. “We continue to use PPE, masking in all clinical areas, and continue to screen daily all employees and visitors,” he said.
AdventHealth, the 12th largest hospital system in the nation with 49 hospitals, has at least 20 hospitals with vaccination rates lower than 50%, according to HHS data.
Other hospital systems have approached hesitation around the COVID vaccines differently.
When infectious disease experts at Vanderbilt Hospital in Nashville realized early on that many of their workers felt unsure about the vaccines, they set out to provide a wealth of information.
“There was a lot of hesitancy and skepticism,” said William Schaffner, MD, a professor of preventive medicine and infectious disease at Vanderbilt. So the infectious disease division put together a multifaceted program including Q&As, educational sessions, and one-on-one visits with employees “from the custodians all the way up to the C-Suite,” he said.
Today, HHS data shows the hospital is 83% vaccinated. Dr. Schaffner thinks the true number is probably higher, about 90%. “We’re very pleased with that,” he said.
In his experience with flu vaccinations, it was extremely difficult in the first year to get workers to take flu shots. The second year it was easier. By the third year it was humdrum, he said, because it had become a cultural norm.
Dr. Schaffner expects winning people over to the COVID vaccines will follow a similar course, but “we’re not there yet,” he said.
Protecting patients and caregivers
There is no question that health care workers carried a heavy load through the worst months of the pandemic. Many of them worked to the point of exhaustion and burnout. Some were the only conduits between isolated patients and their families, holding hands and mobile phones so distanced loved ones could video chat. Many were left inadequately protected because of shortages of masks, gowns, gloves, and other gear.
An investigation by Kaiser Health News and The Guardian recently revealed that more than 3,600 health care workers died in COVID’s first year in the United States.
Vaccination of health care workers is important to protect these frontline workers and their families who will continue to be at risk of coming into contact with the infection, even as the number of cases falls.
Hesitancy in health care is also dangerous because these clinicians and allied health workers – who may not show any symptoms – can also carry the virus to someone who wouldn’t survive an infection, including patients with organ transplants, those with autoimmune diseases, premature infants, and the elderly.
It is not known how often patients in the United States are infected with COVID in health care settings, but case reports reveal that hospitals are still experiencing outbreaks.
On June 1, Northern Lights A.R. Gould Hospital in Presque Isle, Maine, announced a COVID outbreak on its medical-surgical unit. As of June 22, 13 residents and staff have caught the virus, according to the Maine Centers for Disease Control, which is investigating. Four of the first five staff members to test positive had not been fully vaccinated.
According to HHS data, about 20% of the health care workers at that hospital are still unvaccinated.
Oregon Health & Science University experienced a COVID outbreak connected to the hospital’s cardiovascular care unit from April to mid-May of this year. According to hospital spokesperson Tracy Brawley, a patient visitor brought the infection to campus, where it ultimately spread to 14 others, including “patients, visitors, employees, and learners.”
In a written statement, the hospital said “nearly all” health care workers who tested positive were previously vaccinated and experienced no symptoms or only minor ones. The hospital said it hasn’t identified any onward transmission from health care workers to patients, and also stated: “It is not yet understood how transmission may have occurred between patients, visitors, and health care workers.”
In March, an unvaccinated health care worker in Kentucky carried a SARS-CoV-2 variant back to the nursing home where the person worked. Some 90% of the residents were fully vaccinated. Ultimately, 26 patients were infected; 18 of them were fully vaccinated. And 20 health care workers, four of whom were vaccinated, were infected.
Vaccines slowed the virus down and made infections less severe, but in this fragile population, they couldn’t stop it completely. One resident, who had survived a bout of COVID almost a year earlier, died. According to the CDC’s Morbidity and Mortality Weekly Report, 47% of the workers in that facility were unvaccinated.
In the United Kingdom, statistics collected through that country’s National Health Service also suggest a heavy toll. More than 32,300 patients caught COVID in English hospitals since March 2020. Up to 8,700 of them died, according to a recent analysis by The Guardian. The U.K. government recently made COVID vaccinations mandatory for health care workers.
COVID delays cancer care
When Mr. Oswalt, the Fort Worth, Texas man with non-Hodgkin lymphoma, contracted COVID-19, the virus took down his kidneys first. Toxins were building up in his blood, so doctors prescribed dialysis to support his body and buy his kidneys time to heal.
He was in one of these dialysis treatments when his lungs succumbed.
“Look, I can’t breathe,” he told the nurse who was supervising his treatment. The nurse gestured to an oxygen tank already hanging by his side, and said, “You should be OK.”
But he wasn’t.
“I can’t breathe,” Mr. Oswalt said again. Then the air hunger hit. Mr. Oswalt began gasping and couldn’t stop. Today, his voice breaks when he describes this moment. “A lot of it becomes a blur.”
When Mr. Oswalt, 61, regained consciousness, he was hooked up to a ventilator to ease his breathing.
For days, Mr. Oswalt clung to the edge of life. His wife, Molly, who wasn’t allowed to see him in the hospital, got a call that he might not make it through the night. She made frantic phone calls to her brother and sister and prayed.
Mr. Oswalt was on a ventilator for about a week. His kidneys and lungs healed enough so that he could restart his chemotherapy. He was eventually discharged home on January 22.
The last time he was scanned, the large tumor in his chest had shrunk from the size of a grapefruit to the size of a dime.
But having COVID on top of cancer has had a devastating effect on his life. Before he got sick, Molly said, he couldn’t stay still. He was busy all the time. After spending months in the hospital, his energy was depleted. He couldn’t keep his swimming pool installation business going.
He and Molly had to give up their house in Fort Worth and move in with family in Amarillo. He has had to pause his cancer treatments while doctors wait for his kidneys to heal. Relatives have been raising money on GoFundMe to pay their bills.
Months after moving across the state to Amarillo and hoping for better days, Tim said he got good news this week: He no longer needs dialysis. A new round of tests found no signs of cancer. His white blood cell count is back to normal. His lymph nodes are no longer swollen.
He goes back for another scan in a few weeks, but the doctor told him she isn’t going to recommend any further chemo at this point.
“It was shocking, to tell you the truth. It still is. When I talk about it, I get kind of emotional” about his recovery, he said.
Tim said he was really dreading more chemotherapy. His hair has just started growing back. He can finally taste food again. He wasn’t ready to face more side effects from the treatments, or the COVID – he no longer knows exactly which diagnosis led to his most debilitating symptoms.
He said his ordeal has left him with no patience for health care workers who don’t think they need to be vaccinated.
The way he sees it, it’s no different than the electrical training he had to get before he could wire the lights and pumps in a swimming pool.
“You know, if I don’t certify and keep my license, I can’t work on anything electrical. So, if I’ve made the choice not to go down and take the test and get a license, then I made the choice not to work on electrical stuff,” he said.
He supports the growing number of hospitals that have made vaccination mandatory for their workers.
“They don’t let electricians put people at risk. And they shouldn’t let health care workers for sure,” he said.
A version of this article first appeared on Medscape.com.
Artificial intelligence, COVID-19, and the future of pandemics
Editor’s note: This article has been provided by The Doctors Company, the exclusively endorsed medical malpractice carrier for the Society of Hospital Medicine.
Artificial intelligence (AI) has proven of value in the COVID-19 pandemic and shows promise for mitigating future health care crises. During the pandemic’s first wave in New York, for example, Mount Sinai Health System used an algorithm to help identify patients ready for discharge. Such systems can help overburdened hospitals manage personnel and the flow of supplies in a medical crisis so they can continue to provide superior patient care.1
Pandemic applications have demonstrated AI’s potential not only to lift administrative burdens, but also to give physicians back what Eric Topol, MD, founder and director of Scripps Research Translational Institute and author of Deep Medicine, calls “the gift of time.”2 More time with patients contributes to clear communication and positive relationships, which lower the odds of medical errors, enhance patient safety, and potentially reduce physicians’ risks of certain types of litigation.3
However, physicians and health systems will need to approach AI with caution. Many unknowns remain – including potential liability risks and the potential for worsening preexisting bias. The law will need to evolve to account for AI-related liability scenarios, some of which are yet to be imagined.
Like any emerging technology, AI brings risk, but its promise of benefit should outweigh the probability of negative consequences – provided we remain aware of and mitigate the potential for AI-induced adverse events.
AI’s pandemic success limited due to fragmented data
Innovation is the key to success in any crisis, and many health care providers have shown their ability to innovate with AI during the pandemic. For example, researchers at the University of California, San Diego, health system who were designing an AI program to help doctors spot pneumonia on a chest x-ray retooled their application to assist physicians fighting coronavirus.4
Meanwhile, AI has been used to distinguish COVID-19–specific symptoms: It was a computer sifting medical records that took anosmia, loss of the sense of smell, from an anecdotal connection to an officially recognized early symptom of the virus.5 This information now helps physicians distinguish COVID-19 from influenza.
However, holding back more innovation is the fragmentation of health care data in the United States. Most AI applications for medicine rely on machine learning; that is, they train on historical patient data to recognize patterns. Therefore, “Everything that we’re doing gets better with a lot more annotated datasets,” Dr. Topol says. Unfortunately, because of our disparate systems, we don’t have centralized data.6 And even if our data were centralized, researchers lack enough reliable COVID-19 data to perfect algorithms in the short term.
Or, put in bleaker terms by the Washington Post: “One of the biggest challenges has been that much data remains siloed inside incompatible computer systems, hoarded by business interests and tangled in geopolitics.”7
The good news is that machine learning and data science platform Kaggle is hosting the COVID-19 Open Research Dataset, or CORD-19, which contains well over 100,000 scholarly articles on COVID-19, SARS, and other relevant infections.8 In lieu of a true central repository of anonymized health data, such large datasets can help train new AI applications in search of new diagnostic tools and therapies.
AI introduces new questions around liability
While AI may eventually be assigned legal personhood, it is not, in fact, a person: It is a tool wielded by individual clinicians, by teams, by health systems, even multiple systems collaborating. Our current liability laws are not ready for the era of digital medicine.
