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The Health Wrap: food costs, oral health and aged care, drug and alcohol use – and coronavirus vaccine news

In her latest edition of The Health Wrap, Dr Lesley Russell investigates progress in coronavirus vaccine development, an aged care program called Senior Smiles, and the latest in a long line of inquiries into food costs for remote Indigenous communities, as well as new findings on drug and alcohol use.

For those in need, she has more than one good news story to share.


Lesley Russell writes:

Keeping current on the coronavirus pandemic is an increasingly difficult, time-consuming task. Kudos to my Croakey colleagues who do such an excellent job – every day there are new posts. 

On the science front, it is fascinating, confronting and confusing to follow the research findings and track how the knowledge base is growing.

I was slow to discover the Coronavirus Research Updates from Nature which provides some excellent summaries.

The New York Times has recently instigated the Coronavirus Drug and Treatment Tracker which rates treatments for effectiveness and safety (and pseudoscience). STAT News also has an excellent COVID-19 tracker with an international focus.

If, like me, you are interested in the under-reporting of deaths due to coronavirus, The Economist is tracking these “excess deaths” across countries.

Australia does not appear – I’m not sure if that is because we don’t have a problem or because we don’t recognise we have a problem.


Progress on vaccine development

There have been some interesting updates on the science around immunity against the new coronavirus and what this means for the development of a vaccine; there has also been news on the vaccine front.

A candidate vaccine against coronavirus developed by US-based Moderna Inc in conjunction with the National Institutes of Health (NIH) as part of the US Government’s Operation Warp Speed (with funding of US$438 million from the Government plus an unspecified amount from the Coalition for Epidemic Preparedness Innovations), appears to be safe and to trigger an immune response, according to data just released in a preliminary report published by the New England Journal of Medicine. The clinical trial was led by Dr Tony Fauci’s Vaccine Research Center at NIH.

The company is claiming there are indications that the vaccine (based on a messenger RNA that encodes the spike glycoprotein which mediates virus attachment and entry to cells) is both safe and effective, while admitting that the protective effect is not yet known.

The levels of protective antibodies produced by the trial participants were similar to those found in patients who have recovered from COVID-19, suggesting that the candidate vaccine provides the same protection as an infection.

Experts who have reviewed the results say it’s unclear if the responses obtained are enough to protect someone from infection with coronavirus.

I’m not an immunology expert, but here’s a summary of what the published data show (and there’s a good editorial summary here).

This was a Phase 1 trial involving 45 healthy volunteers aged 18-55 years. Three groups of 15 subjects were given 2 vaccinations 28 days apart with doses of 25 micrograms, 100 micrograms or 250 micrograms of vaccine protein. Their B-cell antibody response was measured up to 57 days and compared to that of people who have recovered from COVID-19.

The data show that the two higher doses generated antibody levels similar to those found in convalescent serum (there is substantial variability here) and that side effects (fatigue, chills, muscle pain) were common but not considered sufficiently serious to stop the trial.

A Phase 2 study involving 600 healthy adults who are receiving either 50 or 100 microgram doses is already underway; a larger Phase 3 trial with 30,000 participants using just 100 microgram doses is planned to begin on July 27.  Some patients in this phase will also receive a placebo.

Although it seems to have gathered the most publicity, it should be noted that the Moderna vaccine is not the only one progressing through clinical trials – an article from Bloomberg News highlights some of the other work being done, with equal success. The New York Times has a Coronavirus Vaccine Tracker that is regularly updated; it shows 23 vaccines in human studies.

So far, so good, encouraging even. But what else is needed?

The vaccine trial has not yet shown that the antibodies generated will last long enough at levels high enough to be effective for a meaningful period of time (for example, one year).

Several recent studies – from London, Munich and China – seem to indicate that immunity in those who have recovered from COVID-19 may only last for a few months (you can read expert responses to the UK paper here).

There is currently insufficient evidence to say that people cannot get re-infected with the new coronavirus and there are a few reports of patients getting a second infection. Researchers don’t yet know what level of neutralising antibodies is needed to fight off reinfection by SARS-CoV-2, or at least to reduce COVID-19 symptoms in a second illness.

Most of the coronavirus vaccine focus is on antibodies. These are immunoglobulins (proteins) produced by B cells in response to infection (or the injection of an appropriate part of a virus like the coronavirus spike) and they block the virus from binding to cells. 

