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Research examines links between ‘long COVID’ and ME/CFS
Some patients who had COVID-19 continue to have symptoms weeks to months later, even after they no longer test positive for the virus. In two recent reports – one published in JAMA in July and another published in Morbidity and Mortality Weekly Report in August – chronic fatigue was listed as the top symptom among individuals still feeling unwell beyond 2 weeks after COVID-19 onset.
Although some of the reported persistent symptoms appear specific to SARS-CoV-2 – such as cough, chest pain, and dyspnea – others overlap with the diagnostic criteria for ME/CFS, which is defined by substantial, profound fatigue for at least 6 months, postexertional malaise, unrefreshing sleep, and one or both of orthostatic intolerance and/or cognitive impairment. Although the etiology of ME/CFS is unclear, the condition commonly arises following a viral illness.
At the virtual meeting of the International Association for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis August 21, the opening session was devoted to research documenting the extent to which COVID-19 survivors subsequently meet ME/CFS criteria, and to exploring underlying mechanisms.
“It offers a lot of opportunities for us to study potentially early ME/CFS and how it develops, but in addition, a lot of the research that has been done on ME/CFS may also provide answers for COVID-19,” IACFS/ME vice president Lily Chu, MD, said in an interview.
A hint from the SARS outbreak
This isn’t the first time researchers have seen a possible link between a coronavirus and ME/CFS, Harvey Moldofsky, MD, told attendees. To illustrate that point, Dr. Moldofsky, of the department of psychiatry (emeritus) at the University of Toronto, reviewed data from a previously published case-controlled study, which included 22 health care workers who had been infected in 2003 with SARS-CoV-1 and continued to report chronic fatigue, musculoskeletal pain, and disturbed and unrefreshing sleep with EEG-documented sleep disturbances 1-3 years following the illness. None had been able to return to work by 1 year.
“We’re looking at similar symptoms now” among survivors of COVID-19, Dr. Moldofsky said. “[T]he key issue is that we have no idea of its prevalence. … We need epidemiologic studies.”
Distinguishing ME/CFS from other post–COVID-19 symptoms
Not everyone who has persistent symptoms after COVID-19 will develop ME/CFS, and distinguishing between cases may be important.
Clinically, Dr. Chu said, one way to assess whether a patient with persistent COVID-19 symptoms might be progressing to ME/CFS is to ask him or her specifically about the level of fatigue following physical exertion and the timing of any fatigue. With ME/CFS, postexertional malaise often involves a dramatic exacerbation of symptoms such as fatigue, pain, and cognitive impairment a day or 2 after exertion rather than immediately following it. In contrast, shortness of breath during exertion isn’t typical of ME/CFS.
Objective measures of ME/CFS include low natural killer cell function (the test can be ordered from commercial labs but requires rapid transport of the blood sample), and autonomic dysfunction assessed by a tilt-table test.
While there is currently no cure for ME/CFS, diagnosing it allows for the patient to be taught “pacing” in which the person conserves his or her energy by balancing activity with rest. “That type of behavioral technique is valuable for everyone who suffers from a chronic disease with fatigue. It can help them be more functional,” Dr. Chu said.
If a patient appears to be exhibiting signs of ME/CFS, “don’t wait until they hit the 6-month mark to start helping them manage their symptoms,” she said. “Teaching pacing to COVID-19 patients who have a lot of fatigue isn’t going to harm them. As they get better they’re going to just naturally do more. But if they do have ME/CFS, [pacing] stresses their system less, since the data seem to be pointing to deficiencies in producing energy.”
Will COVID-19 unleash a new wave of ME/CFS patients?
Much of the session at the virtual meeting was devoted to ongoing studies. For example, Leonard Jason, PhD, of the Center for Community Research at DePaul University, Chicago, described a prospective study launched in 2014 that looked at risk factors for developing ME/CFS in college students who contracted infectious mononucleosis as a result of Epstein-Barr virus. Now, his team is also following students from the same cohort who develop COVID-19.
Because the study included collection of baseline biological samples, the results could help reveal predisposing factors associated with long-term illness from either virus.
Another project, funded by the Open Medicine Foundation, will follow patients who are discharged from the ICU following severe COVID-19 illness. Blood, urine, and cerebrospinal fluid will be collected from those with persistent symptoms at 6 months, along with questionnaire data. At 18-24 months, those who continue to report symptoms will undergo more intensive evaluation using genomics, metabolomics, and proteomics.
“We’re taking advantage of this horrible situation, hoping to understand how a serious viral infection might lead to ME/CFS,” said lead investigator Ronald Tompkins, MD, ScD, chief medical officer at the Open Medicine Foundation and a faculty member at Harvard Medical School, Boston. The results, he said, “might give us insight into potential drug targets or biomarkers useful for prevention and treatment strategies.”
Meanwhile, Sadie Whittaker, PhD, head of the Solve ME/CFS initiative, described her organization’s new plan to use their registry to prospectively track the impact of COVID-19 on people with ME/CFS.
She noted that they’ve also teamed up with “long-COVID” communities including Body Politic. “Our goal is to form a coalition to study together or at least harmonize data … and understand what’s going on through the power of bigger sample sizes,” Dr. Whittaker said.
None of the speakers disclosed relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Some patients who had COVID-19 continue to have symptoms weeks to months later, even after they no longer test positive for the virus. In two recent reports – one published in JAMA in July and another published in Morbidity and Mortality Weekly Report in August – chronic fatigue was listed as the top symptom among individuals still feeling unwell beyond 2 weeks after COVID-19 onset.
Although some of the reported persistent symptoms appear specific to SARS-CoV-2 – such as cough, chest pain, and dyspnea – others overlap with the diagnostic criteria for ME/CFS, which is defined by substantial, profound fatigue for at least 6 months, postexertional malaise, unrefreshing sleep, and one or both of orthostatic intolerance and/or cognitive impairment. Although the etiology of ME/CFS is unclear, the condition commonly arises following a viral illness.
At the virtual meeting of the International Association for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis August 21, the opening session was devoted to research documenting the extent to which COVID-19 survivors subsequently meet ME/CFS criteria, and to exploring underlying mechanisms.
“It offers a lot of opportunities for us to study potentially early ME/CFS and how it develops, but in addition, a lot of the research that has been done on ME/CFS may also provide answers for COVID-19,” IACFS/ME vice president Lily Chu, MD, said in an interview.
A hint from the SARS outbreak
This isn’t the first time researchers have seen a possible link between a coronavirus and ME/CFS, Harvey Moldofsky, MD, told attendees. To illustrate that point, Dr. Moldofsky, of the department of psychiatry (emeritus) at the University of Toronto, reviewed data from a previously published case-controlled study, which included 22 health care workers who had been infected in 2003 with SARS-CoV-1 and continued to report chronic fatigue, musculoskeletal pain, and disturbed and unrefreshing sleep with EEG-documented sleep disturbances 1-3 years following the illness. None had been able to return to work by 1 year.
“We’re looking at similar symptoms now” among survivors of COVID-19, Dr. Moldofsky said. “[T]he key issue is that we have no idea of its prevalence. … We need epidemiologic studies.”
Distinguishing ME/CFS from other post–COVID-19 symptoms
Not everyone who has persistent symptoms after COVID-19 will develop ME/CFS, and distinguishing between cases may be important.
Clinically, Dr. Chu said, one way to assess whether a patient with persistent COVID-19 symptoms might be progressing to ME/CFS is to ask him or her specifically about the level of fatigue following physical exertion and the timing of any fatigue. With ME/CFS, postexertional malaise often involves a dramatic exacerbation of symptoms such as fatigue, pain, and cognitive impairment a day or 2 after exertion rather than immediately following it. In contrast, shortness of breath during exertion isn’t typical of ME/CFS.
Objective measures of ME/CFS include low natural killer cell function (the test can be ordered from commercial labs but requires rapid transport of the blood sample), and autonomic dysfunction assessed by a tilt-table test.
While there is currently no cure for ME/CFS, diagnosing it allows for the patient to be taught “pacing” in which the person conserves his or her energy by balancing activity with rest. “That type of behavioral technique is valuable for everyone who suffers from a chronic disease with fatigue. It can help them be more functional,” Dr. Chu said.
If a patient appears to be exhibiting signs of ME/CFS, “don’t wait until they hit the 6-month mark to start helping them manage their symptoms,” she said. “Teaching pacing to COVID-19 patients who have a lot of fatigue isn’t going to harm them. As they get better they’re going to just naturally do more. But if they do have ME/CFS, [pacing] stresses their system less, since the data seem to be pointing to deficiencies in producing energy.”
Will COVID-19 unleash a new wave of ME/CFS patients?
Much of the session at the virtual meeting was devoted to ongoing studies. For example, Leonard Jason, PhD, of the Center for Community Research at DePaul University, Chicago, described a prospective study launched in 2014 that looked at risk factors for developing ME/CFS in college students who contracted infectious mononucleosis as a result of Epstein-Barr virus. Now, his team is also following students from the same cohort who develop COVID-19.
Because the study included collection of baseline biological samples, the results could help reveal predisposing factors associated with long-term illness from either virus.
Another project, funded by the Open Medicine Foundation, will follow patients who are discharged from the ICU following severe COVID-19 illness. Blood, urine, and cerebrospinal fluid will be collected from those with persistent symptoms at 6 months, along with questionnaire data. At 18-24 months, those who continue to report symptoms will undergo more intensive evaluation using genomics, metabolomics, and proteomics.
“We’re taking advantage of this horrible situation, hoping to understand how a serious viral infection might lead to ME/CFS,” said lead investigator Ronald Tompkins, MD, ScD, chief medical officer at the Open Medicine Foundation and a faculty member at Harvard Medical School, Boston. The results, he said, “might give us insight into potential drug targets or biomarkers useful for prevention and treatment strategies.”
Meanwhile, Sadie Whittaker, PhD, head of the Solve ME/CFS initiative, described her organization’s new plan to use their registry to prospectively track the impact of COVID-19 on people with ME/CFS.
She noted that they’ve also teamed up with “long-COVID” communities including Body Politic. “Our goal is to form a coalition to study together or at least harmonize data … and understand what’s going on through the power of bigger sample sizes,” Dr. Whittaker said.
None of the speakers disclosed relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Some patients who had COVID-19 continue to have symptoms weeks to months later, even after they no longer test positive for the virus. In two recent reports – one published in JAMA in July and another published in Morbidity and Mortality Weekly Report in August – chronic fatigue was listed as the top symptom among individuals still feeling unwell beyond 2 weeks after COVID-19 onset.
Although some of the reported persistent symptoms appear specific to SARS-CoV-2 – such as cough, chest pain, and dyspnea – others overlap with the diagnostic criteria for ME/CFS, which is defined by substantial, profound fatigue for at least 6 months, postexertional malaise, unrefreshing sleep, and one or both of orthostatic intolerance and/or cognitive impairment. Although the etiology of ME/CFS is unclear, the condition commonly arises following a viral illness.
At the virtual meeting of the International Association for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis August 21, the opening session was devoted to research documenting the extent to which COVID-19 survivors subsequently meet ME/CFS criteria, and to exploring underlying mechanisms.
“It offers a lot of opportunities for us to study potentially early ME/CFS and how it develops, but in addition, a lot of the research that has been done on ME/CFS may also provide answers for COVID-19,” IACFS/ME vice president Lily Chu, MD, said in an interview.
A hint from the SARS outbreak
This isn’t the first time researchers have seen a possible link between a coronavirus and ME/CFS, Harvey Moldofsky, MD, told attendees. To illustrate that point, Dr. Moldofsky, of the department of psychiatry (emeritus) at the University of Toronto, reviewed data from a previously published case-controlled study, which included 22 health care workers who had been infected in 2003 with SARS-CoV-1 and continued to report chronic fatigue, musculoskeletal pain, and disturbed and unrefreshing sleep with EEG-documented sleep disturbances 1-3 years following the illness. None had been able to return to work by 1 year.
“We’re looking at similar symptoms now” among survivors of COVID-19, Dr. Moldofsky said. “[T]he key issue is that we have no idea of its prevalence. … We need epidemiologic studies.”
Distinguishing ME/CFS from other post–COVID-19 symptoms
Not everyone who has persistent symptoms after COVID-19 will develop ME/CFS, and distinguishing between cases may be important.
Clinically, Dr. Chu said, one way to assess whether a patient with persistent COVID-19 symptoms might be progressing to ME/CFS is to ask him or her specifically about the level of fatigue following physical exertion and the timing of any fatigue. With ME/CFS, postexertional malaise often involves a dramatic exacerbation of symptoms such as fatigue, pain, and cognitive impairment a day or 2 after exertion rather than immediately following it. In contrast, shortness of breath during exertion isn’t typical of ME/CFS.
Objective measures of ME/CFS include low natural killer cell function (the test can be ordered from commercial labs but requires rapid transport of the blood sample), and autonomic dysfunction assessed by a tilt-table test.
While there is currently no cure for ME/CFS, diagnosing it allows for the patient to be taught “pacing” in which the person conserves his or her energy by balancing activity with rest. “That type of behavioral technique is valuable for everyone who suffers from a chronic disease with fatigue. It can help them be more functional,” Dr. Chu said.
If a patient appears to be exhibiting signs of ME/CFS, “don’t wait until they hit the 6-month mark to start helping them manage their symptoms,” she said. “Teaching pacing to COVID-19 patients who have a lot of fatigue isn’t going to harm them. As they get better they’re going to just naturally do more. But if they do have ME/CFS, [pacing] stresses their system less, since the data seem to be pointing to deficiencies in producing energy.”
Will COVID-19 unleash a new wave of ME/CFS patients?
Much of the session at the virtual meeting was devoted to ongoing studies. For example, Leonard Jason, PhD, of the Center for Community Research at DePaul University, Chicago, described a prospective study launched in 2014 that looked at risk factors for developing ME/CFS in college students who contracted infectious mononucleosis as a result of Epstein-Barr virus. Now, his team is also following students from the same cohort who develop COVID-19.
Because the study included collection of baseline biological samples, the results could help reveal predisposing factors associated with long-term illness from either virus.
Another project, funded by the Open Medicine Foundation, will follow patients who are discharged from the ICU following severe COVID-19 illness. Blood, urine, and cerebrospinal fluid will be collected from those with persistent symptoms at 6 months, along with questionnaire data. At 18-24 months, those who continue to report symptoms will undergo more intensive evaluation using genomics, metabolomics, and proteomics.