AI algorithms are not perfect. Because we know that diagnostic error is already a major allegation in malpractice claims, we must ask: What happens when a patient alleges that diagnostic error occurred because a physician or physicians leaned too heavily on AI?
In the United States, testing delays have threatened the safety of patients, physicians, and the public by delaying diagnosis of COVID-19. But again, health care providers have applied real innovation – generating novel and useful ideas and applying those ideas – to this problem. For example, researchers at Mount Sinai became the first in the country to combine AI with imaging and clinical data to produce an algorithm that can detect COVID-19 based on computed tomography scans of the chest, in combination with patient information and exposure history.9
AI in health care can help mitigate bias – or worsen it
Machine learning is only as good as the information provided to train the machine. Models trained on partial datasets can skew toward demographics that turned up more often in the data – for example, White race or men over 60. There is concern that “analyses based on faulty or biased algorithms could exacerbate existing racial gaps and other disparities in health care.”10 Already during the pandemic’s first waves, multiple AI systems used to classify x-rays have been found to show racial, gender, and socioeconomic biases.11
Such bias could create high potential for poor recommendations, including false positives and false negatives. It’s critical that system builders are able to explain and qualify their training data and that those who best understand AI-related system risks are the ones who influence health care systems or alter applications to mitigate AI-related harms.12
AI can help spot the next outbreak
More than a week before the World Health Organization released its first warning about a novel coronavirus, the AI platform BlueDot, created in Toronto, spotted an unusual cluster of pneumonia cases in Wuhan, China. Meanwhile, at Boston Children’s Hospital, the AI application Healthmap was scanning social media and news sites for signs of disease cluster, and it, too, flagged the first signs of what would become the COVID-19 outbreak – days before the WHO’s first formal alert.13
These innovative applications of AI in health care demonstrate real promise in detecting future outbreaks of new viruses early. This will allow health care providers and public health officials to get information out sooner, reducing the load on health systems, and ultimately, saving lives.
Dr. Anderson is chairman and chief executive officer, The Doctors Company and TDC Group.
References
1. Gold A. “Coronavirus tests the value of artificial intelligence in medicine” Fierce Biotech. 2020 May 22.
2. Topol E. “Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again” (New York: Hachette Book Group; 2019:285).
3. The Doctors Company. “The Algorithm Will See You Now: How AI’s Healthcare Potential Outweighs Its Risk” 2020 Jan.
4. Gold A. Coronavirus tests the value of artificial intelligence in medicine. Fierce Biotech. 2020 May 22.
5. Cha AE. Artificial intelligence and COVID-19: Can the machines save us? Washington Post. 2020 Nov 1.
6. Reuter E. Hundreds of AI solutions proposed for pandemic, but few are proven. MedCity News. 2020 May 28.
7. Cha AE. Artificial intelligence and COVID-19: Can the machines save us? Washington Post. 2020 Nov 1.
8. Lee K. COVID-19 will accelerate the AI health care revolution. Wired. 2020 May 22.
9. Mei X et al. Artificial intelligence–enabled rapid diagnosis of patients with COVID-19. Nat Med. 2020 May 19;26:1224-8. doi: 10.1038/s41591-020-0931-3.
10. Cha AE. Artificial intelligence and COVID-19: Can the machines save us? Washington Post. 2020 Nov 1.
11. Wiggers K. Researchers find evidence of racial, gender, and socioeconomic bias in chest X-ray classifiers. The Machine: Making Sense of AI. 2020 Oct 21.
12. The Doctors Company. “The Algorithm Will See You Now: How AI’s Healthcare Potential Outweighs Its Risk” 2020 Jan.
13. Sewalk K. Innovative disease surveillance platforms detected early warning signs for novel coronavirus outbreak (nCoV-2019). The Disease Daily. 2020 Jan 31.
Editor’s note: This article has been provided by The Doctors Company, the exclusively endorsed medical malpractice carrier for the Society of Hospital Medicine.
Artificial intelligence (AI) has proven of value in the COVID-19 pandemic and shows promise for mitigating future health care crises. During the pandemic’s first wave in New York, for example, Mount Sinai Health System used an algorithm to help identify patients ready for discharge. Such systems can help overburdened hospitals manage personnel and the flow of supplies in a medical crisis so they can continue to provide superior patient care.1
Pandemic applications have demonstrated AI’s potential not only to lift administrative burdens, but also to give physicians back what Eric Topol, MD, founder and director of Scripps Research Translational Institute and author of Deep Medicine, calls “the gift of time.”2 More time with patients contributes to clear communication and positive relationships, which lower the odds of medical errors, enhance patient safety, and potentially reduce physicians’ risks of certain types of litigation.3
However, physicians and health systems will need to approach AI with caution. Many unknowns remain – including potential liability risks and the potential for worsening preexisting bias. The law will need to evolve to account for AI-related liability scenarios, some of which are yet to be imagined.
Like any emerging technology, AI brings risk, but its promise of benefit should outweigh the probability of negative consequences – provided we remain aware of and mitigate the potential for AI-induced adverse events.
AI’s pandemic success limited due to fragmented data
Innovation is the key to success in any crisis, and many health care providers have shown their ability to innovate with AI during the pandemic. For example, researchers at the University of California, San Diego, health system who were designing an AI program to help doctors spot pneumonia on a chest x-ray retooled their application to assist physicians fighting coronavirus.4
Meanwhile, AI has been used to distinguish COVID-19–specific symptoms: It was a computer sifting medical records that took anosmia, loss of the sense of smell, from an anecdotal connection to an officially recognized early symptom of the virus.5 This information now helps physicians distinguish COVID-19 from influenza.
However, holding back more innovation is the fragmentation of health care data in the United States. Most AI applications for medicine rely on machine learning; that is, they train on historical patient data to recognize patterns. Therefore, “Everything that we’re doing gets better with a lot more annotated datasets,” Dr. Topol says. Unfortunately, because of our disparate systems, we don’t have centralized data.6 And even if our data were centralized, researchers lack enough reliable COVID-19 data to perfect algorithms in the short term.
Or, put in bleaker terms by the Washington Post: “One of the biggest challenges has been that much data remains siloed inside incompatible computer systems, hoarded by business interests and tangled in geopolitics.”7
The good news is that machine learning and data science platform Kaggle is hosting the COVID-19 Open Research Dataset, or CORD-19, which contains well over 100,000 scholarly articles on COVID-19, SARS, and other relevant infections.8 In lieu of a true central repository of anonymized health data, such large datasets can help train new AI applications in search of new diagnostic tools and therapies.
AI introduces new questions around liability
While AI may eventually be assigned legal personhood, it is not, in fact, a person: It is a tool wielded by individual clinicians, by teams, by health systems, even multiple systems collaborating. Our current liability laws are not ready for the era of digital medicine.
AI algorithms are not perfect. Because we know that diagnostic error is already a major allegation in malpractice claims, we must ask: What happens when a patient alleges that diagnostic error occurred because a physician or physicians leaned too heavily on AI?
In the United States, testing delays have threatened the safety of patients, physicians, and the public by delaying diagnosis of COVID-19. But again, health care providers have applied real innovation – generating novel and useful ideas and applying those ideas – to this problem. For example, researchers at Mount Sinai became the first in the country to combine AI with imaging and clinical data to produce an algorithm that can detect COVID-19 based on computed tomography scans of the chest, in combination with patient information and exposure history.9
AI in health care can help mitigate bias – or worsen it
Machine learning is only as good as the information provided to train the machine. Models trained on partial datasets can skew toward demographics that turned up more often in the data – for example, White race or men over 60. There is concern that “analyses based on faulty or biased algorithms could exacerbate existing racial gaps and other disparities in health care.”10 Already during the pandemic’s first waves, multiple AI systems used to classify x-rays have been found to show racial, gender, and socioeconomic biases.11
Such bias could create high potential for poor recommendations, including false positives and false negatives. It’s critical that system builders are able to explain and qualify their training data and that those who best understand AI-related system risks are the ones who influence health care systems or alter applications to mitigate AI-related harms.12
AI can help spot the next outbreak
More than a week before the World Health Organization released its first warning about a novel coronavirus, the AI platform BlueDot, created in Toronto, spotted an unusual cluster of pneumonia cases in Wuhan, China. Meanwhile, at Boston Children’s Hospital, the AI application Healthmap was scanning social media and news sites for signs of disease cluster, and it, too, flagged the first signs of what would become the COVID-19 outbreak – days before the WHO’s first formal alert.13
These innovative applications of AI in health care demonstrate real promise in detecting future outbreaks of new viruses early. This will allow health care providers and public health officials to get information out sooner, reducing the load on health systems, and ultimately, saving lives.
Dr. Anderson is chairman and chief executive officer, The Doctors Company and TDC Group.
References
1. Gold A. “Coronavirus tests the value of artificial intelligence in medicine” Fierce Biotech. 2020 May 22.
2. Topol E. “Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again” (New York: Hachette Book Group; 2019:285).
3. The Doctors Company. “The Algorithm Will See You Now: How AI’s Healthcare Potential Outweighs Its Risk” 2020 Jan.
4. Gold A. Coronavirus tests the value of artificial intelligence in medicine. Fierce Biotech. 2020 May 22.
5. Cha AE. Artificial intelligence and COVID-19: Can the machines save us? Washington Post. 2020 Nov 1.
6. Reuter E. Hundreds of AI solutions proposed for pandemic, but few are proven. MedCity News. 2020 May 28.
7. Cha AE. Artificial intelligence and COVID-19: Can the machines save us? Washington Post. 2020 Nov 1.
8. Lee K. COVID-19 will accelerate the AI health care revolution. Wired. 2020 May 22.
9. Mei X et al. Artificial intelligence–enabled rapid diagnosis of patients with COVID-19. Nat Med. 2020 May 19;26:1224-8. doi: 10.1038/s41591-020-0931-3.
10. Cha AE. Artificial intelligence and COVID-19: Can the machines save us? Washington Post. 2020 Nov 1.
11. Wiggers K. Researchers find evidence of racial, gender, and socioeconomic bias in chest X-ray classifiers. The Machine: Making Sense of AI. 2020 Oct 21.
