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The Health Wrap: obesity, non-COVID19 patients, the “missing deaths”, mental health, public health funding and NZ’s “First Bloke”

In her latest edition of The Health Wrap, Dr Lesley Russell looks at coronavirus issues, including the impact of obesity, Italian insights on asymptomatic infection, concern about what is happening for acute non-COVID19 patients, and the “missing deaths” in the pandemic.

She also digs down into a US report on the impact of chronic underfunding on America’s public health system – very timely reading also for Australia, and canvases concerns about the mental health impacts of the pandemic, particularly for health care workers, as we await important reports on mental health reform in Australia.

And a compelling combination: New Zealand police and the PM’s “bloke”.


Lesley Russell writes:

As usual for these past few editions of The Health Wrap, I try to summarise some of the issues around the coronavirus pandemic that may not have been covered in great detail elsewhere.

Please make sure you regularly check out the great articles that show up every day at Croakey. You will also find the analyses that journalist Juliette O’Brien does (available at covid19data.com.au) very interesting and useful.

Obesity as a risk factor

An analysis of 15,100 patients across the United Kingdom hospitalised with COVID-19 found that obesity  increases the likelihood of severe complications. The reasons for this are not known, but it has previously been postulated that greater inflammation of adipose tissue, the fatty layer under the skin and around internal organs, may contribute to an enhanced “cytokine storm” which is life threatening.

Although people with obesity frequently have other medical problems (such as heart disease and diabetes), studies (see for example, this one from New York  and this report from the CDC) that obesity in and of itself is the most significant risk factor, after only older age – and surprisingly more so than asthma and other chronic respiratory conditions –  for being hospitalised with COVID-19. Young adults with obesity appear to be at particular risk.

This is bad news for the United States where two-thirds of adults are overweight or obese, and especially for African Americans and other people of colour who have higher rates of obesity and are already bearing a disproportionate burden of COVID-19 deaths.

It also means the coronavirus could exact a steep toll in US regions like the South and the Midwest, where obesity is more prevalent than in the Northeast.

Intriguingly, there are thoughts that people with obesity may shed the virus for longer and that their quarantine should likely be longer than that for lower weight individuals. This paper, just out, proposes that adipose tissue in patients with obesity infected with coronavirus acts as a virus reservoir with increased shedding and immune and cytokine activation.

Asymptomatic infection and infectivity

I came across this Italian study, interesting because of its background as well as its findings.

On 21 February 2020, a resident of the municipality of Vo’, a small town near Padua, died of pneumonia due to coronavirus infection. This was the first COVID-19 death detected in Italy following the emergence of SARS-CoV-2 in Wuhan.

In response, the regional authorities imposed a lockdown of the whole municipality for 14 days. Information on the demography, clinical presentation, hospitalisation, contact network and presence of coronavirus infection in nasopharyngeal swabs was collected for 85.9 percent of the population at the time the lockdown started and for 71.5 percent of the population at the end of the lockdown.

The study found that 43.2 percent of the confirmed infections detected across the two surveys were asymptomatic. There was no statistically significant difference in the viral load of symptomatic versus asymptomatic infections.

This provides important new insights into the monitoring and testing needed to know the full extent of coronavirus infection in the community.


Where are the non COVID-19 patients?

Patients with heart attacks, strokes, appendicitis, gall bladder infections and bowel obstructions have “vanished”  from hospitals in New York city and across the United States, in the UK, Europe and China. Many doctors believe the pandemic has produced a silent sub-epidemic of people who need care at hospitals but dare not come in.

report to be published in the Journal of the American College of Cardiology found a 38 percent drop in the expected number of patients receiving cardiac catheterisations for a life-threatening event known as a STEMI – the blockage of one of the major arteries that supplies blood to the heart.

At the University of Miami-Jackson Memorial Comprehensive Stroke Center, the March census of stroke patients is down almost 30 percent from February.

What is happening? With a medical history that puts them at increased risk of infection, some of the heart patients may not be missing but are among the seriously ill people in COVID-19 wards. And in New York city, some people who suffer cardiac arrests never make it to a hospital because paramedics now transport patients only if their pulse returns after CPR or defibrillation.

The New England Journal of Medicine recently ran an article on the toll the pandemic is having on patients who do not have coronavirus, asking “how do we best care for people with non–COVID-related disease”?

There is a distressing trade-off between patients’ needs for procedures and the need to protect caregivers from infection and preserve hospital capacity. For many interventions, the line between urgent and non-urgent can be drawn only in retrospect.

Cancer care and transplantation surgery have been disproportionately affected by COVID-19 – and these are issues in Australia too.

In a recent survey by the American Cancer Society’s Cancer Action Network, nearly one in four cancer patients reported delays in their care because of the pandemic, including access to in-person appointments, imaging, surgery and other services.