“We’re taking advantage of this horrible situation, hoping to understand how a serious viral infection might lead to ME/CFS,” said lead investigator Ronald Tompkins, MD, ScD, chief medical officer at the Open Medicine Foundation and a faculty member at Harvard Medical School, Boston. The results, he said, “might give us insight into potential drug targets or biomarkers useful for prevention and treatment strategies.”
Meanwhile, Sadie Whittaker, PhD, head of the Solve ME/CFS initiative, described her organization’s new plan to use their registry to prospectively track the impact of COVID-19 on people with ME/CFS.
She noted that they’ve also teamed up with “long-COVID” communities including Body Politic. “Our goal is to form a coalition to study together or at least harmonize data … and understand what’s going on through the power of bigger sample sizes,” Dr. Whittaker said.
None of the speakers disclosed relevant financial relationships.
A version of this article originally appeared on Medscape.com.
FDA authorizes convalescent plasma for COVID-19
Convalescent plasma contains antibodies from the blood of recovered COVID-19 patients, which can be used to treat people with severe infections. Convalescent plasma has been used to treat patients for other infectious diseases. The authorization allows the plasma to be distributed in the United States and administered by health care providers.
“COVID-19 convalescent plasma is safe and shows promising efficacy,” Stephen Hahn, MD, commissioner of the FDA, said during a press briefing with President Donald Trump.
In April, the FDA approved a program to test convalescent plasma in COVID-19 patients at the Mayo Clinic, followed by other institutions. More than 90,000 patients have enrolled in the program, and 70,000 have received the treatment, Dr. Hahn said.
The data indicate that the plasma can reduce mortality in patients by 35%, particularly if patients are treated within 3 days of being diagnosed. Those who have benefited the most were under age 80 and not on artificial respiration, Alex Azar, the secretary for the Department of Health & Human Services, said during the briefing.
“We dream, in drug development, of something like a 35% mortality reduction,” he said.
But top scientists pushed back against the announcement.
Eric Topol, MD, director of the Scripps Research Translational Institute, professor of molecular medicine, and executive vice president of Scripps Research, said the data the FDA are relying on did not come from the rigorous randomized, double-blind placebo trials that best determine if a treatment is successful.
Still, convalescent plasma is “one more tool added to the arsenal” of combating COVID-19, Mr. Azar said. The FDA will continue to study convalescent plasma as a COVID-19 treatment, Dr. Hahn added.
“We’re waiting for more data. We’re going to continue to gather data,” Dr. Hahn said during the briefing, but the current results meet FDA criteria for issuing an emergency use authorization.
Convalescent plasma “may be effective in lessening the severity or shortening the length of COVID-19 illness in some hospitalized patients,” according to the FDA announcement. Potential side effects include allergic reactions, transfusion-transmitted infections, and transfusion-associated lung injury.
“We’ve seen a great deal of demand for this from doctors around the country,” Dr. Hahn said during the briefing. “The EUA … allows us to continue that and meet that demand.”
Dr. Topol, however, said it appears Trump and the FDA are playing politics with science.
“There’s no evidence to support any survival benefit,” Dr. Topol said on Twitter. “Two days ago [the] FDA’s website stated there was no evidence for an EUA.”
The American Red Cross and other blood centers put out a national call for blood donors in July, especially for patients who have recovered from COVID-19. Mr. Azar and Dr. Hahn emphasized the need for blood donors during the press briefing.
“If you donate plasma, you could save a life,” Mr. Azar said.
The study has not been peer reviewed and did not include a placebo group for comparison, STAT reported.
Last week several health officials warned that the scientific data were too weak to warrant an emergency authorization, the New York Times reported.
A version of this originally appeared on WebMD.com.
Convalescent plasma contains antibodies from the blood of recovered COVID-19 patients, which can be used to treat people with severe infections. Convalescent plasma has been used to treat patients for other infectious diseases. The authorization allows the plasma to be distributed in the United States and administered by health care providers.
“COVID-19 convalescent plasma is safe and shows promising efficacy,” Stephen Hahn, MD, commissioner of the FDA, said during a press briefing with President Donald Trump.
In April, the FDA approved a program to test convalescent plasma in COVID-19 patients at the Mayo Clinic, followed by other institutions. More than 90,000 patients have enrolled in the program, and 70,000 have received the treatment, Dr. Hahn said.
The data indicate that the plasma can reduce mortality in patients by 35%, particularly if patients are treated within 3 days of being diagnosed. Those who have benefited the most were under age 80 and not on artificial respiration, Alex Azar, the secretary for the Department of Health & Human Services, said during the briefing.
“We dream, in drug development, of something like a 35% mortality reduction,” he said.
But top scientists pushed back against the announcement.
Eric Topol, MD, director of the Scripps Research Translational Institute, professor of molecular medicine, and executive vice president of Scripps Research, said the data the FDA are relying on did not come from the rigorous randomized, double-blind placebo trials that best determine if a treatment is successful.
Still, convalescent plasma is “one more tool added to the arsenal” of combating COVID-19, Mr. Azar said. The FDA will continue to study convalescent plasma as a COVID-19 treatment, Dr. Hahn added.
“We’re waiting for more data. We’re going to continue to gather data,” Dr. Hahn said during the briefing, but the current results meet FDA criteria for issuing an emergency use authorization.
Convalescent plasma “may be effective in lessening the severity or shortening the length of COVID-19 illness in some hospitalized patients,” according to the FDA announcement. Potential side effects include allergic reactions, transfusion-transmitted infections, and transfusion-associated lung injury.
“We’ve seen a great deal of demand for this from doctors around the country,” Dr. Hahn said during the briefing. “The EUA … allows us to continue that and meet that demand.”
Dr. Topol, however, said it appears Trump and the FDA are playing politics with science.
“There’s no evidence to support any survival benefit,” Dr. Topol said on Twitter. “Two days ago [the] FDA’s website stated there was no evidence for an EUA.”
The American Red Cross and other blood centers put out a national call for blood donors in July, especially for patients who have recovered from COVID-19. Mr. Azar and Dr. Hahn emphasized the need for blood donors during the press briefing.
“If you donate plasma, you could save a life,” Mr. Azar said.
The study has not been peer reviewed and did not include a placebo group for comparison, STAT reported.
Last week several health officials warned that the scientific data were too weak to warrant an emergency authorization, the New York Times reported.
A version of this originally appeared on WebMD.com.
Convalescent plasma contains antibodies from the blood of recovered COVID-19 patients, which can be used to treat people with severe infections. Convalescent plasma has been used to treat patients for other infectious diseases. The authorization allows the plasma to be distributed in the United States and administered by health care providers.
“COVID-19 convalescent plasma is safe and shows promising efficacy,” Stephen Hahn, MD, commissioner of the FDA, said during a press briefing with President Donald Trump.
In April, the FDA approved a program to test convalescent plasma in COVID-19 patients at the Mayo Clinic, followed by other institutions. More than 90,000 patients have enrolled in the program, and 70,000 have received the treatment, Dr. Hahn said.
The data indicate that the plasma can reduce mortality in patients by 35%, particularly if patients are treated within 3 days of being diagnosed. Those who have benefited the most were under age 80 and not on artificial respiration, Alex Azar, the secretary for the Department of Health & Human Services, said during the briefing.
“We dream, in drug development, of something like a 35% mortality reduction,” he said.
But top scientists pushed back against the announcement.
Eric Topol, MD, director of the Scripps Research Translational Institute, professor of molecular medicine, and executive vice president of Scripps Research, said the data the FDA are relying on did not come from the rigorous randomized, double-blind placebo trials that best determine if a treatment is successful.
Still, convalescent plasma is “one more tool added to the arsenal” of combating COVID-19, Mr. Azar said. The FDA will continue to study convalescent plasma as a COVID-19 treatment, Dr. Hahn added.
“We’re waiting for more data. We’re going to continue to gather data,” Dr. Hahn said during the briefing, but the current results meet FDA criteria for issuing an emergency use authorization.
Convalescent plasma “may be effective in lessening the severity or shortening the length of COVID-19 illness in some hospitalized patients,” according to the FDA announcement. Potential side effects include allergic reactions, transfusion-transmitted infections, and transfusion-associated lung injury.
“We’ve seen a great deal of demand for this from doctors around the country,” Dr. Hahn said during the briefing. “The EUA … allows us to continue that and meet that demand.”
Dr. Topol, however, said it appears Trump and the FDA are playing politics with science.
“There’s no evidence to support any survival benefit,” Dr. Topol said on Twitter. “Two days ago [the] FDA’s website stated there was no evidence for an EUA.”
The American Red Cross and other blood centers put out a national call for blood donors in July, especially for patients who have recovered from COVID-19. Mr. Azar and Dr. Hahn emphasized the need for blood donors during the press briefing.
“If you donate plasma, you could save a life,” Mr. Azar said.
The study has not been peer reviewed and did not include a placebo group for comparison, STAT reported.
Last week several health officials warned that the scientific data were too weak to warrant an emergency authorization, the New York Times reported.
A version of this originally appeared on WebMD.com.
Tailored messaging needed to get cancer screening back on track
In late June, Lisa Richardson, MD, emerged from Atlanta, Georgia’s initial COVID-19 lockdown, and “got back out there” for some overdue doctor’s appointments, including a mammogram.
The mammogram was a particular priority for her, since she is director of the CDC’s Division of Cancer Prevention and Control. But she knows that cancer screening is going to be a much tougher sell for the average person going forward in the pandemic era.
“It really is a challenge trying to get people to feel comfortable coming back in to be screened,” she said. Richardson was speaking recently at the AACR virtual meeting: COVID-19 and Cancer, a virtual symposium on cancer prevention and early detection in the COVID-19 pandemic organized by the American Association for Cancer Research.
While health service shutdowns and stay-at-home orders forced the country’s initial precipitous decline in cancer screening, fear of contracting COVID-19 is a big part of what is preventing patients from returning.
“We’ve known even pre-pandemic that people were hesitant to do cancer screening and in some ways this has really given them an out to say, ‘Well, I’m going to hold off on that colonoscopy,’ ” Amy Leader, MD, from Thomas Jefferson University’s Kimmel Cancer Center in Philadelphia, Pennsylvania, said during the symposium.
Estimating the pandemic’s impact on cancer care
While the impact of the pandemic on cancer can only be estimated at the moment, the prospects are already daunting, said Richardson, speculating that the hard-won 26% drop in cancer mortality over the past two decades “may be put on hold or reversed” by COVID-19.
There could be as many as 10,000 excess deaths in the US from colorectal and breast cancer alone because of COVID-19 delays, predicted Norman E. Sharpless, director of the US National Cancer Institute in Bethesda, Maryland.
But even Sharpless acknowledges that his modeling gives a conservative estimate, “as it does not consider other cancer types, it does not account for the additional nonlethal morbidity from upstaging, and it assumes a moderate disruption in care that completely resolves after 6 months.”
With still no end to the pandemic in sight, the true scope of cancer screening and treatment disruptions will take a long time to assess, but several studies presented during the symposium revealed some early indications.
A national survey launched in mid-May, which involved 534 women either diagnosed with breast cancer or undergoing screening or diagnostic evaluation for it, found that delays in screening were reported by 31.7% of those with breast cancer, and 26.7% of those without. Additionally, 21% of those on active treatment for breast cancer reported treatment delays.
“It’s going to be really important to implement strategies to help patients return to care ... creating a culture and a feeling of safety among patients and communicating through the uncertainty that exists in the pandemic,” said study investigator Erica T. Warner, ScD MPH, from Massachusetts General Hospital, Boston.
Screening for prostate cancer (via prostate-specific antigen testing) also declined, though not as dramatically as that for breast cancer, noted Mara Epstein, ScD, from The Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester. Her study at a large healthcare provider group compared rates of both screening and diagnostic mammographies, and also PSA testing, as well as breast and prostate biopsies in the first five months of 2020 vs the same months in 2019.
While a decrease from 2019 to 2020 was seen in all procedures over the entire study period, the greatest decline was seen in April for screening mammography (down 98%), and tomosynthesis (down 96%), as well as PSA testing (down 83%), she said.
More recent figures are hard to come by, but a recent weekly survey from the Primary Care Collaborative shows 46% of practices are offering preventive and chronic care management visits, but patients are not scheduling them, and 44% report that in-person visit volume is between 30%-50% below normal over the last 4 weeks.
Will COVID-19 exacerbate racial disparities in cancer?
Neither of the studies presented at the symposium analyzed cancer care disruptions by race, but there was concern among some panelists that cancer care disparities that existed before the pandemic will be magnified further.
“Over the next several months and into the next year there’s going to be some catch-up in screening and treatment, and one of my concerns is minority and underserved populations will not partake in that catch-up the way many middle-class Americans will,” said Otis Brawley, MD, from Johns Hopkins University, Baltimore, Maryland.
There is ample evidence that minority populations have been disproportionately hit by COVID-19, job losses, and lost health insurance, said the CDC’s Richardson, and all these factors could widen the cancer gap.
“It’s not a race thing, it’s a ‘what do you do thing,’ and an access to care thing, and what your socioeconomic status is,” Richardson said in an interview. “People who didn’t have sick leave before the pandemic still don’t have sick leave; if they didn’t have time to get their mammogram they still don’t have time.”
But she acknowledges that evidence is still lacking. Could some minority populations actually be less fearful of medical encounters because their work has already prevented them from sheltering in place? “It could go either way,” she said. “They might be less wary of venturing out into the clinic, but they also might reason that they’ve exposed themselves enough already at work and don’t want any additional exposure.”
In that regard, Richardson suggests population-specific messaging will be an important way of communicating with under-served populations to restart screening.
“We’re struggling at CDC with how to develop messages that resonate within different communities, because we’re missing the point of actually speaking to people within their culture and within the places that they live,” she said. “Just saying the same thing and putting a black face on it is not going to make a difference; you actually have to speak the language of the people you’re trying to reach — the same message in different packages.”
To that end, even before the pandemic, the CDC supported the development of Make It Your Own, a website that uses “evidence-based strategies” to assist healthcare organizations in customizing health information “by race, ethnicity, age, gender and location”, and target messages to “specific populations, cultural groups and languages”.
But Mass General’s Warner says she’s not sure she would argue for messages to be tailored by race, “at least not without evidence that values and priorities regarding returning to care differ between racial/ethnic groups.”
“Tailoring in the absence of data requires assumptions that may or may not be correct and ignores within-group heterogeneity,” Warner told Medscape Medical News. “However, I do believe that messaging about return to cancer screening and care should be multifaceted and use diverse imagery. This recognizes that some messages will resonate more or less with individuals based on their own characteristics, of which race may be one.”