12. The Doctors Company. “The Algorithm Will See You Now: How AI’s Healthcare Potential Outweighs Its Risk” 2020 Jan.
13. Sewalk K. Innovative disease surveillance platforms detected early warning signs for novel coronavirus outbreak (nCoV-2019). The Disease Daily. 2020 Jan 31.
Editor’s note: This article has been provided by The Doctors Company, the exclusively endorsed medical malpractice carrier for the Society of Hospital Medicine.
Artificial intelligence (AI) has proven of value in the COVID-19 pandemic and shows promise for mitigating future health care crises. During the pandemic’s first wave in New York, for example, Mount Sinai Health System used an algorithm to help identify patients ready for discharge. Such systems can help overburdened hospitals manage personnel and the flow of supplies in a medical crisis so they can continue to provide superior patient care.1
Pandemic applications have demonstrated AI’s potential not only to lift administrative burdens, but also to give physicians back what Eric Topol, MD, founder and director of Scripps Research Translational Institute and author of Deep Medicine, calls “the gift of time.”2 More time with patients contributes to clear communication and positive relationships, which lower the odds of medical errors, enhance patient safety, and potentially reduce physicians’ risks of certain types of litigation.3
However, physicians and health systems will need to approach AI with caution. Many unknowns remain – including potential liability risks and the potential for worsening preexisting bias. The law will need to evolve to account for AI-related liability scenarios, some of which are yet to be imagined.
Like any emerging technology, AI brings risk, but its promise of benefit should outweigh the probability of negative consequences – provided we remain aware of and mitigate the potential for AI-induced adverse events.
AI’s pandemic success limited due to fragmented data
Innovation is the key to success in any crisis, and many health care providers have shown their ability to innovate with AI during the pandemic. For example, researchers at the University of California, San Diego, health system who were designing an AI program to help doctors spot pneumonia on a chest x-ray retooled their application to assist physicians fighting coronavirus.4
Meanwhile, AI has been used to distinguish COVID-19–specific symptoms: It was a computer sifting medical records that took anosmia, loss of the sense of smell, from an anecdotal connection to an officially recognized early symptom of the virus.5 This information now helps physicians distinguish COVID-19 from influenza.
However, holding back more innovation is the fragmentation of health care data in the United States. Most AI applications for medicine rely on machine learning; that is, they train on historical patient data to recognize patterns. Therefore, “Everything that we’re doing gets better with a lot more annotated datasets,” Dr. Topol says. Unfortunately, because of our disparate systems, we don’t have centralized data.6 And even if our data were centralized, researchers lack enough reliable COVID-19 data to perfect algorithms in the short term.
Or, put in bleaker terms by the Washington Post: “One of the biggest challenges has been that much data remains siloed inside incompatible computer systems, hoarded by business interests and tangled in geopolitics.”7
The good news is that machine learning and data science platform Kaggle is hosting the COVID-19 Open Research Dataset, or CORD-19, which contains well over 100,000 scholarly articles on COVID-19, SARS, and other relevant infections.8 In lieu of a true central repository of anonymized health data, such large datasets can help train new AI applications in search of new diagnostic tools and therapies.
AI introduces new questions around liability
While AI may eventually be assigned legal personhood, it is not, in fact, a person: It is a tool wielded by individual clinicians, by teams, by health systems, even multiple systems collaborating. Our current liability laws are not ready for the era of digital medicine.
AI algorithms are not perfect. Because we know that diagnostic error is already a major allegation in malpractice claims, we must ask: What happens when a patient alleges that diagnostic error occurred because a physician or physicians leaned too heavily on AI?
In the United States, testing delays have threatened the safety of patients, physicians, and the public by delaying diagnosis of COVID-19. But again, health care providers have applied real innovation – generating novel and useful ideas and applying those ideas – to this problem. For example, researchers at Mount Sinai became the first in the country to combine AI with imaging and clinical data to produce an algorithm that can detect COVID-19 based on computed tomography scans of the chest, in combination with patient information and exposure history.9
AI in health care can help mitigate bias – or worsen it
Machine learning is only as good as the information provided to train the machine. Models trained on partial datasets can skew toward demographics that turned up more often in the data – for example, White race or men over 60. There is concern that “analyses based on faulty or biased algorithms could exacerbate existing racial gaps and other disparities in health care.”10 Already during the pandemic’s first waves, multiple AI systems used to classify x-rays have been found to show racial, gender, and socioeconomic biases.11
Such bias could create high potential for poor recommendations, including false positives and false negatives. It’s critical that system builders are able to explain and qualify their training data and that those who best understand AI-related system risks are the ones who influence health care systems or alter applications to mitigate AI-related harms.12
AI can help spot the next outbreak
More than a week before the World Health Organization released its first warning about a novel coronavirus, the AI platform BlueDot, created in Toronto, spotted an unusual cluster of pneumonia cases in Wuhan, China. Meanwhile, at Boston Children’s Hospital, the AI application Healthmap was scanning social media and news sites for signs of disease cluster, and it, too, flagged the first signs of what would become the COVID-19 outbreak – days before the WHO’s first formal alert.13
These innovative applications of AI in health care demonstrate real promise in detecting future outbreaks of new viruses early. This will allow health care providers and public health officials to get information out sooner, reducing the load on health systems, and ultimately, saving lives.
Dr. Anderson is chairman and chief executive officer, The Doctors Company and TDC Group.
References
1. Gold A. “Coronavirus tests the value of artificial intelligence in medicine” Fierce Biotech. 2020 May 22.
2. Topol E. “Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again” (New York: Hachette Book Group; 2019:285).
3. The Doctors Company. “The Algorithm Will See You Now: How AI’s Healthcare Potential Outweighs Its Risk” 2020 Jan.
4. Gold A. Coronavirus tests the value of artificial intelligence in medicine. Fierce Biotech. 2020 May 22.
5. Cha AE. Artificial intelligence and COVID-19: Can the machines save us? Washington Post. 2020 Nov 1.
6. Reuter E. Hundreds of AI solutions proposed for pandemic, but few are proven. MedCity News. 2020 May 28.
7. Cha AE. Artificial intelligence and COVID-19: Can the machines save us? Washington Post. 2020 Nov 1.
8. Lee K. COVID-19 will accelerate the AI health care revolution. Wired. 2020 May 22.
9. Mei X et al. Artificial intelligence–enabled rapid diagnosis of patients with COVID-19. Nat Med. 2020 May 19;26:1224-8. doi: 10.1038/s41591-020-0931-3.
10. Cha AE. Artificial intelligence and COVID-19: Can the machines save us? Washington Post. 2020 Nov 1.
11. Wiggers K. Researchers find evidence of racial, gender, and socioeconomic bias in chest X-ray classifiers. The Machine: Making Sense of AI. 2020 Oct 21.
12. The Doctors Company. “The Algorithm Will See You Now: How AI’s Healthcare Potential Outweighs Its Risk” 2020 Jan.
13. Sewalk K. Innovative disease surveillance platforms detected early warning signs for novel coronavirus outbreak (nCoV-2019). The Disease Daily. 2020 Jan 31.
‘Staggering’ doubling of type 2 diabetes in children during pandemic
The incidence of type 2 diabetes in children appears to have doubled during the COVID-19 pandemic, data from two new U.S. studies suggest, with the lead investigator of one saying she was “surprised by the staggering increase in cases of type 2 diabetes ... and the increase in severity of presentation.”
Findings from the two separate retrospective chart reviews – one conducted in Washington, D.C., and the other in Baton Rouge, La. – were presented June 25 at the annual scientific sessions of the American Diabetes Association.
Although the two studies differed somewhat in the clinical parameters examined, both revealed a similar doubling of the rates of hospitalizations for type 2 diabetes among youth during 2020, compared with the same time period in 2019, as well as greater severity of metabolic disturbance.
And, as has been previously described with type 2 diabetes in youth, African American ethnicity predominated in both cohorts.
“Although we could not assess the cause of the increases in type 2 diabetes from our data, these disparities suggest that indirect effects of social distancing measures, including school closure and unemployment, are placing undue burden on underserved communities. Decreases in well-child care and fears of seeking medical care during the pandemic may have also contributed,” lead investigator of one of the studies, pediatric endocrinologist Brynn E. Marks, MD, Children’s National Hospital, Washington, said in an interview.
More hospitalizations, racial disparities aggravated by COVID-19
Lead author of the other study, Daniel S. Hsia, MD, Pennington Biomedical Research Center, Baton Rouge, said in an interview: “Since the pandemic, our data suggest that more children may be diagnosed with type 2 diabetes and may require hospitalization when they are diagnosed. Looking at both datasets, there appears to be a racial disparity in type 2 diabetes diagnoses that has only been exacerbated by the COVID-19 pandemic.”
Of concern, Dr. Hsia said, “The incidence rate of type 2 diabetes in children was already on the rise before the pandemic. While there may be a brief leveling off now that children are getting regular health care and going back to school in person, I believe these rates will continue to rise especially in light of the childhood obesity rates not improving.”
Their dataset captured all youth who were newly diagnosed with type 2 diabetes during the first full year of the COVID-19 pandemic, from March 11, 2020, to March 10, 2021, and compared those data with the time period from March 11, 2019, to March 10, 2020.
During the pandemic, the number of cases of type 2 diabetes increased by 182%, from 50 in 2019 to 141 in 2020. The average age at diagnosis was about 14 years in both time periods.
In the prepandemic period, 18 (36%) diagnosed with type 2 diabetes required inpatient admission, compared with 85 (60.3%) during the pandemic. At Children’s National, youth with suspected new-onset type 2 diabetes aren’t typically hospitalized unless they have severe hyperglycemia, ketosis, or are unable to schedule urgent outpatient follow-up, Dr. Marks noted.
The proportions of youth with new-onset type 2 diabetes who presented in diabetic ketoacidosis (DKA) rose from 2 (4%) prepandemic to 33 (23.4%) during the pandemic. Presentation with hyperosmolar DKA rose from 0 to 13 (9.2%).
