In her latest edition of The Health Wrap, Dr Lesley Russell reports on efforts to address racism, coronavirus research and related controversies, aged care concerns, and developments in telehealth. She also shares a new rendition of Billy Joel’s “Stay at Home State of Mind”.
Lesley Russell writes:
The issues around the coronavirus pandemic continue to dominate the news, drowned out only by the Black Lives Matter protests, now reaching out beyond the United States.
Here in Australia I see this outgrowth positively, hoping that it will increase Australians’ awareness of the dreadful rate of incarceration of Aboriginal and Torres Strait Islander people (highlighted by new data) and ongoing failures to implement recommendations from the 1991 Royal Commission into Aboriginal Deaths in Custody.
For a United States perspective, there is a great set of resources here on why social justice is a public health issue. See also this BMJ Opinion “There is no stopping covid-19 without stopping racism”.
High levels of asymptomatic coronavirus infections
If you catch coronavirus, what are the chances of being asymptomatic?
They are surprisingly high, probably around 40 percent, according to a study recently published in the Annals of Internal Medicine.
This review and synthesis of the available international evidence found the number of people tested who were asymptomatic ranged widely (from 6.3 percent in a nursing home to 96 percent in prisoners) but on average asymptomatic persons accounted for 40-45 percent of SARS-CoV-19 infections.
Two additional findings (not new) were cause for concern: asymptomatic people can transmit the virus to others for an extended period, perhaps longer than 14 days; and the absence of symptoms may not necessarily imply an absence of harm as many with asymptomatic infections were found to have subclinical lung abnormalities, as detected by computed tomography (CT) scans.
While CT scans have picked up COVID-19 pneumonia in asymptomatic patients, they are not effective for ruling out the disease.
Radiologists around the world are sharing CT scans and X-rays to help each other understand how coronavirus affects the lungs through Radiopaedia, a wiki-based collaborative, funded in 2005 by Australian radiographer, Professor Frank Gaillard.
The increasingly complicated hydroxychloroquine story
This is a story in two parts.
1. Hydroxychloroqine as a prophylactic to prevent coronavirus infection
A new study published in The New England Journal of Medicine finds that taking hydroxychloroquine does not protect people from becoming infected with coronavirus and suggests the drug is no more effective than a placebo (so much for President’s Trump’s advice!).
The randomised controlled trial, which was carried out in the US and Canada, recruited people who were at moderate to high risk of contracting coronavirus. It was set up to compare what happened in people given hydroxychloroquine within four days of exposure and those given placebo pills instead.
However, the trial had many limitations, acknowledged by the investigators (and the endless commentary on social media). In an accompanying NEJM editorial, the results are described as “more provocative than definitive, suggesting the potential prevention benefit(s) of hydroxychloroquine remain to be determined”.
2. Hydroxychloroquine as a treatment for people who have COVID-19
The situation and the science here are much murkier. This involves two studies on treatments for COVID-19, using the same apparently suspect data base of patients, published in two major journals, and both now retracted.
A number of previous studies in very ill coronavirus patients have linked hydroxychloroquine to dangerous heart-rhythm disorders (especially so when combined with the antibiotic azithromycin) and in the US, both the Food and Drug Administration and the National Institute of Allergy and Infectious Diseases have warned that it should not be used outside of clinical trials or in hospitals.
The first study, published in May in The Lancet, concluded that hydroxychloroquine was ineffective against the virus, a finding in line with several other studies, but – for the first time – also linked the drug to a higher risk of death.
There were swift reactions with two major hydroxychloroquine clinical trials by the WHO and the United Kingdom put on hold (the WHO trial has since recommenced) and the drug banned as a coronavirus treatment in France, Belgium and Italy.
But the study drew concerns from scientists who demanded the authors share their full dataset, which came from a little-known health data analytics company called Surgisphere and which claimed to be based on 96,000 hospitalised COVID-19 patients from 617 hospitals across six continents. On May 29 the authors corrected some of their data but claimed their conclusions remained unchanged.
