RESEARCH BRIEFING – WEEK IN REVIEW
Following the killing of George Floyd by Minneapolis police officers on May 25th, massive protests against police brutality and structural racism began under the banner of Black Lives Matter. As of July 3, polls estimate that between 15 million and 26 million people had participated at some point in the demonstrations in the United States, which would make it the largest protest in US history. In the wake of these protests, many public health officials and physicians have worried that there would be a surge of covid-19 infections. However early data now suggests the opposite. A working paper from the National Bureau of Economic Research used data from 315 American cities with at least 100,000 residents, covering the period of May 25th (the day George Floyd was killed) to June 20th to estimate the impact mass protests had on social distancing and covid-19 case growth. The researchers used event-study analysis with cell-phone tracking data as well as local prevalence of covid-19 cases from the United States CDC to compare the experience of the 281 cities where protests erupted with 34 cities where they did not. Perhaps counter-intuitively, the researchers found compelling evidence that stay-at-home behavior increased in cities with large-scale protests. The authors go on to assert that they "found no evidence that urban protests reignited covid-19 case growth during the more than three weeks following protest onset." They further hypothesize that this finding may be due to an increase in avoidance behavior by non-protestors in the regions, limitations on travel, mask-wearing, and other social distancing behavior on part of the protestors. Alternatively, it may be that the characteristics of the protest attendees (on average, younger than the general population) did develop more infections that have been detected, but have gone undiagnosed. Other studies have found that younger persons show milder symptoms of covid-19 or have symptom-free SARS-CoV-2 infections and are therefore less likely to get tested. The authors point out that the results do not imply that large outdoor gatherings are safe in general, however as the compensatory avoidance behavior of non-protestors likely contributed to overall net effects observed in the general population. 8 July 2020.
While a great deal of literature describes the clinical features of acute covid-19, little is known about whether recovered patients have persistent symptoms. A new Research Letter in JAMA describes the symptoms of 143 recovered patients in Italy. On average, patients were assessed two months after their initial covid-19 symptoms. Over 87% of patients reported at least one symptom deemed to be related to SARS-CoV-2. The most common complaints were fatigue and difficulty breathing. Other "classic" covid-19" symptoms such as cough, loss of smell, taste, and of appetite were reported in some patients at the time of follow-up, but far less. The study provides some indication that recovery from covid-19 may take longer than is commonly appreciated. It may be that some patients are left with chronic symptoms. A limitation of this study is that these findings are not unusual for patients with other forms of pneumonia (i.e. this may not be unique to covid-19). Also, it is unknown how many of these patients had any of these symptoms prior to their covid-19 illness. It is known that individuals with pre-existing medical conditions are more likely to have more severe cases of covid-19. Those same persons may have rougher roads to recovery. 10 July 2020.
A new study in JAMA Neurology assessed whether covid-19 infection increases the risk for acute ischemic stroke. Previous studies indicate that SARS-CoV-2 may increase the likelihood that abnormally high amounts of blood clots occur in infected patients, a condition that physicians call a "hypercoagulable" state. Scientists already know from previous research that the infection with influenza virus is associated with higher risks of stroke. Therefore, covid-19 researchers performed a retrospective study of medical charts from two academic hospitals in New York City. The study analyzed the clinical outcomes of patients who were evaluated for covid-19 from March 4th, 2020 to May 2nd, 2020. The frequency of strokes in these patients was compared to a cohort of patients diagnosed with influenza A or influenza B (the two most common forms of seasonal influenza) from January 1st, 2016 to May 31st, 2018. Of the 1,916 patients diagnosed with covid-19, 1.6% also suffered an acute ischemic stroke during their covid-19 infection. Compared to patients with influenza A/B in the previous years included in the analysis, the rate of stroke among those 1,486 patients was only 0.2%. After adjusting for risk factors that are commonly associated with increased risk of stroke, patients with covid-19 had significantly higher odds of experiencing an acute ischemic stroke compared to patients with influenza A or B. While this retrospective study does not fully answer the question as to whether covid-19 confers an increased risk of stroke compared to other viral illnesses, it is a reasonable "hypothesis-generating study." Given the many known issues related to access to care, drug shortages, and other pandemic-related difficulties, there are likely to be important external factors that contribute to the association between covid-19 and acute ischemic strokes. Nevertheless, the data from this study suggest that the possibility of a genuine increase in the rate of new strokes in patients with covid-19 is concerning and warrants further investigation. Abbreviated from Brief19 for 6 July 2020.