Warner does believe in the power of tailored messaging though. “Part of the onus for healthcare institutions and providers is to make some decisions about who it is really important to bring back in soonest,” she said.
“Those are the ones we want to prioritize, as opposed to those who we want to get back into care but we don’t need to get them in right now,” Warner emphasized. “As they are balancing all the needs of their family and their community and their other needs, messaging that adds additional stress, worry, anxiety and shame is not what we want to do. So really we need to distinguish between these populations, identify the priorities, hit the hard message to people who really need it now, and encourage others to come back in as they can.”
Building trust
All the panelists agreed that building trust with the public will be key to getting cancer care back on track.
“I don’t think anyone trusts the healthcare community right now, but we already had this baseline distrust of healthcare among many minority communities, and now with COVID-19, the African American community in particular is seeing people go into the hospital and never come back,” said Richardson.
For Warner, the onus really falls on healthcare institutions. “We have to be proactive and not leave the burden of deciding when and how to return to care up to patients,” she said.
“What we need to focus on as much as possible is to get people to realize it is safe to come see the doctor,” said Johns Hopkins oncologist Brawley. “We have to make it safe for them to come see us, and then we have to convince them it is safe to come see us.”
Venturing out to her mammography appointment in early June, Richardson said she felt safe. “Everything was just the way it was supposed to be, everyone was masked, everyone was washing their hands,” she said.
Yet, by mid-June she had contracted COVID-19. “I don’t know where I got it,” she said. “No matter how careful you are, understand that if you’re in a total red spot, as I am, you can just get it.”
This article first appeared on Medscape.com.
In late June, Lisa Richardson, MD, emerged from Atlanta, Georgia’s initial COVID-19 lockdown, and “got back out there” for some overdue doctor’s appointments, including a mammogram.
The mammogram was a particular priority for her, since she is director of the CDC’s Division of Cancer Prevention and Control. But she knows that cancer screening is going to be a much tougher sell for the average person going forward in the pandemic era.
“It really is a challenge trying to get people to feel comfortable coming back in to be screened,” she said. Richardson was speaking recently at the AACR virtual meeting: COVID-19 and Cancer, a virtual symposium on cancer prevention and early detection in the COVID-19 pandemic organized by the American Association for Cancer Research.
While health service shutdowns and stay-at-home orders forced the country’s initial precipitous decline in cancer screening, fear of contracting COVID-19 is a big part of what is preventing patients from returning.
“We’ve known even pre-pandemic that people were hesitant to do cancer screening and in some ways this has really given them an out to say, ‘Well, I’m going to hold off on that colonoscopy,’ ” Amy Leader, MD, from Thomas Jefferson University’s Kimmel Cancer Center in Philadelphia, Pennsylvania, said during the symposium.
Estimating the pandemic’s impact on cancer care
While the impact of the pandemic on cancer can only be estimated at the moment, the prospects are already daunting, said Richardson, speculating that the hard-won 26% drop in cancer mortality over the past two decades “may be put on hold or reversed” by COVID-19.
There could be as many as 10,000 excess deaths in the US from colorectal and breast cancer alone because of COVID-19 delays, predicted Norman E. Sharpless, director of the US National Cancer Institute in Bethesda, Maryland.
But even Sharpless acknowledges that his modeling gives a conservative estimate, “as it does not consider other cancer types, it does not account for the additional nonlethal morbidity from upstaging, and it assumes a moderate disruption in care that completely resolves after 6 months.”
With still no end to the pandemic in sight, the true scope of cancer screening and treatment disruptions will take a long time to assess, but several studies presented during the symposium revealed some early indications.
A national survey launched in mid-May, which involved 534 women either diagnosed with breast cancer or undergoing screening or diagnostic evaluation for it, found that delays in screening were reported by 31.7% of those with breast cancer, and 26.7% of those without. Additionally, 21% of those on active treatment for breast cancer reported treatment delays.
“It’s going to be really important to implement strategies to help patients return to care ... creating a culture and a feeling of safety among patients and communicating through the uncertainty that exists in the pandemic,” said study investigator Erica T. Warner, ScD MPH, from Massachusetts General Hospital, Boston.
Screening for prostate cancer (via prostate-specific antigen testing) also declined, though not as dramatically as that for breast cancer, noted Mara Epstein, ScD, from The Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester. Her study at a large healthcare provider group compared rates of both screening and diagnostic mammographies, and also PSA testing, as well as breast and prostate biopsies in the first five months of 2020 vs the same months in 2019.
While a decrease from 2019 to 2020 was seen in all procedures over the entire study period, the greatest decline was seen in April for screening mammography (down 98%), and tomosynthesis (down 96%), as well as PSA testing (down 83%), she said.
More recent figures are hard to come by, but a recent weekly survey from the Primary Care Collaborative shows 46% of practices are offering preventive and chronic care management visits, but patients are not scheduling them, and 44% report that in-person visit volume is between 30%-50% below normal over the last 4 weeks.
Will COVID-19 exacerbate racial disparities in cancer?
Neither of the studies presented at the symposium analyzed cancer care disruptions by race, but there was concern among some panelists that cancer care disparities that existed before the pandemic will be magnified further.
“Over the next several months and into the next year there’s going to be some catch-up in screening and treatment, and one of my concerns is minority and underserved populations will not partake in that catch-up the way many middle-class Americans will,” said Otis Brawley, MD, from Johns Hopkins University, Baltimore, Maryland.
There is ample evidence that minority populations have been disproportionately hit by COVID-19, job losses, and lost health insurance, said the CDC’s Richardson, and all these factors could widen the cancer gap.
“It’s not a race thing, it’s a ‘what do you do thing,’ and an access to care thing, and what your socioeconomic status is,” Richardson said in an interview. “People who didn’t have sick leave before the pandemic still don’t have sick leave; if they didn’t have time to get their mammogram they still don’t have time.”
But she acknowledges that evidence is still lacking. Could some minority populations actually be less fearful of medical encounters because their work has already prevented them from sheltering in place? “It could go either way,” she said. “They might be less wary of venturing out into the clinic, but they also might reason that they’ve exposed themselves enough already at work and don’t want any additional exposure.”
In that regard, Richardson suggests population-specific messaging will be an important way of communicating with under-served populations to restart screening.
“We’re struggling at CDC with how to develop messages that resonate within different communities, because we’re missing the point of actually speaking to people within their culture and within the places that they live,” she said. “Just saying the same thing and putting a black face on it is not going to make a difference; you actually have to speak the language of the people you’re trying to reach — the same message in different packages.”
To that end, even before the pandemic, the CDC supported the development of Make It Your Own, a website that uses “evidence-based strategies” to assist healthcare organizations in customizing health information “by race, ethnicity, age, gender and location”, and target messages to “specific populations, cultural groups and languages”.
But Mass General’s Warner says she’s not sure she would argue for messages to be tailored by race, “at least not without evidence that values and priorities regarding returning to care differ between racial/ethnic groups.”
“Tailoring in the absence of data requires assumptions that may or may not be correct and ignores within-group heterogeneity,” Warner told Medscape Medical News. “However, I do believe that messaging about return to cancer screening and care should be multifaceted and use diverse imagery. This recognizes that some messages will resonate more or less with individuals based on their own characteristics, of which race may be one.”
Warner does believe in the power of tailored messaging though. “Part of the onus for healthcare institutions and providers is to make some decisions about who it is really important to bring back in soonest,” she said.
“Those are the ones we want to prioritize, as opposed to those who we want to get back into care but we don’t need to get them in right now,” Warner emphasized. “As they are balancing all the needs of their family and their community and their other needs, messaging that adds additional stress, worry, anxiety and shame is not what we want to do. So really we need to distinguish between these populations, identify the priorities, hit the hard message to people who really need it now, and encourage others to come back in as they can.”
Building trust
All the panelists agreed that building trust with the public will be key to getting cancer care back on track.
“I don’t think anyone trusts the healthcare community right now, but we already had this baseline distrust of healthcare among many minority communities, and now with COVID-19, the African American community in particular is seeing people go into the hospital and never come back,” said Richardson.
For Warner, the onus really falls on healthcare institutions. “We have to be proactive and not leave the burden of deciding when and how to return to care up to patients,” she said.
“What we need to focus on as much as possible is to get people to realize it is safe to come see the doctor,” said Johns Hopkins oncologist Brawley. “We have to make it safe for them to come see us, and then we have to convince them it is safe to come see us.”
Venturing out to her mammography appointment in early June, Richardson said she felt safe. “Everything was just the way it was supposed to be, everyone was masked, everyone was washing their hands,” she said.
Yet, by mid-June she had contracted COVID-19. “I don’t know where I got it,” she said. “No matter how careful you are, understand that if you’re in a total red spot, as I am, you can just get it.”
This article first appeared on Medscape.com.
In late June, Lisa Richardson, MD, emerged from Atlanta, Georgia’s initial COVID-19 lockdown, and “got back out there” for some overdue doctor’s appointments, including a mammogram.
The mammogram was a particular priority for her, since she is director of the CDC’s Division of Cancer Prevention and Control. But she knows that cancer screening is going to be a much tougher sell for the average person going forward in the pandemic era.
“It really is a challenge trying to get people to feel comfortable coming back in to be screened,” she said. Richardson was speaking recently at the AACR virtual meeting: COVID-19 and Cancer, a virtual symposium on cancer prevention and early detection in the COVID-19 pandemic organized by the American Association for Cancer Research.
While health service shutdowns and stay-at-home orders forced the country’s initial precipitous decline in cancer screening, fear of contracting COVID-19 is a big part of what is preventing patients from returning.
“We’ve known even pre-pandemic that people were hesitant to do cancer screening and in some ways this has really given them an out to say, ‘Well, I’m going to hold off on that colonoscopy,’ ” Amy Leader, MD, from Thomas Jefferson University’s Kimmel Cancer Center in Philadelphia, Pennsylvania, said during the symposium.
Estimating the pandemic’s impact on cancer care
While the impact of the pandemic on cancer can only be estimated at the moment, the prospects are already daunting, said Richardson, speculating that the hard-won 26% drop in cancer mortality over the past two decades “may be put on hold or reversed” by COVID-19.
There could be as many as 10,000 excess deaths in the US from colorectal and breast cancer alone because of COVID-19 delays, predicted Norman E. Sharpless, director of the US National Cancer Institute in Bethesda, Maryland.
But even Sharpless acknowledges that his modeling gives a conservative estimate, “as it does not consider other cancer types, it does not account for the additional nonlethal morbidity from upstaging, and it assumes a moderate disruption in care that completely resolves after 6 months.”
With still no end to the pandemic in sight, the true scope of cancer screening and treatment disruptions will take a long time to assess, but several studies presented during the symposium revealed some early indications.
A national survey launched in mid-May, which involved 534 women either diagnosed with breast cancer or undergoing screening or diagnostic evaluation for it, found that delays in screening were reported by 31.7% of those with breast cancer, and 26.7% of those without. Additionally, 21% of those on active treatment for breast cancer reported treatment delays.
“It’s going to be really important to implement strategies to help patients return to care ... creating a culture and a feeling of safety among patients and communicating through the uncertainty that exists in the pandemic,” said study investigator Erica T. Warner, ScD MPH, from Massachusetts General Hospital, Boston.
Screening for prostate cancer (via prostate-specific antigen testing) also declined, though not as dramatically as that for breast cancer, noted Mara Epstein, ScD, from The Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester. Her study at a large healthcare provider group compared rates of both screening and diagnostic mammographies, and also PSA testing, as well as breast and prostate biopsies in the first five months of 2020 vs the same months in 2019.
While a decrease from 2019 to 2020 was seen in all procedures over the entire study period, the greatest decline was seen in April for screening mammography (down 98%), and tomosynthesis (down 96%), as well as PSA testing (down 83%), she said.
More recent figures are hard to come by, but a recent weekly survey from the Primary Care Collaborative shows 46% of practices are offering preventive and chronic care management visits, but patients are not scheduling them, and 44% report that in-person visit volume is between 30%-50% below normal over the last 4 weeks.
Will COVID-19 exacerbate racial disparities in cancer?
Neither of the studies presented at the symposium analyzed cancer care disruptions by race, but there was concern among some panelists that cancer care disparities that existed before the pandemic will be magnified further.
“Over the next several months and into the next year there’s going to be some catch-up in screening and treatment, and one of my concerns is minority and underserved populations will not partake in that catch-up the way many middle-class Americans will,” said Otis Brawley, MD, from Johns Hopkins University, Baltimore, Maryland.
There is ample evidence that minority populations have been disproportionately hit by COVID-19, job losses, and lost health insurance, said the CDC’s Richardson, and all these factors could widen the cancer gap.
“It’s not a race thing, it’s a ‘what do you do thing,’ and an access to care thing, and what your socioeconomic status is,” Richardson said in an interview. “People who didn’t have sick leave before the pandemic still don’t have sick leave; if they didn’t have time to get their mammogram they still don’t have time.”
But she acknowledges that evidence is still lacking. Could some minority populations actually be less fearful of medical encounters because their work has already prevented them from sheltering in place? “It could go either way,” she said. “They might be less wary of venturing out into the clinic, but they also might reason that they’ve exposed themselves enough already at work and don’t want any additional exposure.”
In that regard, Richardson suggests population-specific messaging will be an important way of communicating with under-served populations to restart screening.
“We’re struggling at CDC with how to develop messages that resonate within different communities, because we’re missing the point of actually speaking to people within their culture and within the places that they live,” she said. “Just saying the same thing and putting a black face on it is not going to make a difference; you actually have to speak the language of the people you’re trying to reach — the same message in different packages.”
To that end, even before the pandemic, the CDC supported the development of Make It Your Own, a website that uses “evidence-based strategies” to assist healthcare organizations in customizing health information “by race, ethnicity, age, gender and location”, and target messages to “specific populations, cultural groups and languages”.
But Mass General’s Warner says she’s not sure she would argue for messages to be tailored by race, “at least not without evidence that values and priorities regarding returning to care differ between racial/ethnic groups.”
“Tailoring in the absence of data requires assumptions that may or may not be correct and ignores within-group heterogeneity,” Warner told Medscape Medical News. “However, I do believe that messaging about return to cancer screening and care should be multifaceted and use diverse imagery. This recognizes that some messages will resonate more or less with individuals based on their own characteristics, of which race may be one.”
Warner does believe in the power of tailored messaging though. “Part of the onus for healthcare institutions and providers is to make some decisions about who it is really important to bring back in soonest,” she said.