Then, just a few days later, the study was retracted. Three of the four researchers acknowledged they “can no longer vouch for the veracity of the primary data sources” and that Surgisphere would not hand over its full dataset for independent audit due to “client agreements and confidentiality agreements”. The fourth co-author of the study (who was also the founder of Surgisphere) was not listed alongside the other authors who retracted the paper.
A second paper using Surgisphere data and published in The New England Journal of Medicine by the same researchers, that found common drugs given for heart disease were not associated with a higher risk of death in COVID-19 patients, was retracted at the same time.
It’s a dreadful, convoluted story. This article in the New York Times is a good summary of the issues.
A major fallout from this debacle is that trust in science (even that published in world-recognised journals) is undermined at a time when it is already being challenged. Peer review (at least in the first instance) has not lived up to expectations. How can something like this be prevented in the future?
These exposures were due in large part to investigations in The Guardian and The Scientist that raised serious questions about Surgisphere’s history. It also seems, based on work done by Melissa Davey at The Guardian Australia, that some of the same authors, using data from the same source, were involved in a pre-print article about the use of the anti-parasite drug ivermectin to treat COVID-19 patients.
Meanwhile in Australia two clinical studies of hydroxychloroquine, are proceeding, with one reported to be costing taxpayers $170,000. I’ll leave to someone more knowledgeable than I am to determine if this is a good use of precious research funding.
I offer two useful resources for these difficult times:
- How You Should Read Coronavirus Studies, or Any Science Paper in the New York Times.
- Retraction Watch lists 15 retracted papers, 2 temporary retractions and one Expression of Concern on it coronavirus (COVID-19) page.
Trump Administration picks vaccine favourites
The 2 June 2020 version of the WHO draft landscape of COVID-19 vaccine candidates lists ten candidate vaccines in clinical evaluation (five of these are being developed in China) and 123 candidates in preclinical evaluation.
In late April the Trump Administration announced Operation Warp Speed, a Manhattan Project-style effort to drastically cut the time needed to develop a coronavirus vaccine. The program pulls together private pharmaceutical companies, government agencies and the research arm of the military to try to cut the development time for a vaccine. It has some pretty unreasonable time frames – Trump has said he wants a vaccine by year’s end – but it does have some real heft behind it.
The Trump Administration recently announced it has selected five companies (from a pool of around twelve) as the most likely candidates to produce a vaccine for the coronavirus.
Basically, the Trump people are betting that the operation can identify early the most promising vaccine candidates and thus speed along the development process. Hopefully this also means ensuring the testing for both safety and efficacy is also done to the highest standards. Exactly how this selection was made has been subject to criticism by some US experts.
Of the five companies, three (Oxford University / Astra Zeneca, Moderna and Pfizer) are on the WHO list as having clinical studies underway. The two others (Merck and Johnson & Johnson) are further behind. Merck, which has considerable expertise in vaccine development, has two vaccine candidates in pre-clinical studies.
Two US-based companies on the WHO list of ten did not make the Trump Administration selection. One of these, Novavax, has $384 million from the Coalition for Epidemic Preparedness Innovations (CEPI), which may have excluded it from consideration; the other, Inovio is apparently caught up in a law suit.
Novavax is conducting some of its clinical studies in Australia in conjunction with the University of Queensland. It’s not clear whether this is separate from the work the university has been doing on a coronavirus vaccine (which also has CEPI funding) but I believe it is. Recent media reports say that if the vaccine is shown to work, CSL will be involved in the production technology with talk about production of up to one hundred million doses towards the end of 2021. The agreement would enable CSL to subcontract to other vaccine manufacturers internationally to increase the number of doses being produced.
By my count the US Government has committed several billion dollars to this effort; their selection as finalists will give these companies access to additional government money, help in running clinical trials and financial and logistical support for a manufacturing base that is being built even before it is clear which, if any, of the vaccines in development will work. In return the pharmaceutical companies have committed to deliver hundreds of millions of doses of vaccine to the US.