However, the body can also develop cellular immunity with the production of T cells that recognise and eliminate cells that are infected with the virus.  Recent studies show that people who have been infected with SARS-CoV-2 have T cells that fight the virus, and some people who have not been infected also have protective T-cells – perhaps because they have been exposed to other coronaviruses. Young people are more likely to have a T-cell response that older people because the reservoir of programmable T cells declines with age.

 Many scientists now believe an effective vaccine will need to also involve the generation of cellular immunity. This is much more difficult, and I am unaware of any vaccine efforts focused specifically on this.

Also, there might be some immunity issues peculiar to coronaviruses. Immunity against seasonal human coronaviruses does not last long (6-12 months), although for the original SARS virus (2002-2004), 84 percent of patients infected still had some neutralising antibody at 36 months post infection. For SARS-CoV-2, patients with severe symptoms have a large antibody response and lose these antibodies more slowly than asymptomatic patients.

Many more issues must be addressed before a vaccine is ready for widespread use. They are discussed well in a recent article from National Geographic.

Finally, it’s worth noting that despite whatever gloss the Moderna executives might put on these results (which are boosting their stock), Fauci is still cautiously maintaining that a vaccine is some way off.

In a conversation with Dr Francis Collins, director of the NIH, on Facebook Live this past week (as pictured above), he said: “We hope that by end of this year, or the beginning of 2021 we will at least have an answer whether the vaccine or vaccines – plural – are safe and effective.”

There’s an update on Australian efforts in coronavirus vaccine development and related issues such as ensuring supply here.

This Twitter thread might help explain the complicated immunology science that underpins vaccine development – along with some great diagrams.


Risk factors for coronavirus death

In the United Kingdom

Nature has just published a huge study of 17 million people – described as the largest of its kind – looking at the factors that raise an individual’s chances of dying from COVID-19. The study used National Health Service records to look at the impact of coronavirus on England’s population, beyond those people admitted to hospital.

The results are not surprising and echo those found elsewhere: COVID-19-related death is associated with being male, being older age and deprivation (both with a strong gradient), diabetes, severe asthma, several other chronic diseases, and race. Only a small part of the substantially increased risks of COVID-19-related death among non-white groups and among people living in more deprived areas can be attributed to existing conditions.

There are obvious ramifications for policy work here, as previously outlined in the Fenton report “Beyond the data: Understanding the impact of COVID-19 on BAME communities”. I wrote about this in a previous edition of The Health Wrap.

In the United States

Meanwhile, in the United States, official statistics show that Latinos are hospitalised and dying from the coronavirus at four times the rates of whites and even those high numbers may be seriously underestimated. A summary of these findings is  here in the Washington Post.

A large part of the problem lies in how different parts of government and the healthcare system (and individuals themselves) categorise race and ethnicity. The terms Latino and Hispanic are often used interchangeably (I confess I usually use Hispanic).

But strictly speaking, Hispanic is used to refer to people who are from Spanish-speaking populations and Latino refers to people who are from Latin America. Each of these populations actually includes a number of racial and ethnic groups and individuals from the same racial or ethnic group may identify differently. The count is further muddled because 37 percent of Hispanics/Latinos identify with at least one other racial or ethnic group. 

Public health experts say Hispanics/Latinos may be more vulnerable to the virus as a result of the same factors that have put minorities at risk across the country. Many have low-paying service jobs that have either been lost or that require them to work through the pandemic and interact with the public. A large number also lack access to healthcare, which contributes to higher rates of diabetes and other conditions that make this population more susceptible to complications from the virus.  

As a result, the number of Hispanics/Latinos with COVID-19 is staggering.

In Iowa, they account for 24 percent of coronavirus cases although they are only six percent of the population. In Washington State they make up 13 percent of the population but 44 percent of cases.

In Florida, they are just over 25 percent of the population but account for 40 percent of virus cases where ethnicity is known. The number of Hispanic/Latino deaths in Chicago has surpassed the death toll of all other groups, including African Americans.


Improving oral health in aged care

This past week the Royal Commission on Aged Care Quality and Safety has heard evidence on mental health, allied health and oral health care needs. (And a reminder, the deadline for submission to the Royal Commission is 31 July.) 

Among those giving evidence on the oral health needs of the elderly was Associate Professor Janet Wallace from the University of Newcastle.

Wallace has done something that is every public health wonk’s dream – she turned her PhD study into a program, Senior Smiles, that now delivers oral health care to people in residential aged care facilities (RACFs) on the Central Coast.