However, during the pandemic only five youth were actively infected with SARS-CoV-2 at the time of type 2 diabetes diagnosis among the 90 tested.
Dr. Marks said: “We believe the increase in inpatient admissions was due to more severe presentation during the pandemic. ...We were surprised by the staggering increase in cases of type 2 diabetes ... and the increase in severity of presentation.”
Shift in diagnoses to type 2 diabetes
The pandemic also appears to have shifted the proportion of youth diagnosed with type 2 diabetes, compared with type 1 diabetes. Whereas 24% of youth with new-onset diabetes prepandemic had type 2 diabetes and the rest had type 1 diabetes, during pandemic the proportion with type 2 diabetes rose to 44%.
“Rates of type 2 diabetes rose steadily at a rate of 1.45 cases per month throughout the course of the pandemic, suggesting a cumulative effect of the indirect effects of social distancing measures,” Dr. Marks said.
Furthermore, she added, whereas 60% of youth diagnosed with type 2 diabetes before the pandemic were female, the rate fell to 40% during the pandemic. This trend might be because of activity levels in that, while male adolescents are typically more active, rates of exercise fell in both sexes during the pandemic but declined more sharply in males such that activity levels between the sexes became equal.
Although type 2 diabetes in youth has always been more common in ethnic minorities, the pandemic appears to have exacerbated these disparities.
While 58% of youth diagnosed with type 2 diabetes prepandemic identified as non-Hispanic Black, that proportion rose to 76.7% during the pandemic. Among Black youth with new-onset type 2 diabetes, 31 of 33 presented in DKA, and 12 of the 13 who presented in hyperosmolar DKA during the pandemic were Black.
“Strategies to promote health equity and address the undue burden of the COVID-19 pandemic on underserved communities must be developed to avoid worsening disparities and long-term health outcomes,” Dr. Marks said.
‘A microcosm’: Similar findings in a smaller population
Dr. Hsia and colleagues looked at a smaller number of patients in a shorter time period. In March–December 2019, the hospitalization rate for new-onset type 2 diabetes was 0.27% (8 out of 2,964 hospitalizations), compared with 0.62% (17 out of 2,729 hospitalizations) during the same period in 2020 (P < .048) – also more than a doubling. Age at admission, sex, and body mass index didn’t differ between the two groups.
Criteria for DKA were met by three children in 2019 versus eight in 2020, and hyperosmolar hyperglycemic syndrome in zero versus two, respectively. Mean hemoglobin A1c on admission was 12.4% in 2019 versus 13.1% in 2020 (P = .59), and mean serum glucose was 441 mg/dL versus 669 mg/dL (P = .14), respectively. Serum osmolality on admission was 314 mmol/kg in 2019 versus 335 mmol/kg in 2020 (P = .19).
“Clinically speaking the differences in the lab values were significant, but we did not have enough numbers ... to see a statistically significant difference. I think by looking at more centers, our site likely represents a microcosm of what is happening across the country,” Dr. Hsia said.
In 2019, 7 of the 8 children were African American, as were 16 of the 17 children in 2020. The other single child in each group was White.
Dr. Hsia said: “Larger studies that include more patients are needed to confirm our initial findings. More research is needed to understand why this increasing trend of type 2 diabetes diagnoses in children may be occurring [and] to better understand how stay-at-home orders and other restrictions due to COVID-19 have worsened risk factors for type 2 diabetes.”
“These include decreased physical activity, more screen time, disturbed sleep, and increased intake of processed foods, which can all lead to weight gain,” he concluded.
Dr. Marks reported receiving research support from Tandem, Dexcom, and the Cystic Fibrosis Foundation. Dr. Hsia reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
The incidence of type 2 diabetes in children appears to have doubled during the COVID-19 pandemic, data from two new U.S. studies suggest, with the lead investigator of one saying she was “surprised by the staggering increase in cases of type 2 diabetes ... and the increase in severity of presentation.”
Findings from the two separate retrospective chart reviews – one conducted in Washington, D.C., and the other in Baton Rouge, La. – were presented June 25 at the annual scientific sessions of the American Diabetes Association.
Although the two studies differed somewhat in the clinical parameters examined, both revealed a similar doubling of the rates of hospitalizations for type 2 diabetes among youth during 2020, compared with the same time period in 2019, as well as greater severity of metabolic disturbance.
And, as has been previously described with type 2 diabetes in youth, African American ethnicity predominated in both cohorts.
“Although we could not assess the cause of the increases in type 2 diabetes from our data, these disparities suggest that indirect effects of social distancing measures, including school closure and unemployment, are placing undue burden on underserved communities. Decreases in well-child care and fears of seeking medical care during the pandemic may have also contributed,” lead investigator of one of the studies, pediatric endocrinologist Brynn E. Marks, MD, Children’s National Hospital, Washington, said in an interview.
More hospitalizations, racial disparities aggravated by COVID-19
Lead author of the other study, Daniel S. Hsia, MD, Pennington Biomedical Research Center, Baton Rouge, said in an interview: “Since the pandemic, our data suggest that more children may be diagnosed with type 2 diabetes and may require hospitalization when they are diagnosed. Looking at both datasets, there appears to be a racial disparity in type 2 diabetes diagnoses that has only been exacerbated by the COVID-19 pandemic.”
Of concern, Dr. Hsia said, “The incidence rate of type 2 diabetes in children was already on the rise before the pandemic. While there may be a brief leveling off now that children are getting regular health care and going back to school in person, I believe these rates will continue to rise especially in light of the childhood obesity rates not improving.”
Their dataset captured all youth who were newly diagnosed with type 2 diabetes during the first full year of the COVID-19 pandemic, from March 11, 2020, to March 10, 2021, and compared those data with the time period from March 11, 2019, to March 10, 2020.
During the pandemic, the number of cases of type 2 diabetes increased by 182%, from 50 in 2019 to 141 in 2020. The average age at diagnosis was about 14 years in both time periods.
In the prepandemic period, 18 (36%) diagnosed with type 2 diabetes required inpatient admission, compared with 85 (60.3%) during the pandemic. At Children’s National, youth with suspected new-onset type 2 diabetes aren’t typically hospitalized unless they have severe hyperglycemia, ketosis, or are unable to schedule urgent outpatient follow-up, Dr. Marks noted.
The proportions of youth with new-onset type 2 diabetes who presented in diabetic ketoacidosis (DKA) rose from 2 (4%) prepandemic to 33 (23.4%) during the pandemic. Presentation with hyperosmolar DKA rose from 0 to 13 (9.2%).
However, during the pandemic only five youth were actively infected with SARS-CoV-2 at the time of type 2 diabetes diagnosis among the 90 tested.
Dr. Marks said: “We believe the increase in inpatient admissions was due to more severe presentation during the pandemic. ...We were surprised by the staggering increase in cases of type 2 diabetes ... and the increase in severity of presentation.”
Shift in diagnoses to type 2 diabetes
The pandemic also appears to have shifted the proportion of youth diagnosed with type 2 diabetes, compared with type 1 diabetes. Whereas 24% of youth with new-onset diabetes prepandemic had type 2 diabetes and the rest had type 1 diabetes, during pandemic the proportion with type 2 diabetes rose to 44%.
“Rates of type 2 diabetes rose steadily at a rate of 1.45 cases per month throughout the course of the pandemic, suggesting a cumulative effect of the indirect effects of social distancing measures,” Dr. Marks said.
Furthermore, she added, whereas 60% of youth diagnosed with type 2 diabetes before the pandemic were female, the rate fell to 40% during the pandemic. This trend might be because of activity levels in that, while male adolescents are typically more active, rates of exercise fell in both sexes during the pandemic but declined more sharply in males such that activity levels between the sexes became equal.
Although type 2 diabetes in youth has always been more common in ethnic minorities, the pandemic appears to have exacerbated these disparities.
While 58% of youth diagnosed with type 2 diabetes prepandemic identified as non-Hispanic Black, that proportion rose to 76.7% during the pandemic. Among Black youth with new-onset type 2 diabetes, 31 of 33 presented in DKA, and 12 of the 13 who presented in hyperosmolar DKA during the pandemic were Black.
“Strategies to promote health equity and address the undue burden of the COVID-19 pandemic on underserved communities must be developed to avoid worsening disparities and long-term health outcomes,” Dr. Marks said.
‘A microcosm’: Similar findings in a smaller population
Dr. Hsia and colleagues looked at a smaller number of patients in a shorter time period. In March–December 2019, the hospitalization rate for new-onset type 2 diabetes was 0.27% (8 out of 2,964 hospitalizations), compared with 0.62% (17 out of 2,729 hospitalizations) during the same period in 2020 (P < .048) – also more than a doubling. Age at admission, sex, and body mass index didn’t differ between the two groups.
Criteria for DKA were met by three children in 2019 versus eight in 2020, and hyperosmolar hyperglycemic syndrome in zero versus two, respectively. Mean hemoglobin A1c on admission was 12.4% in 2019 versus 13.1% in 2020 (P = .59), and mean serum glucose was 441 mg/dL versus 669 mg/dL (P = .14), respectively. Serum osmolality on admission was 314 mmol/kg in 2019 versus 335 mmol/kg in 2020 (P = .19).
“Clinically speaking the differences in the lab values were significant, but we did not have enough numbers ... to see a statistically significant difference. I think by looking at more centers, our site likely represents a microcosm of what is happening across the country,” Dr. Hsia said.
In 2019, 7 of the 8 children were African American, as were 16 of the 17 children in 2020. The other single child in each group was White.
Dr. Hsia said: “Larger studies that include more patients are needed to confirm our initial findings. More research is needed to understand why this increasing trend of type 2 diabetes diagnoses in children may be occurring [and] to better understand how stay-at-home orders and other restrictions due to COVID-19 have worsened risk factors for type 2 diabetes.”
“These include decreased physical activity, more screen time, disturbed sleep, and increased intake of processed foods, which can all lead to weight gain,” he concluded.