“Those are the ones we want to prioritize, as opposed to those who we want to get back into care but we don’t need to get them in right now,” Warner emphasized. “As they are balancing all the needs of their family and their community and their other needs, messaging that adds additional stress, worry, anxiety and shame is not what we want to do. So really we need to distinguish between these populations, identify the priorities, hit the hard message to people who really need it now, and encourage others to come back in as they can.”
Building trust
All the panelists agreed that building trust with the public will be key to getting cancer care back on track.
“I don’t think anyone trusts the healthcare community right now, but we already had this baseline distrust of healthcare among many minority communities, and now with COVID-19, the African American community in particular is seeing people go into the hospital and never come back,” said Richardson.
For Warner, the onus really falls on healthcare institutions. “We have to be proactive and not leave the burden of deciding when and how to return to care up to patients,” she said.
“What we need to focus on as much as possible is to get people to realize it is safe to come see the doctor,” said Johns Hopkins oncologist Brawley. “We have to make it safe for them to come see us, and then we have to convince them it is safe to come see us.”
Venturing out to her mammography appointment in early June, Richardson said she felt safe. “Everything was just the way it was supposed to be, everyone was masked, everyone was washing their hands,” she said.
Yet, by mid-June she had contracted COVID-19. “I don’t know where I got it,” she said. “No matter how careful you are, understand that if you’re in a total red spot, as I am, you can just get it.”
This article first appeared on Medscape.com.
‘The pandemic within the pandemic’
The coronavirus has infected millions of Americans and killed over 174,000. But could it be worse? Maybe.
“Racism is the pandemic within the pandemic,” Marc H. Morial, president and CEO of the National Urban League, said in the 2020 “State of Black America, Unmasked” report.
“Black people with COVID-19 symptoms in February and March were less likely to get tested or treated than white patients,” he wrote.
After less testing and less treatment, the next step seems inevitable. The death rate from COVID-19 is 70 per 100,000 population among Black Americans, compared with 30 per 100,000 for Whites and 34 per 100,000 for Hispanics, the league said based on data from the Johns Hopkins Center for Health Equity.
Black and Hispanic patients with COVID-19 are more likely to have preexisting health conditions, but they “tend to receive less aggressive treatment than white patients,” the report noted. The lower death rate among Hispanics may be explained by the Black population’s greater age, although Hispanic Americans have a higher infection rate (73 per 10,000) than Blacks (62 per 10,000) or Whites (23 per 10,000).
Another possible explanation for the differences in infection rates: Blacks and Hispanics are less able to work at home because they “are overrepresented in low-wage jobs that offer the least flexibility and increase their risk of exposure to the coronavirus,” the league said.
Hispanics and Blacks also are more likely to be uninsured than Whites – 19.5% and 11.5%, respectively, vs. 7.5% – so “they tend to delay seeking treatment and are sicker than white patients when they finally do,” the league said. That may account for their much higher COVID-19 hospitalization rates: 213 per 100,000 for Blacks, 205 for Hispanics, and 46 for Whites.
“The silver lining during these dark times is that this pandemic has revealed our shared vulnerability and our interconnectedness. Many people are beginning to see that when others don’t have the opportunity to be healthy, it puts all of us at risk,” Lisa Cooper, MD, James F. Fries Professor of Medicine and Bloomberg Distinguished Professor in Health Equity at Johns Hopkins University, Baltimore, wrote in an essay accompanying the report.
The coronavirus has infected millions of Americans and killed over 174,000. But could it be worse? Maybe.
“Racism is the pandemic within the pandemic,” Marc H. Morial, president and CEO of the National Urban League, said in the 2020 “State of Black America, Unmasked” report.
“Black people with COVID-19 symptoms in February and March were less likely to get tested or treated than white patients,” he wrote.
After less testing and less treatment, the next step seems inevitable. The death rate from COVID-19 is 70 per 100,000 population among Black Americans, compared with 30 per 100,000 for Whites and 34 per 100,000 for Hispanics, the league said based on data from the Johns Hopkins Center for Health Equity.
Black and Hispanic patients with COVID-19 are more likely to have preexisting health conditions, but they “tend to receive less aggressive treatment than white patients,” the report noted. The lower death rate among Hispanics may be explained by the Black population’s greater age, although Hispanic Americans have a higher infection rate (73 per 10,000) than Blacks (62 per 10,000) or Whites (23 per 10,000).
Another possible explanation for the differences in infection rates: Blacks and Hispanics are less able to work at home because they “are overrepresented in low-wage jobs that offer the least flexibility and increase their risk of exposure to the coronavirus,” the league said.
Hispanics and Blacks also are more likely to be uninsured than Whites – 19.5% and 11.5%, respectively, vs. 7.5% – so “they tend to delay seeking treatment and are sicker than white patients when they finally do,” the league said. That may account for their much higher COVID-19 hospitalization rates: 213 per 100,000 for Blacks, 205 for Hispanics, and 46 for Whites.
“The silver lining during these dark times is that this pandemic has revealed our shared vulnerability and our interconnectedness. Many people are beginning to see that when others don’t have the opportunity to be healthy, it puts all of us at risk,” Lisa Cooper, MD, James F. Fries Professor of Medicine and Bloomberg Distinguished Professor in Health Equity at Johns Hopkins University, Baltimore, wrote in an essay accompanying the report.
The coronavirus has infected millions of Americans and killed over 174,000. But could it be worse? Maybe.
“Racism is the pandemic within the pandemic,” Marc H. Morial, president and CEO of the National Urban League, said in the 2020 “State of Black America, Unmasked” report.
“Black people with COVID-19 symptoms in February and March were less likely to get tested or treated than white patients,” he wrote.
After less testing and less treatment, the next step seems inevitable. The death rate from COVID-19 is 70 per 100,000 population among Black Americans, compared with 30 per 100,000 for Whites and 34 per 100,000 for Hispanics, the league said based on data from the Johns Hopkins Center for Health Equity.
Black and Hispanic patients with COVID-19 are more likely to have preexisting health conditions, but they “tend to receive less aggressive treatment than white patients,” the report noted. The lower death rate among Hispanics may be explained by the Black population’s greater age, although Hispanic Americans have a higher infection rate (73 per 10,000) than Blacks (62 per 10,000) or Whites (23 per 10,000).
Another possible explanation for the differences in infection rates: Blacks and Hispanics are less able to work at home because they “are overrepresented in low-wage jobs that offer the least flexibility and increase their risk of exposure to the coronavirus,” the league said.
Hispanics and Blacks also are more likely to be uninsured than Whites – 19.5% and 11.5%, respectively, vs. 7.5% – so “they tend to delay seeking treatment and are sicker than white patients when they finally do,” the league said. That may account for their much higher COVID-19 hospitalization rates: 213 per 100,000 for Blacks, 205 for Hispanics, and 46 for Whites.
“The silver lining during these dark times is that this pandemic has revealed our shared vulnerability and our interconnectedness. Many people are beginning to see that when others don’t have the opportunity to be healthy, it puts all of us at risk,” Lisa Cooper, MD, James F. Fries Professor of Medicine and Bloomberg Distinguished Professor in Health Equity at Johns Hopkins University, Baltimore, wrote in an essay accompanying the report.
Patient visits post COVID-19
Has telemedicine found its footing?
When Alexander Graham Bell invented the telephone, he accomplished something that many telegraph devotees never thought possible: the synchronous, bidirectional transmission of voice over electrical lines.
This was an incredible milestone in the advancement of mankind and enabled true revolutions in commerce, scientific collaboration, and human interaction. But Mr. Bell knew his invention didn’t represent the final advancement in telecommunication; he was quite prescient in imagining a day when individuals could see each other while speaking on the phone.
Many years later, what was once only a dream is now commonplace, and children growing up today can’t imagine a world where apps such as FaceTime and Skype don’t exist. Until recently, however, the medical community has been slow to adopt the idea of video interactions. This has dramatically changed because of the pandemic and the need for social distancing. It appears that telemedicine has found its footing, but whether it will remain popular once patients feel safe going to see their doctors in person again remains to be seen. This month, we’ll examine a few key issues that will determine the future of virtual medical visits.
Collect calling
The pandemic has wrought both human and economic casualties. With fear, job loss, and regulations leading to decreased spending, many large and small businesses have been and will continue to be unable to survive. Companies, including Brooks Brothers, Hertz, Lord and Taylor, GNC, and J.C. Penney, have declared bankruptcy.1 Medical practices and hospitals have taken cuts to their bottom line, and we’ve heard of many physician groups that have had to enact substantial salary cuts or even lay off providers – something previously unheard of. Recent months have demonstrated the health care community’s commitment to put patients first, but we simply cannot survive if we aren’t adequately reimbursed. Traditionally, this has been a significant roadblock toward the widespread adoption of telemedicine.
In most cases, these visits were not reimbursed at all. Thankfully, shortly after the coronavirus hit our shores, Medicare and Medicaid changed their policies, offering equal payment for video and in-person patient encounters. Most private insurers have followed suit, but the commitment to this payment parity appears – thus far – to be temporary. It is unclear that the financial support of telemedicine will continue post COVID-19, and this has many physicians feeling uncomfortable. In the meantime, many patients have come to prefer virtual visits, appreciating the convenience and efficiency.
Physicians don’t always have the same experience. Telemedicine can be technically challenging and take just as much – or sometimes more – time to navigate and document. Unless they are reimbursed equitably, providers will be forced to limit their use of virtual visits or not offer them at all. This leads to another issue: reliability.
‘Can you hear me now?’
Over the past several months, we have had the opportunity to use telemedicine firsthand and have spoken to many other physicians and patients about their experiences with it. The reports are all quite consistent: Most have had generally positive things to say. Still, some common concerns emerge when diving a bit deeper. Most notably are complaints about usability and reliability of the software.
While there are large telemedicine companies that have developed world-class cross-platform products, many in use today are proprietary and EHR dependent. As a result, the quality varies widely. Many EHR vendors were caught completely off guard by the sudden demand for telemedicine and are playing catch-up as they develop their own virtual visit platforms. While these vendor-developed platforms promise tight integration with patient records, some have significant shortcomings in stability when taxed under high utilization, including choppy video and garbled voice. This simply won’t do if telemedicine is to survive. It is incumbent on software developers and health care providers to invest in high-quality, reliable platforms on which to build their virtual visit offerings. This will ensure a more rapid adoption and the “staying power” of the new technology.
Dialing ‘0’ for the operator
Once seen as a “novelty” offered by only a small number of medical providers, virtual visits now represent a significant and ever-increasing percentage of patient encounters. The technology therefore must be easy to use. Given confidentiality and documentation requirements, along with the broad variety of available computing platforms and devices (e.g., PC, Mac, iOS, and Android), the process is often far from problem free. Patients may need help downloading apps, setting up webcams, or registering for the service. Providers may face issues with Internet connectivity or EHR-related delays.
It is critical that help be available to make the connection seamless and the experience a positive one. We are fortunate to work for a health care institution that has made this a priority, dedicating a team of individuals to provide real-time support to patients and clinicians. Small independent practices may not have this luxury, but we would encourage all providers to engage with their telemedicine or EHR vendors to determine what resources are available when problems arise, as they undoubtedly will.
Answering the call
Like the invention of the telephone, the advent of telemedicine is another milestone on the journey toward better communication with our patients, and it appears to be here to stay. Virtual visits won’t completely replace in-person care, nor minimize the benefit of human interaction, but they will continue to play an important role in the care continuum. By addressing the above concerns, we’ll lay a solid foundation for success and create a positive experience for physicians and patients alike.
Dr. Notte is a family physician and chief medical officer of Abington (Pa.) Hospital–Jefferson Health. Follow him on Twitter (@doctornotte). Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Hospital–Jefferson Health. They have no conflicts related to the content of this piece.
Reference
1. A running list of companies that have filed for bankruptcy during the coronavirus pandemic. Fortune.
Has telemedicine found its footing?
Has telemedicine found its footing?
When Alexander Graham Bell invented the telephone, he accomplished something that many telegraph devotees never thought possible: the synchronous, bidirectional transmission of voice over electrical lines.
This was an incredible milestone in the advancement of mankind and enabled true revolutions in commerce, scientific collaboration, and human interaction. But Mr. Bell knew his invention didn’t represent the final advancement in telecommunication; he was quite prescient in imagining a day when individuals could see each other while speaking on the phone.
Many years later, what was once only a dream is now commonplace, and children growing up today can’t imagine a world where apps such as FaceTime and Skype don’t exist. Until recently, however, the medical community has been slow to adopt the idea of video interactions. This has dramatically changed because of the pandemic and the need for social distancing. It appears that telemedicine has found its footing, but whether it will remain popular once patients feel safe going to see their doctors in person again remains to be seen. This month, we’ll examine a few key issues that will determine the future of virtual medical visits.
Collect calling
The pandemic has wrought both human and economic casualties. With fear, job loss, and regulations leading to decreased spending, many large and small businesses have been and will continue to be unable to survive. Companies, including Brooks Brothers, Hertz, Lord and Taylor, GNC, and J.C. Penney, have declared bankruptcy.1 Medical practices and hospitals have taken cuts to their bottom line, and we’ve heard of many physician groups that have had to enact substantial salary cuts or even lay off providers – something previously unheard of. Recent months have demonstrated the health care community’s commitment to put patients first, but we simply cannot survive if we aren’t adequately reimbursed. Traditionally, this has been a significant roadblock toward the widespread adoption of telemedicine.
In most cases, these visits were not reimbursed at all. Thankfully, shortly after the coronavirus hit our shores, Medicare and Medicaid changed their policies, offering equal payment for video and in-person patient encounters. Most private insurers have followed suit, but the commitment to this payment parity appears – thus far – to be temporary. It is unclear that the financial support of telemedicine will continue post COVID-19, and this has many physicians feeling uncomfortable. In the meantime, many patients have come to prefer virtual visits, appreciating the convenience and efficiency.
Physicians don’t always have the same experience. Telemedicine can be technically challenging and take just as much – or sometimes more – time to navigate and document. Unless they are reimbursed equitably, providers will be forced to limit their use of virtual visits or not offer them at all. This leads to another issue: reliability.
‘Can you hear me now?’
Over the past several months, we have had the opportunity to use telemedicine firsthand and have spoken to many other physicians and patients about their experiences with it. The reports are all quite consistent: Most have had generally positive things to say. Still, some common concerns emerge when diving a bit deeper. Most notably are complaints about usability and reliability of the software.