The covid-19 pandemic represents an opportune time for an expansion of telehealth in the care of patients with a variety of needs. In a recent Viewpoint in JAMA, the unique challenges and opportunities presented for telehealth with regards to SUD were presented. The authors describe the large array of telehealth options, from synchronous videoconferencing between clinicians and patients to unguided mobile health applications including telephone/text/SMS or app-based interventions. During the last six months, several historic regulatory changes have occurred rapidly, particularly at the federal level. Importantly, the Center for Medicare and Medicaid Services has temporarily loosened many previous restrictions, allowing Medicare to cover a variety of additional telehealth services for their participants. One category of change affects remote prescriptions for controlled substances and includes liberalizing of rules so that physicians in some cases can prescribe buprenorphine via telehealth. Despite this updated flexibility, to date the adoption of telehealth for SUDs has been limited compared to other behavioral health or mental health conditions, due largely to the requirement of frequent provider-patient encounters, intensive monitoring (e.g. frequent urine drug screens). In addition, some clinicians have discomfort with the idea of evaluating such patients remotely. Ultimately, a combination of increased provider awareness, regulatory flexibility, and improved digital platforms present a unique opportunity to increase the footprint for care of SUD patients. Abbreviated from Brief19 for 10 July 2020.
POLICY BRIEFING – WEEK IN REVIEW
On a recent call with the National Governors' Association, Vice President Mike Pence and of the Secretary of Health and Human Services Alex Azar reassured state leaders that the coronavirus declaration of a national emergency due to the coronavirus outbreak likely would not be ending any time soon. While the continuance of the nationwide state of emergency is not yet official policy, the high ranking Trump administration members stated that an extension is currently moving through the administrative process. Secretary Azar noted that he didn't know of any reason that the continuance would not be authorized, though those who have watched the often mercurial President closely may have other ideas on that matter. Initially granted in January when the novel coronavirus was still largely in China, the declaration gives sweeping powers to the administration to make swift changes including increasing reimbursement for telehealth visits for the treatment of Medicare beneficiaries and allowing the Food and Drug Administration to temporarily authorize medications and medical devices including diagnostic tests. Under the declaration, state governments can also use federal employees to help with their responses to the pandemic. The public health emergency must be reauthorized every 90 days and is currently set to expire on July 25th. If granted, the extension would be set to expire shortly before Election Day, currently scheduled for November 3rd. Politico. 9 July 2020.
Though at times on the opposite sides of issues, the American Hospital Association (AHA), American Medical Association (AMA) and American Nurses Association (ANA) have come together to release a resoundingly simple and unified message to the American public: wear a facemask. Citing its demonstrated efficacy in controlling the spread of the coronavirus during the initial social distancing phase and the subsequent surge of cases as the restrictions have been lifted, these organizations make the case that scientific evidence supports several tactics in combatting the continued pandemic, of which masks are an important example. As more hospitals approach their intensive care unit capacity, including in parts of Texas and Florida following a recent intense spike in cases there and elsewhere, renewed fears of personal protective equipment shortages have surfaced. These three organizations have come together to argue urgently that now is not the time for laxity. Various. 8 July 2020.
While personal protective equipment (PPE) shortages have not been in the headlines as often lately–largely as a result of lower case counts in the Northeastern United States, especially in New York City–the problem has not disappeared. In fact, PPE shortages continue to be a major compounding factor in the ongoing efforts to limit the impact of the coronavirus pandemic in the US. In new letters to Vice President Pence and the Federal Emergency Management Agency (FEMA), the American Medical Association (AMA) has made new requests in hopes of ensuring adequate supplies of much-needed PPE, especially as case counts surpass daily records. The AMA specifically asked that the White House invoke the Defense Production Act in order to increase production of supplies, citing that while hospitals and nursing homes benefitted from the initial enacting and enforcement of the act, many outpatient practices are still struggling to adequately protect their staff, leading to the diminished ability to care for patients. Similarly, the AMA has asked FEMA to increase the visibility on supply chain data, to determine if the shortages seen in clinics are a result of an overall lack of PPE, backlogs in orders, or other logistical problems. The DPA power is remarkably broad and includes the power to compel domestic manufacturers to produce more of a specific product (such as N95 masks, as the Trump administration required 3M to produce earlier in the pandemic). In addition, under the DPA's "allocation authority," the administration can direct private companies as to whom they must sell such products. In addition to data transparency, the AMA suggests the creation of state or local clearinghouses that could serve as central points of contact for the identification and determination of resource availability and allocation of supplies. The American Medical Association. 6 July 2020.