I foresee many difficult issues ahead about who owns vaccine patents, how the patent licences will be made available, and who gets first access to vaccines. You can read a discussion about this here at The Conversation. European concerns about these issues are discussed here.
Ongoing problems in aged care
The coronavirus pandemic has taken a high toll on frail, elderly residents in residential aged care facilities (RACFs) and has highlighted the ongoing problems with quality, safety and workforce in these facilities.
One of the key issues that underpins these problems – and expect to hear much more about this when the report from the Royal Commission on Aged Care Quality and Safety is released – is the need for profitability, especially driven by the fact that 45 percent of residential aged care beds are operated by for-profit entities. A December 2019 report found that 56 percent of RACFs surveyed were already operating at a loss.
Now the coronavirus pandemic is further undermining the profitability of this sector. Expect ongoing pleas to government about this.
Financial pressures have been exacerbated by the additional costs related to coronavirus, including supplying personal protective equipment, a heightened level of infection control, and resources associated with screening visitors.
To date, the Australian Government has announced some $550 million in support packages to the aged care sector, which will provide $900 per resident in metropolitan areas and approximately $1,350 per resident in regional Australia (it is not clear if these funds have yet been paid out). The industry says this amounts to only an extra $2 per resident per day and that it will need between $1.3 billion and $1.5 billion over the next six months to fund increased staff and safe visitations.
Additional financial pressure is likely if falling occupancy levels – attributed to elderly Australians leaving their residence or delaying moving to a facility due to the coronavirus pandemic – do not recover. The number of occupied aged care beds is likely to drop by two to three percent this financial year, the biggest one year drop in recent memory.
Interestingly, the industry data on occupancy levels differs from that of the federal Department of Health, which keeps its own data. A DoH spokesperson said the “modest reduction” was in line with an ongoing gradual decline and not necessarily a result of COVID-19.
As Professor Kathy Eagar recently tweeted: “There is no point a frail older person being in residential care unless it is safer than being at home.”
A paper she and colleagues published recently in The Medical Journal of Australia highlights how far Australia’s RACFs fall behind best practice staffing levels. (The MJA link to the paper is here and also see an excellent summary here).
The research, commissioned by the Royal Commission into Aged Care Quality and Safety, utilised a “five-star rating system”, used in the US by the Centers for Medicare and Medicaid Services, to assess staffing levels.
When applied to Australian RACFs, the authors found only 1.3 percent of aged care residents live in facilities that have five star, or “best practice”, staffing levels; 14.1 percent of residents are in RACFs with four stars, 27 percent are in RACFs with three stars, and – shockingly – the majority (57.6 percent) of residents live in RACFs that have inadequate (one or two stars) staffing levels.
Dr Ken McCroary, a GP with a special interest in aged care, described some of the findings as “‘horrendous”, while conceding that “the deeper picture is that it’s probably even worse than what the star rating indicates”.
He believes that RACFs, with very frail, sick and dying patients, should be considered as an extension of the hospital system and that consequently “staff are under-funded, under-educated, under-resourced, and under-supported by their managers”.
Professor Eagar says it would take an average staffing increase of 37.3 percent in one or two star rated RACFs to elevate them to “adequate” staffing levels while a nearly 50 percent increase would be needed to reach five stars.
“Residents in Australian RACFs have a right to be safe and to receive clinically competent and adequate care,” the study concluded.
Informal home care providers: the forgotten health-care workers during the COVID-19 pandemic
It is worrying that we hear little or nothing about how the 140,000 or so Australians who receive aged care services in their homes are faring in these coronavirus pandemic times.
And what does the coronavirus pandemic mean for informal home care – not just for the elderly but for people living with disabilities and those who are chronically ill?
And now there is a huge reliance on home care as one pillar of the healthcare system to support people with confirmed or suspected COVID-19.
While the public health emergency is hopefully over in Australia, there will be others, and at such times informal home care providers are a crucial resource that boosts the community’s healthcare capacity, especially in regions with an ageing population and areas with suboptimal healthcare.
A new paper in The Lancet looks at how little we know about the domestic environment for the care of sick and vulnerable people. It makes the point that the physical, mental, and social wellbeing of home care providers has been largely overlooked in the research literature.