While there are large telemedicine companies that have developed world-class cross-platform products, many in use today are proprietary and EHR dependent. As a result, the quality varies widely. Many EHR vendors were caught completely off guard by the sudden demand for telemedicine and are playing catch-up as they develop their own virtual visit platforms. While these vendor-developed platforms promise tight integration with patient records, some have significant shortcomings in stability when taxed under high utilization, including choppy video and garbled voice. This simply won’t do if telemedicine is to survive. It is incumbent on software developers and health care providers to invest in high-quality, reliable platforms on which to build their virtual visit offerings. This will ensure a more rapid adoption and the “staying power” of the new technology.
Dialing ‘0’ for the operator
Once seen as a “novelty” offered by only a small number of medical providers, virtual visits now represent a significant and ever-increasing percentage of patient encounters. The technology therefore must be easy to use. Given confidentiality and documentation requirements, along with the broad variety of available computing platforms and devices (e.g., PC, Mac, iOS, and Android), the process is often far from problem free. Patients may need help downloading apps, setting up webcams, or registering for the service. Providers may face issues with Internet connectivity or EHR-related delays.
It is critical that help be available to make the connection seamless and the experience a positive one. We are fortunate to work for a health care institution that has made this a priority, dedicating a team of individuals to provide real-time support to patients and clinicians. Small independent practices may not have this luxury, but we would encourage all providers to engage with their telemedicine or EHR vendors to determine what resources are available when problems arise, as they undoubtedly will.
Answering the call
Like the invention of the telephone, the advent of telemedicine is another milestone on the journey toward better communication with our patients, and it appears to be here to stay. Virtual visits won’t completely replace in-person care, nor minimize the benefit of human interaction, but they will continue to play an important role in the care continuum. By addressing the above concerns, we’ll lay a solid foundation for success and create a positive experience for physicians and patients alike.
Dr. Notte is a family physician and chief medical officer of Abington (Pa.) Hospital–Jefferson Health. Follow him on Twitter (@doctornotte). Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Hospital–Jefferson Health. They have no conflicts related to the content of this piece.
Reference
1. A running list of companies that have filed for bankruptcy during the coronavirus pandemic. Fortune.
When Alexander Graham Bell invented the telephone, he accomplished something that many telegraph devotees never thought possible: the synchronous, bidirectional transmission of voice over electrical lines.
This was an incredible milestone in the advancement of mankind and enabled true revolutions in commerce, scientific collaboration, and human interaction. But Mr. Bell knew his invention didn’t represent the final advancement in telecommunication; he was quite prescient in imagining a day when individuals could see each other while speaking on the phone.
Many years later, what was once only a dream is now commonplace, and children growing up today can’t imagine a world where apps such as FaceTime and Skype don’t exist. Until recently, however, the medical community has been slow to adopt the idea of video interactions. This has dramatically changed because of the pandemic and the need for social distancing. It appears that telemedicine has found its footing, but whether it will remain popular once patients feel safe going to see their doctors in person again remains to be seen. This month, we’ll examine a few key issues that will determine the future of virtual medical visits.
Collect calling
The pandemic has wrought both human and economic casualties. With fear, job loss, and regulations leading to decreased spending, many large and small businesses have been and will continue to be unable to survive. Companies, including Brooks Brothers, Hertz, Lord and Taylor, GNC, and J.C. Penney, have declared bankruptcy.1 Medical practices and hospitals have taken cuts to their bottom line, and we’ve heard of many physician groups that have had to enact substantial salary cuts or even lay off providers – something previously unheard of. Recent months have demonstrated the health care community’s commitment to put patients first, but we simply cannot survive if we aren’t adequately reimbursed. Traditionally, this has been a significant roadblock toward the widespread adoption of telemedicine.
In most cases, these visits were not reimbursed at all. Thankfully, shortly after the coronavirus hit our shores, Medicare and Medicaid changed their policies, offering equal payment for video and in-person patient encounters. Most private insurers have followed suit, but the commitment to this payment parity appears – thus far – to be temporary. It is unclear that the financial support of telemedicine will continue post COVID-19, and this has many physicians feeling uncomfortable. In the meantime, many patients have come to prefer virtual visits, appreciating the convenience and efficiency.
Physicians don’t always have the same experience. Telemedicine can be technically challenging and take just as much – or sometimes more – time to navigate and document. Unless they are reimbursed equitably, providers will be forced to limit their use of virtual visits or not offer them at all. This leads to another issue: reliability.
‘Can you hear me now?’
Over the past several months, we have had the opportunity to use telemedicine firsthand and have spoken to many other physicians and patients about their experiences with it. The reports are all quite consistent: Most have had generally positive things to say. Still, some common concerns emerge when diving a bit deeper. Most notably are complaints about usability and reliability of the software.
While there are large telemedicine companies that have developed world-class cross-platform products, many in use today are proprietary and EHR dependent. As a result, the quality varies widely. Many EHR vendors were caught completely off guard by the sudden demand for telemedicine and are playing catch-up as they develop their own virtual visit platforms. While these vendor-developed platforms promise tight integration with patient records, some have significant shortcomings in stability when taxed under high utilization, including choppy video and garbled voice. This simply won’t do if telemedicine is to survive. It is incumbent on software developers and health care providers to invest in high-quality, reliable platforms on which to build their virtual visit offerings. This will ensure a more rapid adoption and the “staying power” of the new technology.
Dialing ‘0’ for the operator
Once seen as a “novelty” offered by only a small number of medical providers, virtual visits now represent a significant and ever-increasing percentage of patient encounters. The technology therefore must be easy to use. Given confidentiality and documentation requirements, along with the broad variety of available computing platforms and devices (e.g., PC, Mac, iOS, and Android), the process is often far from problem free. Patients may need help downloading apps, setting up webcams, or registering for the service. Providers may face issues with Internet connectivity or EHR-related delays.
It is critical that help be available to make the connection seamless and the experience a positive one. We are fortunate to work for a health care institution that has made this a priority, dedicating a team of individuals to provide real-time support to patients and clinicians. Small independent practices may not have this luxury, but we would encourage all providers to engage with their telemedicine or EHR vendors to determine what resources are available when problems arise, as they undoubtedly will.
Answering the call
Like the invention of the telephone, the advent of telemedicine is another milestone on the journey toward better communication with our patients, and it appears to be here to stay. Virtual visits won’t completely replace in-person care, nor minimize the benefit of human interaction, but they will continue to play an important role in the care continuum. By addressing the above concerns, we’ll lay a solid foundation for success and create a positive experience for physicians and patients alike.
Dr. Notte is a family physician and chief medical officer of Abington (Pa.) Hospital–Jefferson Health. Follow him on Twitter (@doctornotte). Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Hospital–Jefferson Health. They have no conflicts related to the content of this piece.
Reference
1. A running list of companies that have filed for bankruptcy during the coronavirus pandemic. Fortune.
Swab, spit, stay home? College coronavirus testing plans are all over the map
Yousuf El-Jayyousi, a junior engineering student at the University of Missouri, wanted guidance and reassurance that it would be safe to go back to school for the fall semester. He tuned into a pair of online town halls organized by the university hoping to find that.
He did not.
What he got instead from those town halls last month was encouragement to return to class at the institution affectionately known as Mizzou. The university, in Columbia, would be testing only people with symptoms, and at that point, the university said people who test positive off campus were under no obligation to inform the school.
“It feels like the university doesn’t really care whether we get sick or not,” said El-Jayyousi, who is scheduled for two in-person classes, and lives at home with his parents and 90-year-old grandmother.
He’s seen the studies from researchers at Yale and Harvard that suggest testing needs to be much more widespread. He asked his instructors if he could join lectures remotely once classes begin Monday. One was considering it; the other rejected it.
“It was kind of very dismissive, like ‘so what?’ ” El-Jayyousi said.
But it’s an enormous “so what?” packed with fear and unknowns for Jayyousi and some 20 million other students enrolled in some level of postsecondary education in America, if they are not already online only.
Policies for reentry onto campuses that were abruptly shut in March are all over the map.
Hundreds Undecided
According to the College Crisis Initiative, or C2i, a project of Davidson College that monitors how higher ed is responding to the pandemic, there is nothing resembling a common approach. Of 2,958 institutions it follows, 151 were planning to open fully online, 729 were mostly online and 433 were taking a hybrid approach. Just 75 schools were insisting on students attending fully in person, and 614 were aiming to be primarily in-person. Some 800 others were still deciding, just weeks before instruction was to start.
The decisions often have little correlation with the public health advisories in the region. Mizzou, which is in an area with recent COVID spikes, is holding some in-person instruction and has nearly 7,000 students signed up to live in dorms and other university-owned housing. Harvard, in a region with extremely low rates of viral spread, has opted to go all online and allowed students to defer a year.
The specific circumstances colleges and universities face are as much determined by local fiscal and political dictates as by medicine and epidemiology. It is often unclear who is making the call. So it’s every student for herself to chart these unknown waters, even as students (or their families) have written tuition checks for tens of thousands of dollars and signed leases for campus and off-campus housing.
And the risks – health, educational and financial – boomerang back on individual students: Two weeks after University of North Carolina students, as instructed, returned to the flagship campus in Chapel Hill with the promise of at least some in-person learning, all classes went online. Early outbreaks surged from a few students to more than 130 in a matter of days. Most undergrads have about a week to clear out of their dorms.
“It’s really tough,” said neuroscience major Luke Lawless, 20. “Chapel Hill is an amazing place, and as a senior it’s tough to know that my time’s running out – and the virus only adds to that.”
Location, location, location
C2i’s creator, Davidson education Assistant Professor Chris Marsicano, said the extreme diversity of approaches comes from the sheer diversity of schools, the penchant of many to follow the leads of more prestigious peers, and local politics.
“Some states have very strong and stringent mask requirements. Some have stronger stay-at-home orders. Others are sort of leaving it up to localities. So the confluence of politics, institutional isomorphism – that imitation – and different needs that the institutions have are driving the differences,” Marsicano said.
Location matters a lot, too, Marsicano said, pointing to schools like George Washington University and Boston University in urban settings where the environment is beyond the control of the school, versus a place like the University of the South in remote, rural Sewanee, Tennessee, where 90% of students will return to campus.
“It’s a lot easier to control an outbreak if you are a fairly isolated college campus than if you are in the middle of a city,” Marsicano said.
Student behavior is another wild card, Marsicano said, since even the best plans will fail if college kids “do something stupid, like have a massive frat party without masks.”
“You’ve got student affairs professionals across the country who are screaming at the top of their lungs, ‘We can’t control student behavior when they go off campus’” Marsicano said.
Another factor is a vacuum at the federal level. Although the Department of Education says Secretary Betsy DeVos has held dozens of calls with governors and state education superintendents, there’s no sign of an attempt to offer unified guidance to colleges beyond a webpage that links to relaxed regulatory requirements and anodyne fact sheets from the Centers for Disease Control and Prevention on preventing viral spread.
Even the money that the department notes it has dispensed – $30 billion from Congress’ CARES Act – is weighted toward K-12 schools, with about $13 billion for higher education, including student aid.
The U.S. Senate adjourned last week until Sept. 8, having never taken up a House-passed relief package that included some $30 billion for higher education. A trio of Democratic senators, including Sen. Elizabeth Warren, is calling for national reporting standards on college campuses.
No benchmarks
Campus communities with very different levels of contagion are making opposite calls about in-person learning. Mizzou’s Boone County has seen more than 1,400 confirmed COVID cases after a spike in mid-July. According to the Harvard Global Health Institute’s COVID risk map, Boone has accelerated spread, with 14 infections per day per 100,000 people. The institute advises stay-at-home orders or rigorous testing and tracing at such rates of infection. Two neighboring counties were in the red zone recently, with more than 25 cases per day per 100,000 people. Mizzou has left it up to deans whether classes will meet in person, making a strong argument for face-to-face instruction.
Meanwhile, Columbia University in New York City opted for all online instruction, even though the rate of infection there is a comparatively low 3.8 cases per day per 100,000 people.
Administrators at Mizzou considered and rejected mandatory testing. “All that does is provide one a snapshot of the situation,” University of Missouri system President Mun Choi said in one of the town halls.
Mizzou has an in-house team that will carry out case investigation and contact tracing with the local health department. This week, following questions from the press and pressure from the public, the university announced students will be required to report any positive COVID test to the school.
Who do you test? When?
CDC guidance for higher education suggests there’s not enough data to know whether testing everyone is effective, but some influential researchers, such as those at Harvard and Yale, disagree.
“This virus is subject to silent spreading and asymptomatic spreading, and it’s very hard to play catch-up,” said Yale professor David Paltiel, who studies public health policy. “And so thinking that you can keep your campus safe by simply waiting until students develop symptoms before acting, I think, is a very dangerous game.”
Simulation models conducted by Paltiel and his colleagues show that, of all the factors university administrators can control – including the sensitivity and specificity of COVID-19 tests – the frequency of testing is most important.
He’s “painfully aware” that testing everyone on campus every few days sets a very high bar – logistically, financially, behaviorally – that may be beyond what most schools can reach. But he says the consequences of reopening campuses without those measures are severe, not just for students, but for vulnerable populations among school workers and in the surrounding community.
“You really have to ask yourself whether you have any business reopening if you’re not going to commit to an aggressive program of high-frequency testing,” he said.
The fighting – and testing – Illini
Some institutions that desperately want students to return to campus are backing the goal with a maximal approach to safety and testing.
About a 4-hour drive east along the interstates from Mizzou is the University of Illinois at Urbana-Champaign, whose sports teams are known as the Fighting Illini.
Weeks ago, large white tents with signs reading “Walk-Up COVID-19 Testing” have popped up across campus; there students take a simple saliva test.
“This seems to be a lot easier than sticking a cotton swab up your nose,” graduate student Kristen Muñoz said after collecting a bit of her saliva in a plastic tube and sealing it in a bag labeled “Biohazard.”
In just a few hours, she got back her result: negative.
The school plans to offer free tests to the 50,000 students expected to return this month, as well as some 11,000 faculty and staff members.
“The exciting thing is, because we can test up to 10,000 per day, it allows the scientist to do what’s really the best for trying to protect the community as opposed to having to cut corners, because of the limitations of the testing,” said University of Illinois chemist Martin Burke, who helped develop the campus’s saliva test, which received emergency use authorization from the federal Food and Drug Administration this week.
The test is similar to one designed by Yale and funded by the NBA that cleared the FDA hurdle just before the Illinois test. Both Yale and Illinois hope aggressive testing will allow most undergraduate students to live on campus, even though most classes will be online.
