By Amber Dance

Pandemic lessons may improve long-term health equity

Hard-won achievements against the COVID pandemic and mpox outbreak may help public health officials combat inequities going forward, write Margo Snipe and Kenya Hunter at Capital B.

The pair describe how partnerships with community organizations narrowed the racial gap in vaccination rates in Boston, San Francisco, and Atlanta.

For example, the Boston team deployed health ad campaigns in up to 11 languages, including Spanish and Haitian Creole.

They also ensured that workers at COVID vaccine sites looked like members of the Black communities they wanted to reach.

Officials hope to continue and expand these efforts to counter other health issues, such as diabetes and cardiovascular disease, among underserved populations.

“We’re not just thinking about vaccination, but also thinking about ongoing access to testing, access to influenza vaccination, and really providing comprehensive services,” said Dr. Bisola Ojikutu, executive director of Boston’s health commission.

“Instead of pulling back, we have continued to move forward.”

COVID death rates varied by state

Hawaii saw 147 deaths from COVID per 100,000 people during the pandemic, the lowest rate in the U.S.

Contrast that with Arizona’s 581 deaths per 100,000, the highest rate in the nation.

A new paper in The Lancet delves into the social and political factors that might underlie the nearly fourfold difference across states, using data covering 2020 through mid-2022.

“Death rates in the hardest-hit U.S. states resembled those of countries with no health care infrastructure whatever,” writes Melissa Healy at the Los Angeles Times

The authors found that a lower poverty rate and higher levels of education were linked to lower infection and death rates.

Larger populations of Black or Hispanic individuals were tied to higher death rates.

Vaccine mandates for state employees, mask use and high vaccine uptake were also associated with better COVID outcomes.

High levels of trust of other people, which led to willingness to protect others, was also linked to lower death rates.

“How we feel about one another matters,” said study author and political scientist Thomas J. Bollyke. “The solidarity between people — the feeling that others will also do the right thing, that you’re not being taken advantage of — is a big driver in your willingness to adopt protective behaviors.”

That kind of trust has been declining in the U.S. since the late 20th century, Bollyke added.

In addition, trust in the government has dropped among Black Americans and Republicans during Biden’s tenure, according to a 2022 Pew Research Center report.

A high proportion of Trump voters was also linked to a higher death rate.

“The COVID-19 pandemic clearly exacerbated fundamental social and economic inequities, but science-based interventions and policy changes provided clear impact on mortality rates at the state level,” said ABC News contributor Dr. John Brownstein.

Will we get a spring boost?

The FDA is mulling an additional round of bivalent boosters, possibly for people older than 65 and immunocompromised individuals, reports Rob Stein at NPR.

“Those doses are going to be expiring and will be thrown out,” said Dr. Peter Hotez of the Texas Children’s Hospital for Vaccine Development. “It makes sense to have those shots in arms instead of being tossed.”

A spring booster could address waning immunity in those who got their fall boosters but remain at risk for severe disease or death. 

It’s likely that protection from the bivalent vaccine wanes within months, as occurred with the original-formula shot, and that an additional vaccination would boost protection, writes Dr. Leana S. Wen at The Washington Post.

“The benefit might be negligible for healthy young people,” writes Wen. But she argues that a booster would be an appropriate option for immunocompromised people and older individuals who want to maximize their protection.

Last week, the World Health Organization issued its new guidelines on vaccination. 

The WHO suggested that an additional booster should be available after six or 12 months for older adults, younger adults with conditions such as diabetes, adults and children who are immunocompromised, pregnant people, and frontline health workers.

It said that healthy adults, up to age 50–60, can stop after their first booster.

And the WHO no longer specifically recommends COVID vaccination for children and teens.

The WHO noted that countries should base their individual approaches on their own disease burden and health spending, and that these guidelines only apply to the current COVID situation.

In the U.S., the CDC still recommends that everyone ages six months and older get up to date with COVID vaccines, which includes the bivalent booster for nearly everyone.

The difference between CDC and WHO advice could further confuse the public, microbiologist Stanley Perlman told Bloomberg’s Karen Leigh and Tanaz Meghjani.

COVID’s effect on the brain grows clearer

There may be two categories of long COVID’s effects on the brain, reports Judy George at MedPage Today. 

Researchers found that people who were sick enough to require hospitalization during their initial bout with COVID were most likely to suffer problems with attention, working memory and processing speed.