Dr. Marks reported receiving research support from Tandem, Dexcom, and the Cystic Fibrosis Foundation. Dr. Hsia reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
The incidence of type 2 diabetes in children appears to have doubled during the COVID-19 pandemic, data from two new U.S. studies suggest, with the lead investigator of one saying she was “surprised by the staggering increase in cases of type 2 diabetes ... and the increase in severity of presentation.”
Findings from the two separate retrospective chart reviews – one conducted in Washington, D.C., and the other in Baton Rouge, La. – were presented June 25 at the annual scientific sessions of the American Diabetes Association.
Although the two studies differed somewhat in the clinical parameters examined, both revealed a similar doubling of the rates of hospitalizations for type 2 diabetes among youth during 2020, compared with the same time period in 2019, as well as greater severity of metabolic disturbance.
And, as has been previously described with type 2 diabetes in youth, African American ethnicity predominated in both cohorts.
“Although we could not assess the cause of the increases in type 2 diabetes from our data, these disparities suggest that indirect effects of social distancing measures, including school closure and unemployment, are placing undue burden on underserved communities. Decreases in well-child care and fears of seeking medical care during the pandemic may have also contributed,” lead investigator of one of the studies, pediatric endocrinologist Brynn E. Marks, MD, Children’s National Hospital, Washington, said in an interview.
More hospitalizations, racial disparities aggravated by COVID-19
Lead author of the other study, Daniel S. Hsia, MD, Pennington Biomedical Research Center, Baton Rouge, said in an interview: “Since the pandemic, our data suggest that more children may be diagnosed with type 2 diabetes and may require hospitalization when they are diagnosed. Looking at both datasets, there appears to be a racial disparity in type 2 diabetes diagnoses that has only been exacerbated by the COVID-19 pandemic.”
Of concern, Dr. Hsia said, “The incidence rate of type 2 diabetes in children was already on the rise before the pandemic. While there may be a brief leveling off now that children are getting regular health care and going back to school in person, I believe these rates will continue to rise especially in light of the childhood obesity rates not improving.”
Their dataset captured all youth who were newly diagnosed with type 2 diabetes during the first full year of the COVID-19 pandemic, from March 11, 2020, to March 10, 2021, and compared those data with the time period from March 11, 2019, to March 10, 2020.
During the pandemic, the number of cases of type 2 diabetes increased by 182%, from 50 in 2019 to 141 in 2020. The average age at diagnosis was about 14 years in both time periods.
In the prepandemic period, 18 (36%) diagnosed with type 2 diabetes required inpatient admission, compared with 85 (60.3%) during the pandemic. At Children’s National, youth with suspected new-onset type 2 diabetes aren’t typically hospitalized unless they have severe hyperglycemia, ketosis, or are unable to schedule urgent outpatient follow-up, Dr. Marks noted.
The proportions of youth with new-onset type 2 diabetes who presented in diabetic ketoacidosis (DKA) rose from 2 (4%) prepandemic to 33 (23.4%) during the pandemic. Presentation with hyperosmolar DKA rose from 0 to 13 (9.2%).
However, during the pandemic only five youth were actively infected with SARS-CoV-2 at the time of type 2 diabetes diagnosis among the 90 tested.
Dr. Marks said: “We believe the increase in inpatient admissions was due to more severe presentation during the pandemic. ...We were surprised by the staggering increase in cases of type 2 diabetes ... and the increase in severity of presentation.”
Shift in diagnoses to type 2 diabetes
The pandemic also appears to have shifted the proportion of youth diagnosed with type 2 diabetes, compared with type 1 diabetes. Whereas 24% of youth with new-onset diabetes prepandemic had type 2 diabetes and the rest had type 1 diabetes, during pandemic the proportion with type 2 diabetes rose to 44%.
“Rates of type 2 diabetes rose steadily at a rate of 1.45 cases per month throughout the course of the pandemic, suggesting a cumulative effect of the indirect effects of social distancing measures,” Dr. Marks said.
Furthermore, she added, whereas 60% of youth diagnosed with type 2 diabetes before the pandemic were female, the rate fell to 40% during the pandemic. This trend might be because of activity levels in that, while male adolescents are typically more active, rates of exercise fell in both sexes during the pandemic but declined more sharply in males such that activity levels between the sexes became equal.
Although type 2 diabetes in youth has always been more common in ethnic minorities, the pandemic appears to have exacerbated these disparities.
While 58% of youth diagnosed with type 2 diabetes prepandemic identified as non-Hispanic Black, that proportion rose to 76.7% during the pandemic. Among Black youth with new-onset type 2 diabetes, 31 of 33 presented in DKA, and 12 of the 13 who presented in hyperosmolar DKA during the pandemic were Black.
“Strategies to promote health equity and address the undue burden of the COVID-19 pandemic on underserved communities must be developed to avoid worsening disparities and long-term health outcomes,” Dr. Marks said.
‘A microcosm’: Similar findings in a smaller population
Dr. Hsia and colleagues looked at a smaller number of patients in a shorter time period. In March–December 2019, the hospitalization rate for new-onset type 2 diabetes was 0.27% (8 out of 2,964 hospitalizations), compared with 0.62% (17 out of 2,729 hospitalizations) during the same period in 2020 (P < .048) – also more than a doubling. Age at admission, sex, and body mass index didn’t differ between the two groups.
Criteria for DKA were met by three children in 2019 versus eight in 2020, and hyperosmolar hyperglycemic syndrome in zero versus two, respectively. Mean hemoglobin A1c on admission was 12.4% in 2019 versus 13.1% in 2020 (P = .59), and mean serum glucose was 441 mg/dL versus 669 mg/dL (P = .14), respectively. Serum osmolality on admission was 314 mmol/kg in 2019 versus 335 mmol/kg in 2020 (P = .19).
“Clinically speaking the differences in the lab values were significant, but we did not have enough numbers ... to see a statistically significant difference. I think by looking at more centers, our site likely represents a microcosm of what is happening across the country,” Dr. Hsia said.
In 2019, 7 of the 8 children were African American, as were 16 of the 17 children in 2020. The other single child in each group was White.
Dr. Hsia said: “Larger studies that include more patients are needed to confirm our initial findings. More research is needed to understand why this increasing trend of type 2 diabetes diagnoses in children may be occurring [and] to better understand how stay-at-home orders and other restrictions due to COVID-19 have worsened risk factors for type 2 diabetes.”
“These include decreased physical activity, more screen time, disturbed sleep, and increased intake of processed foods, which can all lead to weight gain,” he concluded.
Dr. Marks reported receiving research support from Tandem, Dexcom, and the Cystic Fibrosis Foundation. Dr. Hsia reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Unmanaged diabetes, high blood glucose tied to COVID-19 severity
Unmanaged diabetes and high blood glucose levels are linked to more severe COVID-19 and worse rates of recovery, according to results of a retrospective study.
Patients not managing their diabetes with medication had more severe COVID-19 and length of hospitalization, compared with those who were taking medication, investigator Sudip Bajpeyi, PhD, said at the annual scientific sessions of the American Diabetes Association.
In addition, patients with higher blood glucose levels had more severe COVID-19 and longer hospital stays.
Those findings underscore the need to assess, monitor, and control blood glucose, especially in vulnerable populations, said Dr. Bajpeyi, director of the Metabolic, Nutrition, and Exercise Research Laboratory in the University of Texas, El Paso, who added that nearly 90% of the study subjects were Hispanic.
“As public health decisions are made, we think fasting blood glucose should be considered in the treatment of hospitalized COVID-19 patients,” he said in a press conference.
Links between diabetes and COVID-19
There are now many reports in medical literature that link diabetes to increased risk of COVID-19 severity, according to Ali Mossayebi, a master’s student who worked on the study. However, there are fewer studies that have looked specifically at the implications of poor diabetes management or acute glycemic control, the investigators said.
It’s known that poorly controlled diabetes can have severe health consequences, including higher risks for life-threatening comorbidities, they added.
Their retrospective study focused on medical records from 364 patients with COVID-19 admitted to a medical center in El Paso. Their mean age was 60 years, and their mean body mass index was 30.3 kg/m2; 87% were Hispanic.
Acute glycemic control was assessed by fasting blood glucose at the time of hospitalization, while chronic glycemic control was assessed by hemoglobin A1c, the investigators said. Severity of COVID-19 was measured with the Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA), which is based on the patient’s respiratory rate, blood pressure, and mental status.
Impact of unmanaged diabetes and high blood glucose
Severity of COVID-19 severity and length of hospital stay were significantly greater in patients with unmanaged diabetes, as compared with those who reported that they managed their diabetes with medication, Dr. Bajpeyi and coinvestigators found.
Among patients with unmanaged diabetes, the mean qSOFA score was 0.22, as compared with 0.44 for patients with managed diabetes. The mean length of hospital stay was 10.8 days for patients with unmanaged diabetes and 8.2 days for those with medication-managed diabetes, according to the abstract.
COVID-19 severity and hospital stay length were highest among patients with acute glycemia, the investigators further reported in an electronic poster that was part of the ADA meeting proceedings.
The mean qSOFA score was about 0.6 for patients with blood glucose levels of at least 126 mg/dL and A1c below 6.5%, and roughly 0.2 for those with normal blood glucose and normal A1c. Similarly, duration of hospital stay was significantly higher for patients with high blood glucose and A1c as compared with those with normal blood glucose and A1c.
Aggressive treatment needed
Findings of this study are in line with previous research showing that in-hospital hyperglycemia is a common and important marker of poor clinical outcome and mortality, with or without diabetes, according to Rodolfo J. Galindo, MD, FACE, medical chair of the hospital diabetes task force at Emory Healthcare System, Atlanta.
“These patients need aggressive treatment of hyperglycemia, regardless of the diagnosis of diabetes or A1c value,” said Dr. Galindo, who was not involved in the study. “They also need outpatient follow-up after discharge, because they may develop diabetes soon after.”
Follow-up within is important because roughly 30% of patients with stress hyperglycemia (increases in blood glucose during an acute illness) will develop diabetes within a year, according to Dr. Galindo.