University of Illinois epidemiologist Becky Smith said they are following data that suggest campuses need to test everyone every few days because the virus is not detectable in infected people for 3 or 4 days.
“But about two days after that, your infectiousness peaks,” she said. “So, we have a very small window of time in which to catch people before they have done most of the infection that they’re going to be doing.”
Campus officials accepted Smith’s recommendation that all faculty, staffers and students participating in any on-campus activities be required to get tested twice a week.
Illinois can do that because its test is convenient and not invasive, which spares the campus from using as much personal protective equipment as the more invasive tests require, Burke said. And on-site analysis avoids backlogs at public health and commercial labs.
Muddled in the middle
Most other colleges fall somewhere between the approaches of Mizzou and the University of Illinois, and many of their students still are uncertain how their fall semester will go.
At the University of Southern California, a private campus of about 48,500 students in Los Angeles, officials had hoped to have about 20% of classes in person – but the county government scaled that back, insisting on tougher rules for reopening than the statewide standards.
If students eventually are allowed back, they will have to show a recent coronavirus test result that they obtained on their own, said Dr. Sarah Van Orman, chief health officer of USC Student Health.
They will be asked to do daily health assessments, such as fever checks, and those who have been exposed to the virus or show symptoms will receive a rapid test, with about a 24-hour turnaround through the university medical center’s lab. “We believe it is really important to have very rapid access to those results,” Van Orman said.
At California State University – the nation’s largest 4-year system, with 23 campuses and nearly a half-million students – officials decided back in May to move nearly all its fall courses online.
“The first priority was really the health and safety of all of the campus community,” said Mike Uhlenkamp, spokesperson for the CSU Chancellor’s Office. About 10% of CSU students are expected to attend some in-person classes, such as nursing lab courses, fine art and dance classes, and some graduate classes.
Uhlenkamp said testing protocols are being left up to each campus, though all are required to follow local safety guidelines. And without a medical campus in the system, CSU campuses do not have the same capacity to take charge of their own testing, as the University of Illinois is doing.
For students who know they won’t be on campus this fall, there is regret at lost social experiences, networking and hands-on learning so important to college.
But the certainty also brings relief.
“I don’t think I would want to be indoors with a group of, you know, even just a handful of people, even if we have masks on,” said Haley Gray, a 28-year-old graduate student at the University of California-Berkeley starting the second year of her journalism program.
She knows she won’t have access to Berkeley’s advanced media labs or the collaborative sessions students experience there. And she said she realized the other day she probably won’t just sit around the student lounge and strike up unexpected friendships.
“That’s a pretty big bummer but, you know, I think overall we’re all just doing our best, and given the circumstances, I feel pretty OK about it,” she said.
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente. This story is part of a partnership that includes KBIA, Illinois Public Media, Side Effects Public Media, NPR and Kaiser Health News.
Yousuf El-Jayyousi, a junior engineering student at the University of Missouri, wanted guidance and reassurance that it would be safe to go back to school for the fall semester. He tuned into a pair of online town halls organized by the university hoping to find that.
He did not.
What he got instead from those town halls last month was encouragement to return to class at the institution affectionately known as Mizzou. The university, in Columbia, would be testing only people with symptoms, and at that point, the university said people who test positive off campus were under no obligation to inform the school.
“It feels like the university doesn’t really care whether we get sick or not,” said El-Jayyousi, who is scheduled for two in-person classes, and lives at home with his parents and 90-year-old grandmother.
He’s seen the studies from researchers at Yale and Harvard that suggest testing needs to be much more widespread. He asked his instructors if he could join lectures remotely once classes begin Monday. One was considering it; the other rejected it.
“It was kind of very dismissive, like ‘so what?’ ” El-Jayyousi said.
But it’s an enormous “so what?” packed with fear and unknowns for Jayyousi and some 20 million other students enrolled in some level of postsecondary education in America, if they are not already online only.
Policies for reentry onto campuses that were abruptly shut in March are all over the map.
Hundreds Undecided
According to the College Crisis Initiative, or C2i, a project of Davidson College that monitors how higher ed is responding to the pandemic, there is nothing resembling a common approach. Of 2,958 institutions it follows, 151 were planning to open fully online, 729 were mostly online and 433 were taking a hybrid approach. Just 75 schools were insisting on students attending fully in person, and 614 were aiming to be primarily in-person. Some 800 others were still deciding, just weeks before instruction was to start.
The decisions often have little correlation with the public health advisories in the region. Mizzou, which is in an area with recent COVID spikes, is holding some in-person instruction and has nearly 7,000 students signed up to live in dorms and other university-owned housing. Harvard, in a region with extremely low rates of viral spread, has opted to go all online and allowed students to defer a year.
The specific circumstances colleges and universities face are as much determined by local fiscal and political dictates as by medicine and epidemiology. It is often unclear who is making the call. So it’s every student for herself to chart these unknown waters, even as students (or their families) have written tuition checks for tens of thousands of dollars and signed leases for campus and off-campus housing.
And the risks – health, educational and financial – boomerang back on individual students: Two weeks after University of North Carolina students, as instructed, returned to the flagship campus in Chapel Hill with the promise of at least some in-person learning, all classes went online. Early outbreaks surged from a few students to more than 130 in a matter of days. Most undergrads have about a week to clear out of their dorms.
“It’s really tough,” said neuroscience major Luke Lawless, 20. “Chapel Hill is an amazing place, and as a senior it’s tough to know that my time’s running out – and the virus only adds to that.”
Location, location, location
C2i’s creator, Davidson education Assistant Professor Chris Marsicano, said the extreme diversity of approaches comes from the sheer diversity of schools, the penchant of many to follow the leads of more prestigious peers, and local politics.
“Some states have very strong and stringent mask requirements. Some have stronger stay-at-home orders. Others are sort of leaving it up to localities. So the confluence of politics, institutional isomorphism – that imitation – and different needs that the institutions have are driving the differences,” Marsicano said.
Location matters a lot, too, Marsicano said, pointing to schools like George Washington University and Boston University in urban settings where the environment is beyond the control of the school, versus a place like the University of the South in remote, rural Sewanee, Tennessee, where 90% of students will return to campus.
“It’s a lot easier to control an outbreak if you are a fairly isolated college campus than if you are in the middle of a city,” Marsicano said.
Student behavior is another wild card, Marsicano said, since even the best plans will fail if college kids “do something stupid, like have a massive frat party without masks.”
“You’ve got student affairs professionals across the country who are screaming at the top of their lungs, ‘We can’t control student behavior when they go off campus’” Marsicano said.
Another factor is a vacuum at the federal level. Although the Department of Education says Secretary Betsy DeVos has held dozens of calls with governors and state education superintendents, there’s no sign of an attempt to offer unified guidance to colleges beyond a webpage that links to relaxed regulatory requirements and anodyne fact sheets from the Centers for Disease Control and Prevention on preventing viral spread.
Even the money that the department notes it has dispensed – $30 billion from Congress’ CARES Act – is weighted toward K-12 schools, with about $13 billion for higher education, including student aid.
The U.S. Senate adjourned last week until Sept. 8, having never taken up a House-passed relief package that included some $30 billion for higher education. A trio of Democratic senators, including Sen. Elizabeth Warren, is calling for national reporting standards on college campuses.
No benchmarks
Campus communities with very different levels of contagion are making opposite calls about in-person learning. Mizzou’s Boone County has seen more than 1,400 confirmed COVID cases after a spike in mid-July. According to the Harvard Global Health Institute’s COVID risk map, Boone has accelerated spread, with 14 infections per day per 100,000 people. The institute advises stay-at-home orders or rigorous testing and tracing at such rates of infection. Two neighboring counties were in the red zone recently, with more than 25 cases per day per 100,000 people. Mizzou has left it up to deans whether classes will meet in person, making a strong argument for face-to-face instruction.
Meanwhile, Columbia University in New York City opted for all online instruction, even though the rate of infection there is a comparatively low 3.8 cases per day per 100,000 people.
Administrators at Mizzou considered and rejected mandatory testing. “All that does is provide one a snapshot of the situation,” University of Missouri system President Mun Choi said in one of the town halls.
Mizzou has an in-house team that will carry out case investigation and contact tracing with the local health department. This week, following questions from the press and pressure from the public, the university announced students will be required to report any positive COVID test to the school.
Who do you test? When?
CDC guidance for higher education suggests there’s not enough data to know whether testing everyone is effective, but some influential researchers, such as those at Harvard and Yale, disagree.
“This virus is subject to silent spreading and asymptomatic spreading, and it’s very hard to play catch-up,” said Yale professor David Paltiel, who studies public health policy. “And so thinking that you can keep your campus safe by simply waiting until students develop symptoms before acting, I think, is a very dangerous game.”
Simulation models conducted by Paltiel and his colleagues show that, of all the factors university administrators can control – including the sensitivity and specificity of COVID-19 tests – the frequency of testing is most important.
He’s “painfully aware” that testing everyone on campus every few days sets a very high bar – logistically, financially, behaviorally – that may be beyond what most schools can reach. But he says the consequences of reopening campuses without those measures are severe, not just for students, but for vulnerable populations among school workers and in the surrounding community.
“You really have to ask yourself whether you have any business reopening if you’re not going to commit to an aggressive program of high-frequency testing,” he said.
The fighting – and testing – Illini
Some institutions that desperately want students to return to campus are backing the goal with a maximal approach to safety and testing.
About a 4-hour drive east along the interstates from Mizzou is the University of Illinois at Urbana-Champaign, whose sports teams are known as the Fighting Illini.
Weeks ago, large white tents with signs reading “Walk-Up COVID-19 Testing” have popped up across campus; there students take a simple saliva test.
“This seems to be a lot easier than sticking a cotton swab up your nose,” graduate student Kristen Muñoz said after collecting a bit of her saliva in a plastic tube and sealing it in a bag labeled “Biohazard.”
In just a few hours, she got back her result: negative.
The school plans to offer free tests to the 50,000 students expected to return this month, as well as some 11,000 faculty and staff members.
“The exciting thing is, because we can test up to 10,000 per day, it allows the scientist to do what’s really the best for trying to protect the community as opposed to having to cut corners, because of the limitations of the testing,” said University of Illinois chemist Martin Burke, who helped develop the campus’s saliva test, which received emergency use authorization from the federal Food and Drug Administration this week.
The test is similar to one designed by Yale and funded by the NBA that cleared the FDA hurdle just before the Illinois test. Both Yale and Illinois hope aggressive testing will allow most undergraduate students to live on campus, even though most classes will be online.
University of Illinois epidemiologist Becky Smith said they are following data that suggest campuses need to test everyone every few days because the virus is not detectable in infected people for 3 or 4 days.
“But about two days after that, your infectiousness peaks,” she said. “So, we have a very small window of time in which to catch people before they have done most of the infection that they’re going to be doing.”
Campus officials accepted Smith’s recommendation that all faculty, staffers and students participating in any on-campus activities be required to get tested twice a week.
Illinois can do that because its test is convenient and not invasive, which spares the campus from using as much personal protective equipment as the more invasive tests require, Burke said. And on-site analysis avoids backlogs at public health and commercial labs.
Muddled in the middle
Most other colleges fall somewhere between the approaches of Mizzou and the University of Illinois, and many of their students still are uncertain how their fall semester will go.
At the University of Southern California, a private campus of about 48,500 students in Los Angeles, officials had hoped to have about 20% of classes in person – but the county government scaled that back, insisting on tougher rules for reopening than the statewide standards.
If students eventually are allowed back, they will have to show a recent coronavirus test result that they obtained on their own, said Dr. Sarah Van Orman, chief health officer of USC Student Health.
They will be asked to do daily health assessments, such as fever checks, and those who have been exposed to the virus or show symptoms will receive a rapid test, with about a 24-hour turnaround through the university medical center’s lab. “We believe it is really important to have very rapid access to those results,” Van Orman said.
At California State University – the nation’s largest 4-year system, with 23 campuses and nearly a half-million students – officials decided back in May to move nearly all its fall courses online.
“The first priority was really the health and safety of all of the campus community,” said Mike Uhlenkamp, spokesperson for the CSU Chancellor’s Office. About 10% of CSU students are expected to attend some in-person classes, such as nursing lab courses, fine art and dance classes, and some graduate classes.
Uhlenkamp said testing protocols are being left up to each campus, though all are required to follow local safety guidelines. And without a medical campus in the system, CSU campuses do not have the same capacity to take charge of their own testing, as the University of Illinois is doing.
For students who know they won’t be on campus this fall, there is regret at lost social experiences, networking and hands-on learning so important to college.
But the certainty also brings relief.
“I don’t think I would want to be indoors with a group of, you know, even just a handful of people, even if we have masks on,” said Haley Gray, a 28-year-old graduate student at the University of California-Berkeley starting the second year of her journalism program.
She knows she won’t have access to Berkeley’s advanced media labs or the collaborative sessions students experience there. And she said she realized the other day she probably won’t just sit around the student lounge and strike up unexpected friendships.
“That’s a pretty big bummer but, you know, I think overall we’re all just doing our best, and given the circumstances, I feel pretty OK about it,” she said.
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente. This story is part of a partnership that includes KBIA, Illinois Public Media, Side Effects Public Media, NPR and Kaiser Health News.
Yousuf El-Jayyousi, a junior engineering student at the University of Missouri, wanted guidance and reassurance that it would be safe to go back to school for the fall semester. He tuned into a pair of online town halls organized by the university hoping to find that.
He did not.
What he got instead from those town halls last month was encouragement to return to class at the institution affectionately known as Mizzou. The university, in Columbia, would be testing only people with symptoms, and at that point, the university said people who test positive off campus were under no obligation to inform the school.
“It feels like the university doesn’t really care whether we get sick or not,” said El-Jayyousi, who is scheduled for two in-person classes, and lives at home with his parents and 90-year-old grandmother.
He’s seen the studies from researchers at Yale and Harvard that suggest testing needs to be much more widespread. He asked his instructors if he could join lectures remotely once classes begin Monday. One was considering it; the other rejected it.
“It was kind of very dismissive, like ‘so what?’ ” El-Jayyousi said.
But it’s an enormous “so what?” packed with fear and unknowns for Jayyousi and some 20 million other students enrolled in some level of postsecondary education in America, if they are not already online only.
Policies for reentry onto campuses that were abruptly shut in March are all over the map.
Hundreds Undecided
According to the College Crisis Initiative, or C2i, a project of Davidson College that monitors how higher ed is responding to the pandemic, there is nothing resembling a common approach. Of 2,958 institutions it follows, 151 were planning to open fully online, 729 were mostly online and 433 were taking a hybrid approach. Just 75 schools were insisting on students attending fully in person, and 614 were aiming to be primarily in-person. Some 800 others were still deciding, just weeks before instruction was to start.