Senior Smiles, mostly funded by philanthropy, involves having a registered dental hygienist on site, with referral to dentists in the community for more complex needs, a regular oral health risk assessment and care plan for each resident, and working with RACF staff to ensure these are implemented. The University of Newcastle has created a Bachelor of Oral Health Therapy degree which includes student placement in RACFs.

The benefits of this program are immediately obvious – decreased GP and hospital visits and better quality of life for the elderly recipients. There are substantial savings too: in five RACFs where Senior Smiles operates, it is estimated that for every dollar invested, there are savings of $3.14 in healthcare and $3.66 in social benefits.

If the program was rolled about across New South Wales, the net value (benefits – savings) would be $143.5 million per year.

As Wallace points out, it is really shockingly short-sighted that oral health is not included as part of the Medicare-funded health assessment for people aged 75 years and over.

Read more about Senior Smiles here and in this 2016 publication “Senior Smiles: preliminary results for a new model of oral health care utilizing the dental hygienist in residential aged care facilities.”  There is a great video here.


Cost of food for remote Indigenous communities

The Standing Committee on Indigenous Affairs of the House of Representatives in the Australian Parliament is undertaking an inquiry into food pricing and food security in remote Indigenous communities. The inquiry is due to report by 30 October 2020. The Terms of Reference are here and the submissions are here.

This has long been a recognised problem. Indeed, it was the subject of a previous inquiry by the committee in 2009. A 2011 fact sheet from the Australian Institute of Family Studies  noted that data from the 2004-05 Aboriginal and Torres Strait Islander Health Performance Framework showed that 24 percent of Indigenous people experienced food insecurity. The Australian National Audit Office did a report in 2014 on Food Security in Remote Indigenous Communities.

The latest Australian Bureau of Statistics figures report 31 percent of Aboriginal and Torres Strait Islander people living in remote communities experience food insecurity, but a study by researchers at the University of Queensland in very remote communities in the Northern Territory found a prevalence of 62 percent.   

In a recent article for Croakey, Professor Bronwyn Fredericks and Dr Odette Best highlighted how longstanding concerns about food insecurity in remote and discrete Indigenous communities are coming to the fore during the coronavirus pandemic, underscoring the need for meaningful reform. It’s sobering to compare this with a Croakey article from 2017 on the cost of eating well (healthily) in remote communities – nothing has changed; indeed, maybe things have worsened.

The Federal Government has an important role to play here – one which has been seriously neglected over the years. In all states except the Northern Territory, Outback Stores Pty Ltd (OBS) supplies food and other household items to remote communities.

OBS is a wholly-owned Commonwealth company (its operation falls under the aegis of the Department of Prime Minister and Cabinet) that was set up in 2006 specifically to improve the health of Indigenous communities. In the Northern Territory, community stores in remote communities are subject to a licensing program that sets standards for quality and healthiness of foods and how stores operate.

A recent article in The Guardian outlines evidence heard by the parliamentary inquiry that poverty is the single greatest contributor to food insecurity.

The Northern Territory market basket survey shows that basic goods in remote stores are 56 percent more expensive than at regional supermarkets. There are also big price differences between communities – with a basket costing $1,150 in one privately owned store, and $680 in a store run by a community group.

The Australian has also run a series of articles reporting on issues with retailers in remote communities. See for example:

It seems there is plenty of room for reform. It is so important that this is done in consultation with the communities.


Results from 2019 National Drug Strategy Household Survey

The Australian Institute of Health and Welfare has just released results from the most recent  National Drug Strategy Household Survey. This looked at tobacco and vaping, alcohol and illegal substance use.

Tobacco and vaping

The data show that fewer Australians are smoking tobacco daily, while more are vaping and using e-cigarettes.

The good news is that only about 3.7 percent of teenagers, 10.7 percent of people in their 20s and 11.6 percent of people in their 30s smoked daily in 2019. These proportions have more than halved since 2001 and the percentage of younger people who have never smoked continued to rise.

The bad news is that e-cigarette use among non-smokers aged 18 to 24 years has quadrupled in six years. This highlights the vaping industry’s continued targeting of this population via youth-oriented marketing and the development of new flavours.

Also worrying is that people in their 40s and 50s are more likely than other age groups to smoke, with about one in six people in these age groups smoking daily in 2019. This proportion has not improved since 2016.

Alcohol consumption

Again there is good news and bad.

Two-thirds of 14 to 17-year-olds have never consumed a full standard drink. The proportion of young people who drink alcohol at risky levels fell between 2001 and 2019. This pattern was seen among all age groups under 40, with the proportion of risky drinkers lowest among teenagers. More Australians are giving up or reducing their alcohol intake, driven by health concerns.