“We do not know in COVID-10 patients if it is only 30%,” he said, “Our thinking in our group is that it’s probably higher.”
Dr. Bajpeyi and coauthors reported no disclosures. Dr. Galindo reported disclosures related to Abbott Diabetes, Boehringer Ingelheim International, Eli Lilly, Novo Nordisk, Sanofi US, Valeritas, and Dexcom.
Unmanaged diabetes and high blood glucose levels are linked to more severe COVID-19 and worse rates of recovery, according to results of a retrospective study.
Patients not managing their diabetes with medication had more severe COVID-19 and length of hospitalization, compared with those who were taking medication, investigator Sudip Bajpeyi, PhD, said at the annual scientific sessions of the American Diabetes Association.
In addition, patients with higher blood glucose levels had more severe COVID-19 and longer hospital stays.
Those findings underscore the need to assess, monitor, and control blood glucose, especially in vulnerable populations, said Dr. Bajpeyi, director of the Metabolic, Nutrition, and Exercise Research Laboratory in the University of Texas, El Paso, who added that nearly 90% of the study subjects were Hispanic.
“As public health decisions are made, we think fasting blood glucose should be considered in the treatment of hospitalized COVID-19 patients,” he said in a press conference.
Links between diabetes and COVID-19
There are now many reports in medical literature that link diabetes to increased risk of COVID-19 severity, according to Ali Mossayebi, a master’s student who worked on the study. However, there are fewer studies that have looked specifically at the implications of poor diabetes management or acute glycemic control, the investigators said.
It’s known that poorly controlled diabetes can have severe health consequences, including higher risks for life-threatening comorbidities, they added.
Their retrospective study focused on medical records from 364 patients with COVID-19 admitted to a medical center in El Paso. Their mean age was 60 years, and their mean body mass index was 30.3 kg/m2; 87% were Hispanic.
Acute glycemic control was assessed by fasting blood glucose at the time of hospitalization, while chronic glycemic control was assessed by hemoglobin A1c, the investigators said. Severity of COVID-19 was measured with the Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA), which is based on the patient’s respiratory rate, blood pressure, and mental status.
Impact of unmanaged diabetes and high blood glucose
Severity of COVID-19 severity and length of hospital stay were significantly greater in patients with unmanaged diabetes, as compared with those who reported that they managed their diabetes with medication, Dr. Bajpeyi and coinvestigators found.
Among patients with unmanaged diabetes, the mean qSOFA score was 0.22, as compared with 0.44 for patients with managed diabetes. The mean length of hospital stay was 10.8 days for patients with unmanaged diabetes and 8.2 days for those with medication-managed diabetes, according to the abstract.
COVID-19 severity and hospital stay length were highest among patients with acute glycemia, the investigators further reported in an electronic poster that was part of the ADA meeting proceedings.
The mean qSOFA score was about 0.6 for patients with blood glucose levels of at least 126 mg/dL and A1c below 6.5%, and roughly 0.2 for those with normal blood glucose and normal A1c. Similarly, duration of hospital stay was significantly higher for patients with high blood glucose and A1c as compared with those with normal blood glucose and A1c.
Aggressive treatment needed
Findings of this study are in line with previous research showing that in-hospital hyperglycemia is a common and important marker of poor clinical outcome and mortality, with or without diabetes, according to Rodolfo J. Galindo, MD, FACE, medical chair of the hospital diabetes task force at Emory Healthcare System, Atlanta.
“These patients need aggressive treatment of hyperglycemia, regardless of the diagnosis of diabetes or A1c value,” said Dr. Galindo, who was not involved in the study. “They also need outpatient follow-up after discharge, because they may develop diabetes soon after.”
Follow-up within is important because roughly 30% of patients with stress hyperglycemia (increases in blood glucose during an acute illness) will develop diabetes within a year, according to Dr. Galindo.
“We do not know in COVID-10 patients if it is only 30%,” he said, “Our thinking in our group is that it’s probably higher.”
Dr. Bajpeyi and coauthors reported no disclosures. Dr. Galindo reported disclosures related to Abbott Diabetes, Boehringer Ingelheim International, Eli Lilly, Novo Nordisk, Sanofi US, Valeritas, and Dexcom.
Unmanaged diabetes and high blood glucose levels are linked to more severe COVID-19 and worse rates of recovery, according to results of a retrospective study.
Patients not managing their diabetes with medication had more severe COVID-19 and length of hospitalization, compared with those who were taking medication, investigator Sudip Bajpeyi, PhD, said at the annual scientific sessions of the American Diabetes Association.
In addition, patients with higher blood glucose levels had more severe COVID-19 and longer hospital stays.
Those findings underscore the need to assess, monitor, and control blood glucose, especially in vulnerable populations, said Dr. Bajpeyi, director of the Metabolic, Nutrition, and Exercise Research Laboratory in the University of Texas, El Paso, who added that nearly 90% of the study subjects were Hispanic.
“As public health decisions are made, we think fasting blood glucose should be considered in the treatment of hospitalized COVID-19 patients,” he said in a press conference.
Links between diabetes and COVID-19
There are now many reports in medical literature that link diabetes to increased risk of COVID-19 severity, according to Ali Mossayebi, a master’s student who worked on the study. However, there are fewer studies that have looked specifically at the implications of poor diabetes management or acute glycemic control, the investigators said.
It’s known that poorly controlled diabetes can have severe health consequences, including higher risks for life-threatening comorbidities, they added.
Their retrospective study focused on medical records from 364 patients with COVID-19 admitted to a medical center in El Paso. Their mean age was 60 years, and their mean body mass index was 30.3 kg/m2; 87% were Hispanic.
Acute glycemic control was assessed by fasting blood glucose at the time of hospitalization, while chronic glycemic control was assessed by hemoglobin A1c, the investigators said. Severity of COVID-19 was measured with the Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA), which is based on the patient’s respiratory rate, blood pressure, and mental status.
Impact of unmanaged diabetes and high blood glucose
Severity of COVID-19 severity and length of hospital stay were significantly greater in patients with unmanaged diabetes, as compared with those who reported that they managed their diabetes with medication, Dr. Bajpeyi and coinvestigators found.
Among patients with unmanaged diabetes, the mean qSOFA score was 0.22, as compared with 0.44 for patients with managed diabetes. The mean length of hospital stay was 10.8 days for patients with unmanaged diabetes and 8.2 days for those with medication-managed diabetes, according to the abstract.
COVID-19 severity and hospital stay length were highest among patients with acute glycemia, the investigators further reported in an electronic poster that was part of the ADA meeting proceedings.
The mean qSOFA score was about 0.6 for patients with blood glucose levels of at least 126 mg/dL and A1c below 6.5%, and roughly 0.2 for those with normal blood glucose and normal A1c. Similarly, duration of hospital stay was significantly higher for patients with high blood glucose and A1c as compared with those with normal blood glucose and A1c.
Aggressive treatment needed
Findings of this study are in line with previous research showing that in-hospital hyperglycemia is a common and important marker of poor clinical outcome and mortality, with or without diabetes, according to Rodolfo J. Galindo, MD, FACE, medical chair of the hospital diabetes task force at Emory Healthcare System, Atlanta.
“These patients need aggressive treatment of hyperglycemia, regardless of the diagnosis of diabetes or A1c value,” said Dr. Galindo, who was not involved in the study. “They also need outpatient follow-up after discharge, because they may develop diabetes soon after.”
Follow-up within is important because roughly 30% of patients with stress hyperglycemia (increases in blood glucose during an acute illness) will develop diabetes within a year, according to Dr. Galindo.
“We do not know in COVID-10 patients if it is only 30%,” he said, “Our thinking in our group is that it’s probably higher.”
Dr. Bajpeyi and coauthors reported no disclosures. Dr. Galindo reported disclosures related to Abbott Diabetes, Boehringer Ingelheim International, Eli Lilly, Novo Nordisk, Sanofi US, Valeritas, and Dexcom.
FROM ADA 2020
Profound brain changes found in patients who died of COVID-19
The most comprehensive molecular study to date of brain tissue from people who died of COVID-19 provides clear evidence that SARS-CoV-2 causes profound molecular changes in the brain, despite no molecular trace of the virus in brain tissue.
“The signature the virus leaves in the brain speaks of strong inflammation and disrupted brain circuits and resembles signatures the field has observed in Alzheimer’s or other neurodegenerative diseases,” senior author Tony Wyss-Coray, PhD, professor of neurology and neurological sciences, Stanford (Calif.) University, told this news organization.
The study was published online June 21 in Nature.
Signs of distress
“We know that up to a third of SARS-CoV-2-infected people show brain symptoms including brain fog, memory problems, and fatigue, and a growing number of people have such symptoms long after they [have] seemingly recovered from virus infection,” said Dr. Wyss-Coray.
“However, we have very little understanding of how the virus causes these symptoms and what its effects are on the brain at a molecular level,” he added.
Using single-cell RNA sequencing, the researchers profiled the transcriptomes of 65,309 nuclei isolated from frontal cortex and choroid plexus samples from eight patients who died of COVID-19 and 14 controls who died of other causes.
There was no molecular evidence of SARS-CoV-2 in brain tissue samples from the patients who died of COVID-19.
Yet, “we were very surprised to learn that no matter which type of cell we studied (different types of nerve cells, immune cells, or different support cells in the brain) there were prominent changes” compared with brain tissue samples from controls who died of other causes, said Dr. Wyss-Coray.
The changes in the COVID-19 brains showed signatures of inflammation, abnormal nerve cell communication, and chronic neurodegeneration.
“Across cell types, COVID-19 perturbations overlap with those in chronic brain disorders and reside in genetic variants associated with cognition, schizophrenia, and depression,” the researchers report.
“Viral infection appears to trigger inflammatory responses throughout the body that may cause inflammatory signaling across the blood–brain barrier, which in turn could ‘trip off’ neuroinflammation in the brain,” Dr. Wyss-Coray said.
The findings may help explain the brain fog, fatigue, and other neurological and psychiatric symptoms of long COVID.
