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The Health Wrap: pandemic alarm on oral health, research on Long COVID, and latest on value-based healthcare

Dentists are sounding the alarm about the pandemic’s impact upon oral health, especially for those children who are most likely to need dental services, reports Associate Professor Lesley Russell in her latest edition of The Health Wrap.

Russell also reviews the latest evidence on Long COVID and vaccination, reports on NHS success in slashing carbon emissions, and summarises a stack of new reports covering mental health, Aboriginal and Torres Strait Islander people’s health, and the social determinants of health.


Lesley Russell writes:

In the pre-vaccine era of the pandemic, experts estimated that somewhere between 10 and 30 percent of people had lingering symptoms of some kind and severity after having COVID; what we now call Long COVID.

Worryingly, research shows that even mild cases of COVID-19 may have neurological effects and there is now a long list of cardiac effects and kidney disease (Another Face of Long COVID: Kidney Disease | MedPage Today)

The two leading theories about what causes Long COVID are (1) that the virus can trigger an autoimmune response that essentially makes the body attack itself, or (2) that viral remnants sometimes linger in the body and cause lasting symptoms.

Several non-peer reviewed studies indicate that people suffering Long COVID symptoms find some relief after receiving a coronavirus vaccine.

Now a study from France, recently released as a preprint by The Lancet, looks at improvements in Long COVID symptoms after the first vaccination against the disease. It found that that vaccination leads to an improvement in symptoms among patients with Long COVID.

These results support the hypothesis that, for at least some patients with Long COVID, the disease is mediated by a persistent viral reservoir and/or by circulating virus fragments – this could help with the search for therapeutics to treat Long COVID. It should also help to reduce vaccine hesitancy among patients with Long COVID.

Data is also starting to emerge in answer to the question of whether vaccinated people who have breakthrough infections can get Long-COVID.

A small study published in The New England Journal of Medicine in July, analysed 39 fully vaccinated Israeli healthcare workers who had breakthrough infections and found almost 20 percent still had symptoms six weeks later. Though its sample size was small, the study demonstrated that Long COVID is possible after a breakthrough infection.

A larger, more recent study, published in The Lancet Infectious Diseases in September, used self-reported symptom data from adults in the United Kingdom who tested positive for COVID-19 after being fully or partially vaccinated, and compared this to data from a control group of unvaccinated people who tested positive for the virus. The researchers found that a fully vaccinated person who experienced a breakthrough infection was half as likely to have COVID-19 symptoms at least a month after diagnosis, compared to an unvaccinated person.

Long COVID has the potential to be a major disease burden in the years ahead. The National Institutes of Health in the United States has committed US$1.15 billion over the next four years into research on long-COVID. In the United Kingdom, the National Institute for Health Research has announced it will invest a total of £38.5 million in studies of long COVID.

As far as I can determine, Australia has yet to make any such commitment, although it’s possible that some of the research that is being funded to find new or repurposed drugs to treat COVID-19 will also benefit Long COVID.

In recent months Croakey Health Media has published a number of articles on Long COVID. Here is some recommended reading:

The ABC Science Friction show did a piece last year, and a recent follow-up, on three UK doctors with long-COVID. You can access both and some additional references here.


Pandemic impacts on dental care

There is growing concern about the impact of the coronavirus pandemic on access to screening and preventive health services and what this means for health outcomes. Largely missing from this debate – because it’s always missing from the health debate – is the impact on dental care and oral health.

An article in the August edition of Bite Magazine sums it up: the lockdowns that Australians have experienced, particularly in Victoria and NSW, have had a significant impact on the provision of dental care for all patients.

It quotes Professor Heiko Spallek, Dean of the Dental School at the University of Sydney: “Lockdowns and closures of dental services for safety reasons, continued reduced operating capacity in some public dental facilities and increasing financial instability will take their toll on Australia’s dental health and, in turn, our health system, and it will affect the vulnerable in our society more than any other.”

Dentists are reporting more emergencies and poorer health outcomes for their patients. There is also real concern about the impact of delayed diagnosis of oral cancers.