In contrast, those whose initial infection was milder tended toward brain fog, headaches, dizziness, and loss of smell and taste.

The different groups may require different treatments, said Dr. Ziyad Al-Aly of the Washington University in St. Louis, who wasn’t involved in the research.

Researchers have also strengthened the neurologic link between long COVID and myalgic encephalomyelitis (ME), commonly known as chronic fatigue syndrome, another condition that can occur post-infection.

In a small brain imaging study, scientists found similarities between long COVID and ME patients, in that both showed an enlarged brainstem, reports Carly Casella at Science Alert.

The brainstem controls brain function as well as respiration, heart function, and digestion.

Its increased size could reflect the presence of a virus, inflammation and swelling, or degeneration of the nerves, according to the study authors.

COVID exposure in pregnant people has also been linked to neurodevelopmental disorders, such as intellectual disabilities or movement disorders, in the boys they deliver (but not girls), reports Nina Cosdon at Contagion Live.

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COVID-19 is moving to the country. While cases were highest in urban areas as the pandemic began, the pattern flipped as summer drew to a close, according to a new report from the Rural Policy Research Institute. Now rural case rates outnumber those in cities, and rural dwellers are at more than twice the risk of death as urbanites.

Experts predict the gap will widen, reports Lauren Weber at Kaiser Health News. “We’ve turned many rural communities into kill boxes,” said the head of the National Rural Health Association, Alan Morgan. “And there’s no movement towards addressing what we’re seeing in many of these communities, either among the public or among governing officials.”

Lower vaccination rates are a key contributor, with a variety of underlying causes. Researchers from Syracuse University point to more Trump voters and fewer people achieving academic degrees. At Healthline, Moira McCarthy cites a “perfect storm of personal freedom beliefs, mistrust of the government, a culture that tends toward taking care of things on their own, highly shared misinformation, and, yes, faith.” Dr. Scott J. Anzalone of Logan, Ohio, told her that since rural COVID-19 rates were low early in the pandemic, it created a “false sense of security” among many residents. People in rural areas are particularly vulnerable to misinformation due to the twin decline of rural health care systems and local news outlets, leaving them no obvious source for accurate health advice, opines Kerry Thomson, executive director of the Center for Rural Engagement at Indiana University, at NBC News.

Lack of access to health care or emergency treatment is also a factor. Writes KHN’s Weber, “The pressures of the pandemic have compounded the problem by deepening staffing shortages at hospitals, creating a cycle of worsening access to care.” When the virus infiltrates rural regions, telehealth can come to the rescue, writes Katie Palmer at STAT. “When we think about diversity, equity, and inclusion, for me it’s not only necessarily race and ethnicity, but it’s geography as well,” Roxie Wells, president of Hoke Hospital in Raeford, North Carolina, tells Palmer. “I truly believe that people who live in rural communities should expect outstanding high-quality care in their communities, and now that telehealth is such a huge part of what we do, I think that it is highly plausible.” But the telehealth revolution has yet to reach many rural areas, reports Erin Brodwin, also at STAT.

A COVID pill so good, they stopped the trial early

The phrase “game changer” appeared in many news stories last week trumpeting the announcement that pharmaceutical maker Merck’s experimental medication halved risk of hospitalization or death in people with mild or moderate COVID. Dr. Anthony Fauci, speaking on CNN’s “State of the Union,” called the company’s results “really quite impressive.” So impressive, in fact, that an independent review board recommended the company cut its trial short to seek emergency authorization as soon as possible. The twice-a-day, easy-to-swallow pill could be a big deal, writes Umair Irfan at Vox, because the COVID-specific treatments already available are “expensive, difficult to administer, not widely available, or only marginally effective.” Antibody treatments and remdesivir, the only antiviral drug with FDA approval, require infusion into the bloodstream by medical providers. In contrast, a pill would require only a prescription and a glass of water.

However, Reuters reports that a pair of Indian drug makers trialing Merck’s formula are seeking to halt their studies in moderate cases for the opposite reason, because the results were lackluster. “It was not immediately clear whether the Indian drug makers and Merck used identical criteria to define moderate COVID-19 cases,” Reuters notes.