“While we studied only brains from people who died of COVID-19, we believe it is likely that similar, but hopefully weaker, signs of inflammation and chronic neurodegeneration will be found in COVID-19 survivors, especially those with chronic brain symptoms,” Dr. Wyss-Coray said.
This research was funded by the Nomis Foundation, the National Institutes of Health, Nan Fung Life Sciences, the Wu Tsai Neurosciences Institute and the Stanford Alzheimer’s Disease Research Center. The authors have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
The most comprehensive molecular study to date of brain tissue from people who died of COVID-19 provides clear evidence that SARS-CoV-2 causes profound molecular changes in the brain, despite no molecular trace of the virus in brain tissue.
“The signature the virus leaves in the brain speaks of strong inflammation and disrupted brain circuits and resembles signatures the field has observed in Alzheimer’s or other neurodegenerative diseases,” senior author Tony Wyss-Coray, PhD, professor of neurology and neurological sciences, Stanford (Calif.) University, told this news organization.
The study was published online June 21 in Nature.
Signs of distress
“We know that up to a third of SARS-CoV-2-infected people show brain symptoms including brain fog, memory problems, and fatigue, and a growing number of people have such symptoms long after they [have] seemingly recovered from virus infection,” said Dr. Wyss-Coray.
“However, we have very little understanding of how the virus causes these symptoms and what its effects are on the brain at a molecular level,” he added.
Using single-cell RNA sequencing, the researchers profiled the transcriptomes of 65,309 nuclei isolated from frontal cortex and choroid plexus samples from eight patients who died of COVID-19 and 14 controls who died of other causes.
There was no molecular evidence of SARS-CoV-2 in brain tissue samples from the patients who died of COVID-19.
Yet, “we were very surprised to learn that no matter which type of cell we studied (different types of nerve cells, immune cells, or different support cells in the brain) there were prominent changes” compared with brain tissue samples from controls who died of other causes, said Dr. Wyss-Coray.
The changes in the COVID-19 brains showed signatures of inflammation, abnormal nerve cell communication, and chronic neurodegeneration.
“Across cell types, COVID-19 perturbations overlap with those in chronic brain disorders and reside in genetic variants associated with cognition, schizophrenia, and depression,” the researchers report.
“Viral infection appears to trigger inflammatory responses throughout the body that may cause inflammatory signaling across the blood–brain barrier, which in turn could ‘trip off’ neuroinflammation in the brain,” Dr. Wyss-Coray said.
The findings may help explain the brain fog, fatigue, and other neurological and psychiatric symptoms of long COVID.
“While we studied only brains from people who died of COVID-19, we believe it is likely that similar, but hopefully weaker, signs of inflammation and chronic neurodegeneration will be found in COVID-19 survivors, especially those with chronic brain symptoms,” Dr. Wyss-Coray said.
This research was funded by the Nomis Foundation, the National Institutes of Health, Nan Fung Life Sciences, the Wu Tsai Neurosciences Institute and the Stanford Alzheimer’s Disease Research Center. The authors have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
The most comprehensive molecular study to date of brain tissue from people who died of COVID-19 provides clear evidence that SARS-CoV-2 causes profound molecular changes in the brain, despite no molecular trace of the virus in brain tissue.
“The signature the virus leaves in the brain speaks of strong inflammation and disrupted brain circuits and resembles signatures the field has observed in Alzheimer’s or other neurodegenerative diseases,” senior author Tony Wyss-Coray, PhD, professor of neurology and neurological sciences, Stanford (Calif.) University, told this news organization.
The study was published online June 21 in Nature.
Signs of distress
“We know that up to a third of SARS-CoV-2-infected people show brain symptoms including brain fog, memory problems, and fatigue, and a growing number of people have such symptoms long after they [have] seemingly recovered from virus infection,” said Dr. Wyss-Coray.
“However, we have very little understanding of how the virus causes these symptoms and what its effects are on the brain at a molecular level,” he added.
Using single-cell RNA sequencing, the researchers profiled the transcriptomes of 65,309 nuclei isolated from frontal cortex and choroid plexus samples from eight patients who died of COVID-19 and 14 controls who died of other causes.
There was no molecular evidence of SARS-CoV-2 in brain tissue samples from the patients who died of COVID-19.
Yet, “we were very surprised to learn that no matter which type of cell we studied (different types of nerve cells, immune cells, or different support cells in the brain) there were prominent changes” compared with brain tissue samples from controls who died of other causes, said Dr. Wyss-Coray.
The changes in the COVID-19 brains showed signatures of inflammation, abnormal nerve cell communication, and chronic neurodegeneration.
“Across cell types, COVID-19 perturbations overlap with those in chronic brain disorders and reside in genetic variants associated with cognition, schizophrenia, and depression,” the researchers report.
“Viral infection appears to trigger inflammatory responses throughout the body that may cause inflammatory signaling across the blood–brain barrier, which in turn could ‘trip off’ neuroinflammation in the brain,” Dr. Wyss-Coray said.
The findings may help explain the brain fog, fatigue, and other neurological and psychiatric symptoms of long COVID.
“While we studied only brains from people who died of COVID-19, we believe it is likely that similar, but hopefully weaker, signs of inflammation and chronic neurodegeneration will be found in COVID-19 survivors, especially those with chronic brain symptoms,” Dr. Wyss-Coray said.
This research was funded by the Nomis Foundation, the National Institutes of Health, Nan Fung Life Sciences, the Wu Tsai Neurosciences Institute and the Stanford Alzheimer’s Disease Research Center. The authors have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Guidance provided for telepsychiatry in tardive dyskinesia
Expert panel reviewed best practices in 2020 while pandemic limited in-person visits
Tardive dyskinesia (TD) can be reasonably managed through telemedicine, but it should be employed as part of a hybrid strategy that ideally includes an office visit at the time of diagnosis and yearly intervals thereafter, according to an expert who spoke at a meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.
In psychiatry in general and in TD specifically, telepsychiatry is useful, but “is not a one-size-fits-all approach,” according to Rif S. El-Mallakh, MD, director of the mood disorder research program at the University of Louisville (Ky.).
Telepsychiatry was already growing as a strategy to expand psychiatric services to communities with limited resources in mental health when the COVID-19 pandemic arrived. Dependence on this type of patient care then exploded out of necessity but in advance of how it might best be applied in specific circumstances.
Best practices panel convened in 2020
The project to develop best practices in TD began in July 2020, when the pandemic was still limiting normal clinician-patient interactions. It was expected from the beginning that recommendations would be applicable to postpandemic circumstances.
There is no reason to expect the forces driving the growth of telepsychiatry, which include convenience of patients and efficiency for clinicians, to dissipate once the pandemic resolves, Dr. El-Mallakh said at the virtual meeting, sponsored by MedscapeLive.
, which consisted of six neurologists, three psychiatrists, and three psychiatric nurse practitioners. The goal was to gather information about the current practice of TD diagnosis and treatment in real-world settings.
With the information on current practices providing a baseline, a virtual roundtable was then convened to develop best-practices recommendations. The deliberations were performed on the basis of expert opinion. There were no statistical methods applied to data collected from the qualitative interviews.
Four key points in recommendations
The panel agreed on four key points: an in-person visit is preferred for initial evaluation and diagnosis; when applied for the evaluation of TD, telepsychiatry should include video; virtual visits cannot completely replace in-person visits; and patients with TD should be evaluated in person at least once per year.
In addition, the panelists recommended specific steps aimed at maximizing the quality of the virtual visit, including confirming that patients have appropriate equipment for video and audio communication. It is also important to recognize that patients or caregivers may require instruction on how to set up the equipment.
Prior to a telemedicine visit, it is appropriate to provide patients with a checklist that includes instructions on adequate lighting and audio. In addition, patient expectations about the goals and processes in the video should be explained.
“Instructional videos prior to the visit might be helpful,” Dr. El-Mallakh said.
Immediately prior to each visit, visual and audio quality should be verified. This allows technical issues, if any, to be resolved.
For the evaluation of TD, the ability to adequately observe body movements is crucial but can pose a challenge in telepsychiatry. To capture hyperkinetic movements and functional impairments with adequate clarity, it might be necessary to engage caregivers to hold the camera or otherwise help the clinician gain an adequate view. Clinicians should consider the limitations of telepsychiatry.
In addition to the challenges of a differential diagnosis for TD that should include such entities as parkinsonism and other drug-induced movement disorders, Dr. El-Mallakh cautioned, “comorbidities add another layer of complexity to TD diagnosis.”
Some in-office visits recommended
It is this complexity that led to the recommendation for an in-person evaluation for new-onset TD, although the expert panel did not characterize an initial in-office visit as mandatory.
Once a diagnosis of TD is established, telepsychiatry can be an efficient strategy for education and for confirming that treatments remain effective. However, Dr. El-Mallakh pointed out that patients can and often do have more than one drug-induced movement disorder at the time of diagnosis or develop additional clinical issues over time.
According to the expert panel, telepsychiatry should not be considered an adequate strategy to manage TD by itself, but “it can be an important component” of care of these patients if used judiciously.
“We have all come to recognize the benefits of telepsychiatry and some of the limitations,” said Jonathan M. Meyer, MD, clinical professor of psychiatry, University of California, San Diego. An author or coauthor of several articles on TD, including a recent study of patient awareness of TD symptoms while on vesicular monoamine transporter 2 inhibitors, Dr. Meyer identified technical problems as among the limitations.
“For movement disorders in particular, low bandwidth, poor video quality and lighting, and inadequate visualization of the trunk and limbs all present issues in diagnosing TD, scoring its severity, and differentiating it from other movement disorders,” he said.
“Nonetheless, I agree with the panel conclusions that in many instances, a video visit can be used to diagnose TD, assess severity, and monitor changes in symptoms over time,” he added, but he did express caution.
“For cases where the diagnosis is in doubt or where comorbid disorders require physical assessment, an in-person examination should be performed before embarking on any TD treatment strategy,” Dr. Meyer said.