Victorian dentist, Associate Professor Matt Hopcraft, said that the most pressing concern is the impact the pandemic continues to have on the provision of dental care to vulnerable children, who already experience higher levels of dental disease and disadvantage in accessing needed care.

It’s telling that the recent report from the Australian Institute of Health and Welfare on the direct and indirect effects of the first year of COVID-19 in Australia fails to mention dental care and the AIHW report on the impacts of COVID-19 on the Medicare Benefits Scheme and the Pharmaceutical Benefits Scheme omits the Child Dental Benefits Schedule (CBDS).

Hopcraft and his colleagues have filled the gap with an analysis of CDBS services provided for the period February to September 2020.

In that six-month time frame, 881,454 fewer dental services were provided in 2020 than 2019, with the largest decline seen in April 2020. Not unexpectedly, there was a greater decline in preventive and diagnostic services, and a smaller decline in endodontic and oral surgery services.

Their conclusion then was that the pandemic was having a significant impact on the provision of dental services to children from lower socioeconomic backgrounds, who already experience higher levels of dental disease and disadvantage in accessing dental care. The impact on oral health will be long lasting.

Now another year has passed with more lockdowns – and further deferrals of needed care and subsequent long-term oral health consequences.

Not surprisingly, there are also reports of blow-outs in waiting times for public dental care in the states. In Victoria the average waiting time is now 23 months and in some clinics it’s over three years. Last September, a year ago, the number of adult patients waiting for public dental treatment in NSW had ballooned out to over 100,000, an increase of 20,000 on the same period in 2019.

The paucity of the public dental system in Australia has been a constant issue for as long as I have been involved in health policy. This is also highlighted by a report last week in The West Australian that public dental waiting lists in Western Australia (a state barely impacted by the pandemic) have quadrupled in the past four years.

Professor Heiko Spallek recently wrote about how the inequalities the pandemic has highlighted includes dental health and dentistry. It’s a great article that includes the impact on dental teaching and research, and the need for the current dialogue on value-based care to include dental services.


Value-based healthcare

Research over the past two decades has established that a significant minority of clinical care is low value, wasteful, or harmful. At the extreme end of low value care is no value care – otherwise known as overdiagnosis.

Overdiagnosis is the detection of conditions that could be safely left undiagnosed and untreated. Too often, once discovered, a cascade of tests and treatment follows, with no benefit to the patient and costs to the healthcare system.

I recently zoomed in to a seminar sponsored by the Australian Institute of Health Innovation where Assistant Professor Ishani Ganguli from Harvard Medical School talked about the “care cascades” (and resultant costs) that result from overdiagnosis. If you are interested in this topic, I really recommend watching this.

Dr Ganguli’s recent work has focused on the unnecessary and inappropriate testing and treatment that results from health checks.  (If you’ve been reading me for a while then you know how I feel about (untargeted) healthcare checks: A call for health checks to help those in need, rather than the worried well.)

In a cohort study of fee-for-service US Medicare beneficiaries who received an annual wellness visit, the authors found that 19 percent of healthy Medicare beneficiaries received routine low-value ECGs, urinalyses, or thyrotropin tests, more often those who were younger, White, and lived in urban, high-income areas. The ECGs and urinalyses were associated with cascades of modest but notable cost.

A paper in the BMJ from Professor Alexandra Barratt and Dr Forbes McGain at the School of Public Health, University of Sydney, looks at how reducing overdiagnosis and over-treatment is an untapped reservoir of potential to cut healthcare’s carbon emissions and reducing healthcare costs.

(Way back in 2015 my colleagues Matthew Anstey and Susan Wells and I wrote an article, published in the MJA, on how hospitals should be exemplars of healthy workplaces and we also considered these issues.)

The National Health Service in England has been working since 2008 to quantify and reduce its carbon footprint.

An article published in The Lancet Planetary Health in February 2021 presents the latest update to the NHS greenhouse gas accounting and identifies interventions for mitigation efforts. The authors make the point that this approach is applicable to other healthcare systems.