Antivirals have been slow in coming compared to antibodies or vaccines; in part that’s because they’re trickier to make. Viruses live inside our own cells and use many of our proteins, so scientists must design molecules that can prevent the viruses from functioning without hurting us, too. (I delved deeper into the difficulties of antiviral research here.) Merck’s drug, molnupiravir (named after Thor’s hammer) works by mimicking a building block for the virus’s genome. When the virus goes to copy its genes, the decoy is incorporated and gums up the works. In addition to Merck’s drug, there are two other main contenders in the race for oral antivirals, as Ed Cara lays out at Gizmodo: Pfizer recently announced progress with a drug that interferes with one of the virus’s enzymes, so it can’t mature and copy itself. And Atea Pharmaceuticals and Roche are jointly developing another decoy drug, like molnupiravir.

The U.S. government has promised to purchase 1.7 million treatment courses of Merck’s drug if it’s authorized, and the meds could be available within months, reports JoNel Aleccia at Kaiser Health News. But many experts hurried to point out that pills are no substitute for vaccines; much better, Fauci said, to avoid the disease altogether.

Workplace vaccine mandates work on many, but not all

“We all respond to deadlines,” New York City Mayor Bill de Blasio told CNN recently. “We all respond to rules.” That certainly seems to be the case for the majority of the Big Apple’s health care workers and educators — well over 90% are now vaccinated, after state and city mandates went into effect on Oct. 4. A similar pattern is playing out in health systems across the country, writes Adeel Hassan at The New York Times. United Airlines recently reported that 96% of employees had gotten a vaccine as required; there were only 232 holdouts left out of 67,000 employees as of October 5. “Relatively few employees flat out resist vaccination,” writes Philip Bump at The Washington Post. Bump suggests that many people who once told pollsters they’d never take the vaccine changed their tune once their job was on the line. However, the mandates have not been without consequences, notes CNN’s Eric Levenson. Some health care systems have had to suspend many noncompliant employees; one in Buffalo, New York had to delay certain elective surgeries and close its doors to new ICU patients as a result.

More at-home tests to come

At-home COVID tests can tell you if you’ve contracted the virus for the cost of $7 to $50, in half an hour or less. That is, if you can find a test to buy — no easy task in the U.S., as The New York Times’ David Leonhardt discovered recently. The FDA has been slow to authorize the tests, leading to a shortage here while citizens of other countries have easy access to plenty of tests, often provided for free. “Knowing your COVID status in real time, on a frequent basis, is more important than ever,” write Dr. Michael J. Mina, an epidemiologist at Harvard, and Dr. Steven Phillips, vice president of science and strategy at the expert advocacy COVID Collaborative, in a recent The New York Times op-ed. “To end the coronavirus’ grip on American society, the United States must embrace rapid testing in a more substantial way.” Two recent moves by the government are poised to help: The FDA authorized a new test that is expected to double availability; and the White House is spending $1 billion on at-home rapid tests in hopes of quadrupling the supply by December.

This holiday season’s hottest item: a window fan?

While it’s tempting to see delta’s demise in ebbing national case rates, hospitalizations and deaths, we are still in the throes of a nasty pandemic. More than 700,000 people have died in the United States alone, and many regions remain in serious trouble. A majority of Alaska hospitals are rationing care. Even well-vaccinated New England is facing a surge that’s filling ICUs. And the California National Guard has been activated to help hospitals in the central and northern parts of the state. “This isn’t the first time a shift in numbers has lulled leaders into a false sense of safety,” writes Sophie Putka at Medpage Today. “It’s impossible to predict what will happen in the coming months — particularly with the potential for new variants, lackluster vaccination rates, and colder weather on the way.”

Nonetheless, as the seasons turn many Americans are looking ahead to the holiday season. So is the CDC, which recently released preliminary guidelines for 2021 holiday festivities — “sort of an epidemiologist’s take on Martha Stewart’s ‘Home for the Holidays’,” quips Bill Chappell at NPR. Key recommendations include holding celebrations out of doors, or if the party must move indoors, keeping doors and windows open with a fan pulling air out through one window so fresh air comes in through the others. For those considering air travel, Dr. Ashish Jha, dean of the Brown University School of Public Health, recently took a cross-country redeye with a barely masked seatmate that led him to conclude it’s time for vaccine mandates for domestic air travel. California Sen. Dianne Feinstein is thinking along similar lines, proposing a bill to require proof of vaccination — or a negative COVID test — before boarding.

Amber Dance | Columnist

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