MedscapeLive and this news organization are owned by the same parent company. Dr. El-Mallakh has ties with Allergan, Janssen, Lundbeck, Otsuka, Takeda, Teva, and Neurocrine Biosciences, which provided funding for this expert panel and summary. Dr. Meyer has ties with Acadia, Alkermes, Allergan, Merck, Neurocrine, Otsuka, Sunovion, and Teva.
Expert panel reviewed best practices in 2020 while pandemic limited in-person visits
Expert panel reviewed best practices in 2020 while pandemic limited in-person visits
Tardive dyskinesia (TD) can be reasonably managed through telemedicine, but it should be employed as part of a hybrid strategy that ideally includes an office visit at the time of diagnosis and yearly intervals thereafter, according to an expert who spoke at a meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.
In psychiatry in general and in TD specifically, telepsychiatry is useful, but “is not a one-size-fits-all approach,” according to Rif S. El-Mallakh, MD, director of the mood disorder research program at the University of Louisville (Ky.).
Telepsychiatry was already growing as a strategy to expand psychiatric services to communities with limited resources in mental health when the COVID-19 pandemic arrived. Dependence on this type of patient care then exploded out of necessity but in advance of how it might best be applied in specific circumstances.
Best practices panel convened in 2020
The project to develop best practices in TD began in July 2020, when the pandemic was still limiting normal clinician-patient interactions. It was expected from the beginning that recommendations would be applicable to postpandemic circumstances.
There is no reason to expect the forces driving the growth of telepsychiatry, which include convenience of patients and efficiency for clinicians, to dissipate once the pandemic resolves, Dr. El-Mallakh said at the virtual meeting, sponsored by MedscapeLive.
, which consisted of six neurologists, three psychiatrists, and three psychiatric nurse practitioners. The goal was to gather information about the current practice of TD diagnosis and treatment in real-world settings.
With the information on current practices providing a baseline, a virtual roundtable was then convened to develop best-practices recommendations. The deliberations were performed on the basis of expert opinion. There were no statistical methods applied to data collected from the qualitative interviews.
Four key points in recommendations
The panel agreed on four key points: an in-person visit is preferred for initial evaluation and diagnosis; when applied for the evaluation of TD, telepsychiatry should include video; virtual visits cannot completely replace in-person visits; and patients with TD should be evaluated in person at least once per year.
In addition, the panelists recommended specific steps aimed at maximizing the quality of the virtual visit, including confirming that patients have appropriate equipment for video and audio communication. It is also important to recognize that patients or caregivers may require instruction on how to set up the equipment.
Prior to a telemedicine visit, it is appropriate to provide patients with a checklist that includes instructions on adequate lighting and audio. In addition, patient expectations about the goals and processes in the video should be explained.
“Instructional videos prior to the visit might be helpful,” Dr. El-Mallakh said.
Immediately prior to each visit, visual and audio quality should be verified. This allows technical issues, if any, to be resolved.
For the evaluation of TD, the ability to adequately observe body movements is crucial but can pose a challenge in telepsychiatry. To capture hyperkinetic movements and functional impairments with adequate clarity, it might be necessary to engage caregivers to hold the camera or otherwise help the clinician gain an adequate view. Clinicians should consider the limitations of telepsychiatry.
In addition to the challenges of a differential diagnosis for TD that should include such entities as parkinsonism and other drug-induced movement disorders, Dr. El-Mallakh cautioned, “comorbidities add another layer of complexity to TD diagnosis.”
Some in-office visits recommended
It is this complexity that led to the recommendation for an in-person evaluation for new-onset TD, although the expert panel did not characterize an initial in-office visit as mandatory.
Once a diagnosis of TD is established, telepsychiatry can be an efficient strategy for education and for confirming that treatments remain effective. However, Dr. El-Mallakh pointed out that patients can and often do have more than one drug-induced movement disorder at the time of diagnosis or develop additional clinical issues over time.
According to the expert panel, telepsychiatry should not be considered an adequate strategy to manage TD by itself, but “it can be an important component” of care of these patients if used judiciously.
“We have all come to recognize the benefits of telepsychiatry and some of the limitations,” said Jonathan M. Meyer, MD, clinical professor of psychiatry, University of California, San Diego. An author or coauthor of several articles on TD, including a recent study of patient awareness of TD symptoms while on vesicular monoamine transporter 2 inhibitors, Dr. Meyer identified technical problems as among the limitations.
“For movement disorders in particular, low bandwidth, poor video quality and lighting, and inadequate visualization of the trunk and limbs all present issues in diagnosing TD, scoring its severity, and differentiating it from other movement disorders,” he said.
“Nonetheless, I agree with the panel conclusions that in many instances, a video visit can be used to diagnose TD, assess severity, and monitor changes in symptoms over time,” he added, but he did express caution.
“For cases where the diagnosis is in doubt or where comorbid disorders require physical assessment, an in-person examination should be performed before embarking on any TD treatment strategy,” Dr. Meyer said.
MedscapeLive and this news organization are owned by the same parent company. Dr. El-Mallakh has ties with Allergan, Janssen, Lundbeck, Otsuka, Takeda, Teva, and Neurocrine Biosciences, which provided funding for this expert panel and summary. Dr. Meyer has ties with Acadia, Alkermes, Allergan, Merck, Neurocrine, Otsuka, Sunovion, and Teva.
Tardive dyskinesia (TD) can be reasonably managed through telemedicine, but it should be employed as part of a hybrid strategy that ideally includes an office visit at the time of diagnosis and yearly intervals thereafter, according to an expert who spoke at a meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.
In psychiatry in general and in TD specifically, telepsychiatry is useful, but “is not a one-size-fits-all approach,” according to Rif S. El-Mallakh, MD, director of the mood disorder research program at the University of Louisville (Ky.).
Telepsychiatry was already growing as a strategy to expand psychiatric services to communities with limited resources in mental health when the COVID-19 pandemic arrived. Dependence on this type of patient care then exploded out of necessity but in advance of how it might best be applied in specific circumstances.
Best practices panel convened in 2020
The project to develop best practices in TD began in July 2020, when the pandemic was still limiting normal clinician-patient interactions. It was expected from the beginning that recommendations would be applicable to postpandemic circumstances.
There is no reason to expect the forces driving the growth of telepsychiatry, which include convenience of patients and efficiency for clinicians, to dissipate once the pandemic resolves, Dr. El-Mallakh said at the virtual meeting, sponsored by MedscapeLive.
, which consisted of six neurologists, three psychiatrists, and three psychiatric nurse practitioners. The goal was to gather information about the current practice of TD diagnosis and treatment in real-world settings.
With the information on current practices providing a baseline, a virtual roundtable was then convened to develop best-practices recommendations. The deliberations were performed on the basis of expert opinion. There were no statistical methods applied to data collected from the qualitative interviews.
Four key points in recommendations
The panel agreed on four key points: an in-person visit is preferred for initial evaluation and diagnosis; when applied for the evaluation of TD, telepsychiatry should include video; virtual visits cannot completely replace in-person visits; and patients with TD should be evaluated in person at least once per year.
In addition, the panelists recommended specific steps aimed at maximizing the quality of the virtual visit, including confirming that patients have appropriate equipment for video and audio communication. It is also important to recognize that patients or caregivers may require instruction on how to set up the equipment.
Prior to a telemedicine visit, it is appropriate to provide patients with a checklist that includes instructions on adequate lighting and audio. In addition, patient expectations about the goals and processes in the video should be explained.
“Instructional videos prior to the visit might be helpful,” Dr. El-Mallakh said.
Immediately prior to each visit, visual and audio quality should be verified. This allows technical issues, if any, to be resolved.
For the evaluation of TD, the ability to adequately observe body movements is crucial but can pose a challenge in telepsychiatry. To capture hyperkinetic movements and functional impairments with adequate clarity, it might be necessary to engage caregivers to hold the camera or otherwise help the clinician gain an adequate view. Clinicians should consider the limitations of telepsychiatry.
In addition to the challenges of a differential diagnosis for TD that should include such entities as parkinsonism and other drug-induced movement disorders, Dr. El-Mallakh cautioned, “comorbidities add another layer of complexity to TD diagnosis.”
Some in-office visits recommended
It is this complexity that led to the recommendation for an in-person evaluation for new-onset TD, although the expert panel did not characterize an initial in-office visit as mandatory.
Once a diagnosis of TD is established, telepsychiatry can be an efficient strategy for education and for confirming that treatments remain effective. However, Dr. El-Mallakh pointed out that patients can and often do have more than one drug-induced movement disorder at the time of diagnosis or develop additional clinical issues over time.
According to the expert panel, telepsychiatry should not be considered an adequate strategy to manage TD by itself, but “it can be an important component” of care of these patients if used judiciously.
“We have all come to recognize the benefits of telepsychiatry and some of the limitations,” said Jonathan M. Meyer, MD, clinical professor of psychiatry, University of California, San Diego. An author or coauthor of several articles on TD, including a recent study of patient awareness of TD symptoms while on vesicular monoamine transporter 2 inhibitors, Dr. Meyer identified technical problems as among the limitations.
“For movement disorders in particular, low bandwidth, poor video quality and lighting, and inadequate visualization of the trunk and limbs all present issues in diagnosing TD, scoring its severity, and differentiating it from other movement disorders,” he said.
“Nonetheless, I agree with the panel conclusions that in many instances, a video visit can be used to diagnose TD, assess severity, and monitor changes in symptoms over time,” he added, but he did express caution.
“For cases where the diagnosis is in doubt or where comorbid disorders require physical assessment, an in-person examination should be performed before embarking on any TD treatment strategy,” Dr. Meyer said.
MedscapeLive and this news organization are owned by the same parent company. Dr. El-Mallakh has ties with Allergan, Janssen, Lundbeck, Otsuka, Takeda, Teva, and Neurocrine Biosciences, which provided funding for this expert panel and summary. Dr. Meyer has ties with Acadia, Alkermes, Allergan, Merck, Neurocrine, Otsuka, Sunovion, and Teva.
FROM CP/AACP PSYCHIATRY UPDATE