The decisions often have little correlation with the public health advisories in the region. Mizzou, which is in an area with recent COVID spikes, is holding some in-person instruction and has nearly 7,000 students signed up to live in dorms and other university-owned housing. Harvard, in a region with extremely low rates of viral spread, has opted to go all online and allowed students to defer a year.
The specific circumstances colleges and universities face are as much determined by local fiscal and political dictates as by medicine and epidemiology. It is often unclear who is making the call. So it’s every student for herself to chart these unknown waters, even as students (or their families) have written tuition checks for tens of thousands of dollars and signed leases for campus and off-campus housing.
And the risks – health, educational and financial – boomerang back on individual students: Two weeks after University of North Carolina students, as instructed, returned to the flagship campus in Chapel Hill with the promise of at least some in-person learning, all classes went online. Early outbreaks surged from a few students to more than 130 in a matter of days. Most undergrads have about a week to clear out of their dorms.
“It’s really tough,” said neuroscience major Luke Lawless, 20. “Chapel Hill is an amazing place, and as a senior it’s tough to know that my time’s running out – and the virus only adds to that.”
Location, location, location
C2i’s creator, Davidson education Assistant Professor Chris Marsicano, said the extreme diversity of approaches comes from the sheer diversity of schools, the penchant of many to follow the leads of more prestigious peers, and local politics.
“Some states have very strong and stringent mask requirements. Some have stronger stay-at-home orders. Others are sort of leaving it up to localities. So the confluence of politics, institutional isomorphism – that imitation – and different needs that the institutions have are driving the differences,” Marsicano said.
Location matters a lot, too, Marsicano said, pointing to schools like George Washington University and Boston University in urban settings where the environment is beyond the control of the school, versus a place like the University of the South in remote, rural Sewanee, Tennessee, where 90% of students will return to campus.
“It’s a lot easier to control an outbreak if you are a fairly isolated college campus than if you are in the middle of a city,” Marsicano said.
Student behavior is another wild card, Marsicano said, since even the best plans will fail if college kids “do something stupid, like have a massive frat party without masks.”
“You’ve got student affairs professionals across the country who are screaming at the top of their lungs, ‘We can’t control student behavior when they go off campus’” Marsicano said.
Another factor is a vacuum at the federal level. Although the Department of Education says Secretary Betsy DeVos has held dozens of calls with governors and state education superintendents, there’s no sign of an attempt to offer unified guidance to colleges beyond a webpage that links to relaxed regulatory requirements and anodyne fact sheets from the Centers for Disease Control and Prevention on preventing viral spread.
Even the money that the department notes it has dispensed – $30 billion from Congress’ CARES Act – is weighted toward K-12 schools, with about $13 billion for higher education, including student aid.
The U.S. Senate adjourned last week until Sept. 8, having never taken up a House-passed relief package that included some $30 billion for higher education. A trio of Democratic senators, including Sen. Elizabeth Warren, is calling for national reporting standards on college campuses.
No benchmarks
Campus communities with very different levels of contagion are making opposite calls about in-person learning. Mizzou’s Boone County has seen more than 1,400 confirmed COVID cases after a spike in mid-July. According to the Harvard Global Health Institute’s COVID risk map, Boone has accelerated spread, with 14 infections per day per 100,000 people. The institute advises stay-at-home orders or rigorous testing and tracing at such rates of infection. Two neighboring counties were in the red zone recently, with more than 25 cases per day per 100,000 people. Mizzou has left it up to deans whether classes will meet in person, making a strong argument for face-to-face instruction.
Meanwhile, Columbia University in New York City opted for all online instruction, even though the rate of infection there is a comparatively low 3.8 cases per day per 100,000 people.
Administrators at Mizzou considered and rejected mandatory testing. “All that does is provide one a snapshot of the situation,” University of Missouri system President Mun Choi said in one of the town halls.
Mizzou has an in-house team that will carry out case investigation and contact tracing with the local health department. This week, following questions from the press and pressure from the public, the university announced students will be required to report any positive COVID test to the school.
Who do you test? When?
CDC guidance for higher education suggests there’s not enough data to know whether testing everyone is effective, but some influential researchers, such as those at Harvard and Yale, disagree.
“This virus is subject to silent spreading and asymptomatic spreading, and it’s very hard to play catch-up,” said Yale professor David Paltiel, who studies public health policy. “And so thinking that you can keep your campus safe by simply waiting until students develop symptoms before acting, I think, is a very dangerous game.”
Simulation models conducted by Paltiel and his colleagues show that, of all the factors university administrators can control – including the sensitivity and specificity of COVID-19 tests – the frequency of testing is most important.
He’s “painfully aware” that testing everyone on campus every few days sets a very high bar – logistically, financially, behaviorally – that may be beyond what most schools can reach. But he says the consequences of reopening campuses without those measures are severe, not just for students, but for vulnerable populations among school workers and in the surrounding community.
“You really have to ask yourself whether you have any business reopening if you’re not going to commit to an aggressive program of high-frequency testing,” he said.
The fighting – and testing – Illini
Some institutions that desperately want students to return to campus are backing the goal with a maximal approach to safety and testing.
About a 4-hour drive east along the interstates from Mizzou is the University of Illinois at Urbana-Champaign, whose sports teams are known as the Fighting Illini.
Weeks ago, large white tents with signs reading “Walk-Up COVID-19 Testing” have popped up across campus; there students take a simple saliva test.
“This seems to be a lot easier than sticking a cotton swab up your nose,” graduate student Kristen Muñoz said after collecting a bit of her saliva in a plastic tube and sealing it in a bag labeled “Biohazard.”
In just a few hours, she got back her result: negative.
The school plans to offer free tests to the 50,000 students expected to return this month, as well as some 11,000 faculty and staff members.
“The exciting thing is, because we can test up to 10,000 per day, it allows the scientist to do what’s really the best for trying to protect the community as opposed to having to cut corners, because of the limitations of the testing,” said University of Illinois chemist Martin Burke, who helped develop the campus’s saliva test, which received emergency use authorization from the federal Food and Drug Administration this week.
The test is similar to one designed by Yale and funded by the NBA that cleared the FDA hurdle just before the Illinois test. Both Yale and Illinois hope aggressive testing will allow most undergraduate students to live on campus, even though most classes will be online.
University of Illinois epidemiologist Becky Smith said they are following data that suggest campuses need to test everyone every few days because the virus is not detectable in infected people for 3 or 4 days.
“But about two days after that, your infectiousness peaks,” she said. “So, we have a very small window of time in which to catch people before they have done most of the infection that they’re going to be doing.”
Campus officials accepted Smith’s recommendation that all faculty, staffers and students participating in any on-campus activities be required to get tested twice a week.
Illinois can do that because its test is convenient and not invasive, which spares the campus from using as much personal protective equipment as the more invasive tests require, Burke said. And on-site analysis avoids backlogs at public health and commercial labs.
Muddled in the middle
Most other colleges fall somewhere between the approaches of Mizzou and the University of Illinois, and many of their students still are uncertain how their fall semester will go.
At the University of Southern California, a private campus of about 48,500 students in Los Angeles, officials had hoped to have about 20% of classes in person – but the county government scaled that back, insisting on tougher rules for reopening than the statewide standards.
If students eventually are allowed back, they will have to show a recent coronavirus test result that they obtained on their own, said Dr. Sarah Van Orman, chief health officer of USC Student Health.
They will be asked to do daily health assessments, such as fever checks, and those who have been exposed to the virus or show symptoms will receive a rapid test, with about a 24-hour turnaround through the university medical center’s lab. “We believe it is really important to have very rapid access to those results,” Van Orman said.
At California State University – the nation’s largest 4-year system, with 23 campuses and nearly a half-million students – officials decided back in May to move nearly all its fall courses online.
“The first priority was really the health and safety of all of the campus community,” said Mike Uhlenkamp, spokesperson for the CSU Chancellor’s Office. About 10% of CSU students are expected to attend some in-person classes, such as nursing lab courses, fine art and dance classes, and some graduate classes.
Uhlenkamp said testing protocols are being left up to each campus, though all are required to follow local safety guidelines. And without a medical campus in the system, CSU campuses do not have the same capacity to take charge of their own testing, as the University of Illinois is doing.
For students who know they won’t be on campus this fall, there is regret at lost social experiences, networking and hands-on learning so important to college.
But the certainty also brings relief.
“I don’t think I would want to be indoors with a group of, you know, even just a handful of people, even if we have masks on,” said Haley Gray, a 28-year-old graduate student at the University of California-Berkeley starting the second year of her journalism program.
She knows she won’t have access to Berkeley’s advanced media labs or the collaborative sessions students experience there. And she said she realized the other day she probably won’t just sit around the student lounge and strike up unexpected friendships.
“That’s a pretty big bummer but, you know, I think overall we’re all just doing our best, and given the circumstances, I feel pretty OK about it,” she said.
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente. This story is part of a partnership that includes KBIA, Illinois Public Media, Side Effects Public Media, NPR and Kaiser Health News.
COVID-19 linked to development of myasthenia gravis
Myasthenia gravis should be added to the growing list of potential neurological sequelae associated with COVID-19, new research suggests. Clinicians from Italy have described what they believe are
“I think it is possible that there could be many more cases,” said lead author Domenico Restivo, MD, of the Garibaldi Hospital, Catania, Italy. “In fact, myasthenia gravis could be underestimated especially in the course of COVID-19 infection in which a specific muscular weakness is frequently present. For this reason, this association is easy to miss if not top of mind,” Dr. Restivo said.
None of the three patients had previous neurologic or autoimmune disorders. In all three cases, symptoms of myasthenia gravis appeared within 5-7 days after onset of fever caused by SARS-CoV-2 infection. The time from presumed SARS-CoV-2 infection to myasthenia gravis symptoms “is consistent with the time from infection to symptoms in other neurologic disorders triggered by infections,” the investigators reported.
The findings were published online August 10 in Annals of Internal Medicine.
First patients
The first patient described in the report was a 64-year-old man who had a fever as high as 39° C (102.2° F) for 4 days. Five days after fever onset, he developed diplopia and muscle fatigue. The patient’s neurologic examination was “unremarkable.” Computed tomography (CT) of the thorax excluded thymoma, and findings on chest radiograph were normal. He tested positive for SARS-CoV-2 on nasopharyngeal swab and real-time reverse transcriptase polymerase chain reaction (RT-PCR).
The patient’s symptoms led the investigators to suspect myasthenia gravis. Repetitive stimulation of the patient’s facial nerve showed a 57% decrement, confirming involvement of the postsynaptic neuromuscular junction. The concentration of AChR antibodies in serum was also elevated (22.8 pmol/L; reference range, <0.4 pmol/L). The patient was treated with pyridostigmine bromide and prednisone and had a response “typical for someone with myasthenia gravis,” the researchers wrote.
The second patient was a 68-year-old man who had a fever as high as 38.8° C (101.8° F) for 7 days. On day 7, he developed muscle fatigue, diplopia, and dysphagia. Findings of a chest CT and neurologic exam were normal. Nasopharyngeal swab and RT-PCR testing for COVID-19 were positive. As with the first patient, myasthenia gravis was suspected because of the patient’s symptoms. Repetitive nerve stimulation revealed a postsynaptic deficit of neuromuscular transmission of the facial (52%) and ulnar (21%) nerves. His serum AChR antibody level was elevated (27.6 pmol/L). The patient improved after one cycle of intravenous immunoglobulin treatment.
Possible mechanisms
The third patient was a 71-year-old woman with cough and a fever up to 38.6° C (101.5° F) for 6 days. She initially tested negative for SARS-CoV-2 on nasopharyngeal swab and RT-PCR. Five days after her symptoms began, she developed bilateral ocular ptosis, diplopia, and hypophonia. CT of the thorax excluded thymoma but showed bilateral interstitial pneumonia. On day 6, she developed dysphagia and respiratory failure, and was transferred to the ICU where she received mechanical ventilation.
Repetitive nerve stimulation revealed a postsynaptic deficit of neuromuscular transmission of the ulnar nerve (56%), and her serum AChR antibody level was elevated (35.6 pmol/L). Five days later, a second nasopharyngeal swab test for SARS-CoV-2 was positive. The patient improved following plasmapheresis treatment and was successfully extubated.
The investigators noted that this patient received hydroxychloroquine the day after the onset of neurologic symptoms, but the drug was withdrawn a day later, so they do not believe that it caused the symptoms of myasthenia gravis.
The observations in these three patients are “consistent with reports of other infections that induce autoimmune disorders, as well as with the growing evidence of other neurologic disorders with presumed autoimmune mechanisms after COVID-19 onset,” the researchers wrote.
They offered several possible explanations for the link between COVID-19 and myasthenia gravis. “Antibodies that are directed against SARS-CoV-2 proteins may cross-react with AChR subunits, because the virus has epitopes that are similar to components of the neuromuscular junction; this is known to occur in other neurologic autoimmune disorders after infection. Alternatively, COVID-19 infection may break immunologic self-tolerance,” the investigators wrote.
“The main message for clinicians is that myasthenia gravis, as well as other neurological disorders associated with autoimmunity, could occur in the course of SARS-CoV-2 infection,” Dr. Restivo said. Prompt recognition of the disease “could lead to a drug treatment that limits its evolution as quickly as possible,” he added.
An “unmasking”
Commenting on the findings, Anthony Geraci, MD, director of neuromuscular medicine, Northwell Health, Great Neck, N.Y., said these case reports of myasthenia gravis after SARS-CoV-2 infection are “not unique or novel as there has been a long understanding that seropositive [AChR antibody-positive] myasthenia gravis can and is frequently ‘unmasked’ in the setting” of several viral and bacterial infections.
“Antibodies in myasthenia gravis are of a type that take several weeks to develop to measurable levels as in the reported cases by Restivo et al., giving strong support to the notion that subclinical myasthenia gravis can be immunologically upregulated in the setting of viral infection and this is a far more likely explanation of the observed association reported,” added Dr. Geraci, who was not involved with the research.
He noted that, at his institution, “we have also observed ocular myasthenia gravis emerge in patients with SARS-CoV-2 infection, with similar double vision and lid droop, as we have seen similarly in patients with Zika, West Nile, and other viral infections, as well as a multiplicity of bacterial infections.”
“Most of our observed patients have responded to treatment much the same as reported by the three cases from Restivo and colleagues,” Dr.Geraci reported.