Before the pandemic, there were about 750 living-donor kidney transplants a week in the United States; by late March, it had dropped to 350 and is still declining.

The possibility that patients may be suffering and even dying at home rather than going to a hospital has led the American College of Cardiology to launch a “Cardiosmart” campaign, an attempt to encourage those with symptoms to seek urgent care and to continue routine appointments, through telemedicine when practical. See this video.

Still from the US ‘Cardiosmart’ campaign

Because Australia has been protected from the worst impacts of the coronavirus pandemic, there has not been such a silent sub-epidemic of people going without care here. Nevertheless, there has been a reduction in visits to doctors’ offices and emergency departments for non-COVID-19 health issues, prompting warnings from Health Minister Greg Hunt that people should not avoid care.

Emergency department presentations at The Alfred and Sandringham Hospitals in Victoria are at their lowest levels in years and they reported one of the quietest Easter periods in recent history. Some of this is actually good news; there have been drops of more than 50 percent in presentations for injuries following car and motorbike accidents, sporting injuries and drug and alcohol issues.

But it is clearly a concern: Emergency physician Dr Mya Cubitt, board member of the Australasian College for Emergency Medicine (ACEM), told Croakey recently she is having to convince patients who need hospital care to stay .

Counting the real coronavirus mortality toll

For some weeks now I have been tracking the issue of the “missing deaths” – in many countries far more people are dying than in previous years, over and above deaths recognised as due to coronavirus (see this article ).

An analysis by the New York Times of mortality data in eleven countries finds that, over the past month, at least 28,000 more people have died than the official COVID-19 death counts have reported.

Recent data from the UK Office of National Statistics (direct link here) show that the true death toll from coronavirus in England and Wales up to April 10 is 41 percent higher than the government’s daily update.

In part, this discrepancy (and some of the discrepancies in other countries) is explained by the fact that daily updates on the government’s website is only for deaths in hospital, and does not include deaths in hospices, residential care and private residences.

In many cases people who die outside of hospital have not been tested to coronavirus and so for many countries the real toll is inevitably higher. One exception is Belgium – which is now top of the leader-board of deaths per capita because authorities have been rigorous about including not only deaths that are confirmed to be virus-related, but those suspected of being linked, whether the patient was tested or not.

Source: Johns Hopkins University

We might never know the true toll of this infection and the excess non-COVID-19 deaths caused by patients not getting the care they needed in a timely fashion.

This paper in the BMJ: Tackling covid-19: are the costs worth the benefits? asks (but does not answer) the ugly question: what are the costs of mortality and morbidity from conditions other than COVID-19 due to reduced use of health services and delays in treatment of other illnesses arising from prioritising resources on COVID-19?


In case you missed it

New England Journal of Medicine: In pursuit of PPE.

“Two semi-trailer trucks, cleverly marked as food-service vehicles, met us at the warehouse. When fully loaded, the trucks would take two distinct routes back to Massachusetts to minimise the chances that their contents would be detained or redirected.”

From the “Only in America” files!

Journals of Gerontology: Aging in times of the COVID-19 pandemic: Avoiding ageism and fostering intergenerational solidarity

“… in this editorial we have been concerned with the effects of the COVID-19 public discourse on the lives of older adults, and the solidarity between generations. We believe that behavioural scientists have a responsibility to participate in the current public discourse to correct misperceptions, over-generalisations, and ethically questionable suggestions.”

European Journal of Preventive Cardiology:  A dialogue between the editor-in-chief and a deputy editor of a cardiology journal during the coronavirus outbreak: Take-home messages from the Italian experience

“It is really unbelievable to think such a tempest could ever happen to us.”

The importance of public health funding

Health emergencies such as the novel coronavirus pandemic and bushfires, together with the ongoing challenges of climate change, vaccine-preventable disease outbreaks, obesity, vaping, rising rates of sexually transmitted infections, the opioid epidemic and suicide, are stark reminders of the critical importance of public health and emergency preparedness programs.

A new report from Trust for America’s Health entitled ‘The impact of chronic underfunding on America’s public health system: trends, risks, and recommendations, 2020” looks at how woefully under-resourced the US public health system is, and makes recommendations for policy actions.

The report finds that health departments across the country “are battling 21st-century health threats with 20th century resources”: this is arguably also true for Australia. Australian politicians and public health officials should read this report and take note.

It reports that the US spends an estimated US$3.6 trillion annually on health, but less than 3 percent of that is directed toward public health and prevention. There is a huge mismatch between need and funding levels. It is estimated that an annual infusion of US$4.5 billion is needed to fully support core public health foundational capabilities at the state, territory, local, and tribal levels nationwide.