On the other hand, there has been little change in the proportion of people drinking at risky levels. And of most concern – one- fifth of Australians, or 4.5 million people, were a victim of an alcohol-related incident in 2019, a proportion that has not changed since 2016.

Illicit drug use

More than two in five Australians have used an illicit drug in their lifetime, and recent cannabis use has increased.

 Over the past two decades, there has been a clear trend of increasing illicit drug use among people in their 40s and 50s and recent cannabis use among those aged 50–59 and 60 and over is at the highest levels since 2001.

Between 2016 and 2019, the proportion of people using pharmaceuticals for non-medical purposes fell. This change has been driven by a reduction in the non-medical use of pain-killers (codeine was made a prescription only medicine in 2018) and opioids.

Two final points: fewer Indigenous Australians are smoking or drinking at risky levels; and smoking rates increase with socioeconomic disadvantage, but illicit drug use is highest in the most advantaged areas.

The report is well-summarised in an article in The Guardian.


Alcohol labelling – a good news story

This really warrants being highlighted as my bi-weekly good news story. And like most public health victories, it is the result of many years of hard work and many David and Goliath battles against well-funded vested interest.

Last Friday the Ministerial Forum on Food Regulation (federal, state, territory and New Zealand ministers with responsibility for food standards) met and agreed to the alcohol labelling recommendations developed by Food Standards Australia and New Zealand (FSANZ) to warn against the hazards of drinking while pregnant.

This comes after years of heated debate between researchers, medical experts, public health organisations and brewers, winemakers and distillers. You can follow the work done by FSANZ here.

Recently Croakey published a piece by Louise Gray, CEO of NOFASD Australia, which outlines the long path to this alcohol labelling victory and the reasons why it is so important in the prevention of Foetal Alcohol Spectrum Disorders (FASD).

The agreed-on label has black, white and red text stating “PREGNANCY WARNING: Alcohol can cause lifelong harm to your baby”.

Manufacturers will now have three years to implement the new label across all alcoholic beverages. The label will be on alcohol bottles of 200ml or more, with smaller bottles to display the pictogram. It has undergone substantial consumer testing.

Professor Fiona Stanley, one of Australia’s most renowned medical researchers and long a champion in this area, said it best: “Alcohol in pregnancy, and its impact on the foetal brain, the baby’s brain, is the most important preventable cause of intellectual disability and other developmental disorders in the world” and arguments from the industry it will cost hundreds of millions of dollars to implement are a “furphy”.

Aboriginal and Torres Strait Islander social justice commissioner, June Oscar, wrote a letter (co-signed by 52 members of the Close the Gap campaign) to the ministers urging the implementation of the labelling recommendations as an “easy step” to protect unborn children from FASD.

The alcohol industry argued that three-colour printing would cost too much and would harm small producers. It was good to see that one winemaker was brave enough to break ranks  with alcohol industry lobbyists and  back the food regulator’s proposed new mandatory pregnancy warning label.

However it was disconcerting to hear that the responsible federal minister Richard Colbeck (who chairs the ministerial forum) proposed an amendment to remove the red ink requirement. This was supported by New South Wales, South Australia and Queensland but voted down by New Zealand, Western Australia, Victoria, Tasmania, the Northern Territory and the ACT.

FARE did some great work getting an Open Letter signed by over 3,700 people and 150 organisations that called on Ministers to put the health and wellbeing of children and families first with a clear, visible health warning on alcohol. The letter ran in newspapers around Australia.

There were jubilant media releases from FARE and the Public Health Association of Australia – and see more of the reaction in this Croakey wrap.


The best of Croakey

Over the past several weeks, Marie McInerney has been covering VicHealth’s webinar series, #HealthReImagined, for the Croakey Conference News Service.

Participants looked at lessons from the pandemic, investigating urban design, healthier work environments, sustainable food systems and jobs, and intersections between the social determinants of health.

Read the coverage here, listen to Cate Carrigan’s podcast report for CroakeyVOICES, and also see some of the extensive Twitter engagement – all of which will be compiled into an e-publication for your reading and listening pleasure.


The good news story

There is not much good news associated with coronavirus these days, but I found this BBC story of youthful ingenuity that boosted my spirits.

And it serves to remind us how lucky we are in these pandemic times to be able to take handwashing for granted.


Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.

Previous editions of The Health Wrap can be read here.

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