Dr Nick Watts, Chief Sustainability Officer for NHS England & NHS improvement, recently sent this email to colleagues in Australia, asking for help in promoting NHS progress in cutting healthcare emissions.

On 2 October, he wrote: “Today, we’ve hit the 12 month milestone since the NHS’s net zero commitment in October 2020, and in a few hours will be reporting on progress to the NHS Public Board. We needed an annualised reduction of approximately 1,260 ktCO2e, and we’ll excitedly report that we’ve hit that target. It’s the equivalent reduction of 1.7 million flights from London to New York, or 1.1 million homes in the UK.”

Watts, McGain and Barrett are speaking at a webinar on 2 December hosted by the NHMRC Partnership Centre for Health System Sustainability and AIHI, Exploring the Nexus of Climate Change, Human Health, and Healthcare System (register here).

The Croakey Conference News Service will cover the event; on Twitter follow #healthclimatesolutions21.


New reports

Australia’s welfare 2021

The AIHW Australia’s Welfare 2021 report is more than the usual report card on the welfare of Australians; it is accompanied by a slew of additional materials – a mix of short statistical snapshots on 43 welfare topics and longer articles on welfare issues.

The key findings are around housing, education and skills, income and employment, social support, justice and safety, and Indigenous Australians. There’s not a lot of good news – it’s clear some Australian communities and individuals are really struggling.

My takeaway is that government supports are critical to ensure that these people get a fair go and equal opportunities for lives of value and dignity.

COVID-19 insights from the 45 and Up Study

I am part of the 45 and Up Study, so I’m always interested in the results that are published regularly.  The October 6 edition of Evidence Matters from the Sax Institute presents some recent findings  on people’s behaviours and attitudes during the pandemic as collected through its COVID Insights Surveys.

Interestingly, given the segment above on dental health, the most recent survey around 16 percent of respondents had missed or delayed a healthcare appointment in the previous month, most commonly a dentist (53 percent) or GP (32 percent) appointment. Sixty-five percent of those hadn’t subsequently sought another appointment.

Modern work practices and mental health

The Black Dog Institute has released new research on how changes to the way people work are impacting Australians’ mental health.

It looks at the technological innovations that have led to wide scale digitisation of work, automation, and the gig economy. At the same time, Australia’s workforce has changed, with greater female participation, an older retirement age and many more people on short term or casual contracts. And then the pandemic and working from home arrived.

The report interrogates the impact these seismic changes had on the mental health of Australian workers and the cost of workplace mental ill-health in lost participation and productivity

Burden of disease findings for Aboriginal and Torres Strait Islander people

The AIHW has released a report on the burden of disease (a measure of healthy life lost because of injury, illness or premature deaths) for Aboriginal and Torres Strait Islander people. Unfortunately the most recent data are from 2018.

The study includes 219 diseases, as well as estimates of the burden attributable to 39 individual risk factors, such as alcohol use and smoking. The study includes results for 2003 and 2011 for comparison, as well as estimates for selected states and territories, by remoteness area and socioeconomic groups.

The good news is that over the 15-year period from 2003 to 2018, after adjusting for population growth and ageing, there has been a 27 percent decline in fatal burden. The not-so-good news is that the non-fatal burden rates have not changed.
Watch the interview here.


The best of Croakey

This Twitter thread on missed opportunities in public health communications has evidently touched a chord.


The good news story

A new study from the University Admission Centre finds that students from disadvantaged backgrounds outperform more advantaged students with the same academic ability in their first year of university. And female and Indigenous students also do better than male and non-Indigenous students with the same Australian Tertiary Admission Rank.

Disadvantaged students do better than advantaged ones at uni: study (smh.com.au)

The corollary for this good news is that more must be done to support students from disadvantaged backgrounds to get to year 12, to aspire to attend university, and to be adequately supported, financially and socially, once they do so.

And here is a great story about two very impressive young Indigenous scientists who are doing excellent things.


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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