  • The Centers for Disease Control and Prevention (CDC) is the primary driver of federal public health funding through grant programs to the states and large cities.  Although the CDC budget has continued to rise, when adjusted for inflation it remains just above the level in FY2008.
  • CDC funding for public health preparedness and response programs has been cut in half over the last decade.
  • The Prevention and Public Health Fund, which was included in Obamacare to expand and sustain the nation’s investment in public health and prevention, remains at half of where it should be funded in 2020 due to the re-appropriation of funds to other spending programs.
  • The Hospital Preparedness Program in the US Department of Health and Human Services – the single source of federal funding to help regional healthcare systems prepare for emergencies – has seen its budget decline from $515 million in FY2004 to $275.5 million in FY2020.
  • Over the past decade, the US public health workforce has shrunk by approximately 56,000 positions, primarily due to funding issues.

The report includes 28 recommendations for policy action within four priority areas:

  • Increased funding to strengthen the public health infrastructure and workforce, including modernising data and surveillance capacities.
  • Safeguarding and improving Americans’ health by investing in chronic disease prevention and the prevention of substance misuse and suicide.
  • Improving emergency preparedness, including preparation for weather-related events and infectious disease outbreaks.
  • Addressing the social determinants of health and advancing health equity.

This finding is worth quoting in full:

An unfortunate pattern has emerged: as a nation, we pay attention to public health investment when there’s a crisis, often borrowing from existing public health budgets (money typically meant to address chronic illness) to pay for the emergency response before falling back into a pattern of under-investing in public health.

This robbing-from-Peter-to-pay-Paul approach has left the nation’s public health infrastructure on a weak footing.”


Mental health: warning on the “second wave”

In a recent media interview, Australian mental health leader Professor Pat McGorry talked about how the necessary responses to the coronavirus pandemic (physical isolation and economic shutdowns) in Australia are “wreaking havoc” on peoples’ mental health and will result in a second wave of illness, “much longer and deeper” than that caused by COVID-19.

He is worried that Australia’s mental health care system, which has not done well in providing care to all who need it, is “not well prepared” for the anticipated surge in care and will be swamped by increased demand in the period ahead.

According to a recent survey by YouGov, more than half of Australians are stressed due to the COVID-19 crisis.

Over three quarters (77 percent) of survey respondents said they were stressed about not seeing their family, 71 percent were unhappy about not being able to see their friends, 60 percent had concerns about not being able to pay their bills, 49 percent feared losing their job, 48 percent worried about not being able to feed their family, and 38 percent were stressed about losing their home.

This is exemplified by outreach for help; for example, Lifeline was hit by a tsunami of desperate calls in March (90,000 calls), recording its highest monthly national total in the organisation’s 56-year history.

The situation is similar in the US where, in a recent Kaiser Family Foundation poll, nearly half (45 percent) of adults reported that their mental health has been negatively impacted due to worry and stress over the virus. The KFF has produced a great brief on The implications of COVID-19 for mental health and substance use that readers might find interesting and/or useful.

Arguably it is healthcare workers on the frontlines of the pandemic who are under the most stress and whose mental health and wellbeing should be of utmost concern. Polling in the UK, reported by The Guardian, found that 50 percent of healthcare workers (71 percent of younger health professionals) said their mental health had deteriorated since the virus began taking its toll.

We have all seen interviews with healthcare workers in New York and the UK who are stunned and exhausted from the unprecedented challenges of treating so many people who are seriously unwell or dying under challenging conditions and, in some cases doing so without adequate PPE.  Many of these workers are at risk of developing post-traumatic stress disorder.

McGorry argues that there is a need to model and measure the coming surge in mental ill health and suicide so we can prepare to flatten this second curve.  Failure to do so will only increase the costs to individuals and society.

In conclusion:

Here is Australia’s COVID-19 National Health Plan – Supporting the mental health of Australians through the Coronavirus pandemic

A reminder that the Productivity Commission’s Mental Health Inquiry must deliver its final report to the Federal Government by May 23.

We are also awaiting the final report from the Royal Commission into Victoria’s Mental Health System. The Commissioners issued a media release on April 16 that acknowledged how the coronavirus pandemic has changed the landscape and impacted their work.

They said:

It is clear, that a future mental health system will need to address responses to large-scale events, such as the recent challenges of drought and bushfires and the current crisis.”


The good news story

This isn’t quite news, but it’s about a relatable and fun way to inform the community about the need for physical isolation during the coronavirus pandemic. It seems no-one does this better than our Kiwi neighbours and it shows in their results – their new coronavirus infections are literally off the charts in the very best way.

Prime Minister Jacinda Ardern is consistently praised for her communications (and I love the signers beside her too – she has her own appointed signer who describes his work as “like juggling and doing gym”), but she has some serious competition from the New Zealand police force.

They have produced a whole series of YouTube videos on staying safe, including this beauty with a guy at home with a toddler and a busy wife (also, see it below: Clarke Gayford – the “Prime Minister’s Bloke”). You can view them here.  And we should all learn to sing the Two Metres Please song.


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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