Policy planners who advocate for home care often make the assumptions that home care providers possess an appropriate level of health literacy, disease knowledge, psychological readiness, and medical care abilities.
Another common assumption is that care recipients live in housing with adequate space where there are facilities for care with ready access to home care materials. There are also issues of domestic violence.
The future of telemedicine
The use of telemedicine has exploded during the coronavirus pandemic, and it is likely these changes will remain even after the coronavirus, especially for those Australians living in medically underserved areas and those who are unable to easily leave their homes for a medical appointment.
The Centre for Online Health at the University of Queensland has analysed the MBS service data since additional telehealth items were added in March. These show that most items are for telephone conferencing (does this means doctors are late-comers to Zoom and Skype?) and mostly for GP consultations.
A further breakdown of data shows that specialists (including psychiatrists) were already conducting some pre-coronavirus videoconference consultations and the level of these did not change significantly in March – there was just a sudden increase in telephone consultations.
In contrast, mental health consultations (by psychologists, occupational therapists and social workers) saw substantial increases via both video and telephone. Most allied health consultations used video and most Nurse Practitioner consultations used telephone.
It would be interesting to know the extent to which these differences reflected the IT equipment and services available to healthcare professionals and patients, and the familiarity and comfort of both groups with the newer video technologies.
Australian Doctor also analysed MBS telehealth data for general practice (many thanks to Geir O’Rourke who publicly released this).
It shows how in April telehealth services for GP mental health services and chronic disease management items almost offset the almost 50 percent drop in face-to-face consultations.
A recent Telehealth services survey from Consumers Health Forum found that more than 80 percent of those who were offered telehealth services used it. The vast majority of people viewed the service as excellent or good quality and there was strong community support for the scheme to continue.
However, the survey did find that key barriers to telehealth services were lack of access to required technology and unreliable internet access. The survey did not address patients’ out-of-pocket costs for these services.
As pointed out in a recent article from Deakin academic, Dr Anna Peeters, the shift to telehealth requires more than a few new Medicare items and the associated financial incentives.
She highlights the work done in Denmark to build a telehealth strategy that recognises the need for integrated, person-centred care, and writes: “Working well includes positive health outcomes, positive patient experience and positive health professional wellbeing. We must also actively monitor the impact on health inequalities and health professionals themselves.”
The US has also seen a huge growth in the use of telehealth services. In March telehealth claims from private health insurers increased an astounding 4,347 percent over March 2019. As in Australia, telehealth services have been available for some years, but uptake had been sluggish until the coronavirus pandemic meant most doctors’ offices and hospitals were effectively off-limits to non-COVID-19 patients.
The NSW Critical Intelligence Unit
In the last edition of The Health Wrap I wrote about what Australian experts are doing to get essential information quickly to political decision makers in these coronavirus times.
The Unit uses evidence from grey and peer reviewed literature to provide rapid reviews on specific issues relating to the current pandemic. The Evidence Checks produced are available on their website, and particularly valuable is the Daily Evidence Digest.
Just one problem – how to keep up with all this reading?
The Health Wrap is introducing a new section, to show some of the discussions generated by recent Croakey articles.
This 27 May article by Summer May Finlay, Where do you fit? Tokenist, ally or accomplice?, generated widespread interest, including republication by the University of Wollongong and Public Health Association of Australia on their websites, as well as media interviews.
See some of the commentary on Twitter.
The good news story
I’m writing this edition of The Health Wrap while listening to ABC Classic Radio’s Beethoven Top 100 Countdown. No wonder I’m at 3000+ words!
This week’s good news story is also about music, but not Beethoven.
It’s the wonderful gang of Emergency Department personnel and associated small people and pets that Dr Clare Skinner rounded up in her spare time (!) from around Australia and New Zealand to sing – in wonderful harmony – a cover of Billy Joel’s “Stay at Home State of Mind”.
I especially love the bagpipes. I’m pleading with Clare et al for more; you will too.
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.