The authors of the study disclosed no conflicts of interest.
A version of this article originally appeared on Medscape.com.
Myasthenia gravis should be added to the growing list of potential neurological sequelae associated with COVID-19, new research suggests. Clinicians from Italy have described what they believe are
“I think it is possible that there could be many more cases,” said lead author Domenico Restivo, MD, of the Garibaldi Hospital, Catania, Italy. “In fact, myasthenia gravis could be underestimated especially in the course of COVID-19 infection in which a specific muscular weakness is frequently present. For this reason, this association is easy to miss if not top of mind,” Dr. Restivo said.
None of the three patients had previous neurologic or autoimmune disorders. In all three cases, symptoms of myasthenia gravis appeared within 5-7 days after onset of fever caused by SARS-CoV-2 infection. The time from presumed SARS-CoV-2 infection to myasthenia gravis symptoms “is consistent with the time from infection to symptoms in other neurologic disorders triggered by infections,” the investigators reported.
The findings were published online August 10 in Annals of Internal Medicine.
First patients
The first patient described in the report was a 64-year-old man who had a fever as high as 39° C (102.2° F) for 4 days. Five days after fever onset, he developed diplopia and muscle fatigue. The patient’s neurologic examination was “unremarkable.” Computed tomography (CT) of the thorax excluded thymoma, and findings on chest radiograph were normal. He tested positive for SARS-CoV-2 on nasopharyngeal swab and real-time reverse transcriptase polymerase chain reaction (RT-PCR).
The patient’s symptoms led the investigators to suspect myasthenia gravis. Repetitive stimulation of the patient’s facial nerve showed a 57% decrement, confirming involvement of the postsynaptic neuromuscular junction. The concentration of AChR antibodies in serum was also elevated (22.8 pmol/L; reference range, <0.4 pmol/L). The patient was treated with pyridostigmine bromide and prednisone and had a response “typical for someone with myasthenia gravis,” the researchers wrote.
The second patient was a 68-year-old man who had a fever as high as 38.8° C (101.8° F) for 7 days. On day 7, he developed muscle fatigue, diplopia, and dysphagia. Findings of a chest CT and neurologic exam were normal. Nasopharyngeal swab and RT-PCR testing for COVID-19 were positive. As with the first patient, myasthenia gravis was suspected because of the patient’s symptoms. Repetitive nerve stimulation revealed a postsynaptic deficit of neuromuscular transmission of the facial (52%) and ulnar (21%) nerves. His serum AChR antibody level was elevated (27.6 pmol/L). The patient improved after one cycle of intravenous immunoglobulin treatment.
Possible mechanisms
The third patient was a 71-year-old woman with cough and a fever up to 38.6° C (101.5° F) for 6 days. She initially tested negative for SARS-CoV-2 on nasopharyngeal swab and RT-PCR. Five days after her symptoms began, she developed bilateral ocular ptosis, diplopia, and hypophonia. CT of the thorax excluded thymoma but showed bilateral interstitial pneumonia. On day 6, she developed dysphagia and respiratory failure, and was transferred to the ICU where she received mechanical ventilation.
Repetitive nerve stimulation revealed a postsynaptic deficit of neuromuscular transmission of the ulnar nerve (56%), and her serum AChR antibody level was elevated (35.6 pmol/L). Five days later, a second nasopharyngeal swab test for SARS-CoV-2 was positive. The patient improved following plasmapheresis treatment and was successfully extubated.
The investigators noted that this patient received hydroxychloroquine the day after the onset of neurologic symptoms, but the drug was withdrawn a day later, so they do not believe that it caused the symptoms of myasthenia gravis.
The observations in these three patients are “consistent with reports of other infections that induce autoimmune disorders, as well as with the growing evidence of other neurologic disorders with presumed autoimmune mechanisms after COVID-19 onset,” the researchers wrote.
They offered several possible explanations for the link between COVID-19 and myasthenia gravis. “Antibodies that are directed against SARS-CoV-2 proteins may cross-react with AChR subunits, because the virus has epitopes that are similar to components of the neuromuscular junction; this is known to occur in other neurologic autoimmune disorders after infection. Alternatively, COVID-19 infection may break immunologic self-tolerance,” the investigators wrote.
“The main message for clinicians is that myasthenia gravis, as well as other neurological disorders associated with autoimmunity, could occur in the course of SARS-CoV-2 infection,” Dr. Restivo said. Prompt recognition of the disease “could lead to a drug treatment that limits its evolution as quickly as possible,” he added.
An “unmasking”
Commenting on the findings, Anthony Geraci, MD, director of neuromuscular medicine, Northwell Health, Great Neck, N.Y., said these case reports of myasthenia gravis after SARS-CoV-2 infection are “not unique or novel as there has been a long understanding that seropositive [AChR antibody-positive] myasthenia gravis can and is frequently ‘unmasked’ in the setting” of several viral and bacterial infections.
“Antibodies in myasthenia gravis are of a type that take several weeks to develop to measurable levels as in the reported cases by Restivo et al., giving strong support to the notion that subclinical myasthenia gravis can be immunologically upregulated in the setting of viral infection and this is a far more likely explanation of the observed association reported,” added Dr. Geraci, who was not involved with the research.
He noted that, at his institution, “we have also observed ocular myasthenia gravis emerge in patients with SARS-CoV-2 infection, with similar double vision and lid droop, as we have seen similarly in patients with Zika, West Nile, and other viral infections, as well as a multiplicity of bacterial infections.”
“Most of our observed patients have responded to treatment much the same as reported by the three cases from Restivo and colleagues,” Dr.Geraci reported.
The authors of the study disclosed no conflicts of interest.
A version of this article originally appeared on Medscape.com.
Myasthenia gravis should be added to the growing list of potential neurological sequelae associated with COVID-19, new research suggests. Clinicians from Italy have described what they believe are
“I think it is possible that there could be many more cases,” said lead author Domenico Restivo, MD, of the Garibaldi Hospital, Catania, Italy. “In fact, myasthenia gravis could be underestimated especially in the course of COVID-19 infection in which a specific muscular weakness is frequently present. For this reason, this association is easy to miss if not top of mind,” Dr. Restivo said.
None of the three patients had previous neurologic or autoimmune disorders. In all three cases, symptoms of myasthenia gravis appeared within 5-7 days after onset of fever caused by SARS-CoV-2 infection. The time from presumed SARS-CoV-2 infection to myasthenia gravis symptoms “is consistent with the time from infection to symptoms in other neurologic disorders triggered by infections,” the investigators reported.
The findings were published online August 10 in Annals of Internal Medicine.
First patients
The first patient described in the report was a 64-year-old man who had a fever as high as 39° C (102.2° F) for 4 days. Five days after fever onset, he developed diplopia and muscle fatigue. The patient’s neurologic examination was “unremarkable.” Computed tomography (CT) of the thorax excluded thymoma, and findings on chest radiograph were normal. He tested positive for SARS-CoV-2 on nasopharyngeal swab and real-time reverse transcriptase polymerase chain reaction (RT-PCR).
The patient’s symptoms led the investigators to suspect myasthenia gravis. Repetitive stimulation of the patient’s facial nerve showed a 57% decrement, confirming involvement of the postsynaptic neuromuscular junction. The concentration of AChR antibodies in serum was also elevated (22.8 pmol/L; reference range, <0.4 pmol/L). The patient was treated with pyridostigmine bromide and prednisone and had a response “typical for someone with myasthenia gravis,” the researchers wrote.
The second patient was a 68-year-old man who had a fever as high as 38.8° C (101.8° F) for 7 days. On day 7, he developed muscle fatigue, diplopia, and dysphagia. Findings of a chest CT and neurologic exam were normal. Nasopharyngeal swab and RT-PCR testing for COVID-19 were positive. As with the first patient, myasthenia gravis was suspected because of the patient’s symptoms. Repetitive nerve stimulation revealed a postsynaptic deficit of neuromuscular transmission of the facial (52%) and ulnar (21%) nerves. His serum AChR antibody level was elevated (27.6 pmol/L). The patient improved after one cycle of intravenous immunoglobulin treatment.
Possible mechanisms
The third patient was a 71-year-old woman with cough and a fever up to 38.6° C (101.5° F) for 6 days. She initially tested negative for SARS-CoV-2 on nasopharyngeal swab and RT-PCR. Five days after her symptoms began, she developed bilateral ocular ptosis, diplopia, and hypophonia. CT of the thorax excluded thymoma but showed bilateral interstitial pneumonia. On day 6, she developed dysphagia and respiratory failure, and was transferred to the ICU where she received mechanical ventilation.
Repetitive nerve stimulation revealed a postsynaptic deficit of neuromuscular transmission of the ulnar nerve (56%), and her serum AChR antibody level was elevated (35.6 pmol/L). Five days later, a second nasopharyngeal swab test for SARS-CoV-2 was positive. The patient improved following plasmapheresis treatment and was successfully extubated.
The investigators noted that this patient received hydroxychloroquine the day after the onset of neurologic symptoms, but the drug was withdrawn a day later, so they do not believe that it caused the symptoms of myasthenia gravis.
The observations in these three patients are “consistent with reports of other infections that induce autoimmune disorders, as well as with the growing evidence of other neurologic disorders with presumed autoimmune mechanisms after COVID-19 onset,” the researchers wrote.
They offered several possible explanations for the link between COVID-19 and myasthenia gravis. “Antibodies that are directed against SARS-CoV-2 proteins may cross-react with AChR subunits, because the virus has epitopes that are similar to components of the neuromuscular junction; this is known to occur in other neurologic autoimmune disorders after infection. Alternatively, COVID-19 infection may break immunologic self-tolerance,” the investigators wrote.
“The main message for clinicians is that myasthenia gravis, as well as other neurological disorders associated with autoimmunity, could occur in the course of SARS-CoV-2 infection,” Dr. Restivo said. Prompt recognition of the disease “could lead to a drug treatment that limits its evolution as quickly as possible,” he added.
An “unmasking”
Commenting on the findings, Anthony Geraci, MD, director of neuromuscular medicine, Northwell Health, Great Neck, N.Y., said these case reports of myasthenia gravis after SARS-CoV-2 infection are “not unique or novel as there has been a long understanding that seropositive [AChR antibody-positive] myasthenia gravis can and is frequently ‘unmasked’ in the setting” of several viral and bacterial infections.
“Antibodies in myasthenia gravis are of a type that take several weeks to develop to measurable levels as in the reported cases by Restivo et al., giving strong support to the notion that subclinical myasthenia gravis can be immunologically upregulated in the setting of viral infection and this is a far more likely explanation of the observed association reported,” added Dr. Geraci, who was not involved with the research.
He noted that, at his institution, “we have also observed ocular myasthenia gravis emerge in patients with SARS-CoV-2 infection, with similar double vision and lid droop, as we have seen similarly in patients with Zika, West Nile, and other viral infections, as well as a multiplicity of bacterial infections.”
“Most of our observed patients have responded to treatment much the same as reported by the three cases from Restivo and colleagues,” Dr.Geraci reported.
The authors of the study disclosed no conflicts of interest.
A version of this article originally appeared on Medscape.com.
NBA star Mason Plumlee on COVID and life inside the Orlando ‘bubble’
Editor’s Note: This transcript from the August 20 episode of the Blood & Cancer podcast has been edited for clarity. Click this link to listen to the full episode.
David Henry, MD: Welcome to this Blood & Cancer podcast. I’m your host, Dr. David Henry. This podcast airs on Thursday morning each week. This interview and others are archived with show notes from our residents at Pennsylvania Hospital at this link.
Each week we interview key opinion leaders involved in various aspects of blood and cancer. Mason was a first round pick in the NBA, a gold medalist for the U.S. men’s national team, and NBA All-Rookie first team honoree. He’s one of the top playmaking forwards in the country, if not the world, in my opinion. In his four-year college career at Duke University, he helped lead the Blue Devils to a National Collegiate Athletic Association (NCAA) championship and twice earned All-America first team academic honors at Duke. So he’s not just a basketball star, but an academic star as well. Mason, thanks so much for taking some time out from the bubble in Florida to talk with us today.
Mason Plumlee: Thanks for having me on. I’m happy to be here.
Henry: Beginning in March, the NBA didn’t know what to do about the COVID pandemic but finally decided to put you professional players in a ‘bubble.’ What did you have to go through to get there? You, your teammates, coaches, trainers, etc. And what’s the ongoing plan to be sure you continue to be safe?
Plumlee: Back to when the season shut down in March, the NBA shut down the practice facilities at the same time. Most people went home. I went back to Indiana. And then, as the idea of this bubble came up and the NBA formalized a plan to start the season again, players started to go back to market. I went back to Denver and was working out there.
About two weeks before we were scheduled to arrive in Orlando, they started testing us every other day. They used the deep nasal swab as well as the throat swab. But they were also taking two to three blood tests in that time period. You needed a certain number of consecutive negative tests before they would allow you to fly on the team plane down to Orlando. So there was an incredible amount of testing in the market. Once you got to Orlando, you went into a 48-hour quarantine. You had to have two negative tests with 48 hours between them before you could leave your hotel room.
Since then, it’s been quite strict down here. And although it’s annoying in a lot of ways, I think it’s one of the reasons our league has been able to pull this off. We’ve had no positive tests within the bubble and we are tested every day. A company called BioReference Laboratories has a setup in one of the meeting rooms here, and it’s like clockwork—we go in, we get our tests. One of my teammates missed a test and they made him stay in his room until he could get another test and get the results, so he missed a game because of that.
Henry: During this bubble time, no one has tested positive—players, coaches, staff?
Plumlee: Correct.
Henry: That’s incredible, and it’s allowed those of us who want to watch the NBA and those of you who are in it professionally to continue the sport. It must be a real nuisance for you and your family and friends, because no one can visit you, right?
Plumlee: Right. There’s no visitation. We had one false positive. It was our media relations person and the actions they took when that positive test came in -- they quarantined him in his room and interviewed everybody he had talked to; they tested anyone who had any interaction with him and those people had to go into quarantine. They’re on top of things down here. In addition to the testing, we each have a pulse oximeter and a thermometer, and we use these to check in everyday on an app. So, they’re getting all the insight they need. After the first round of the playoffs, they’re going to open the bubble to friends and family, but those friends and family will be subject to all the same protocols that we were coming in and once they’re here as well.
Henry: I’m sure you’ve heard about the Broadway star [Nick Cordero] who was healthy and suddenly got sick, lost a leg, and then lost his life. There have been some heart attacks that surprised us. Have your colleagues—players, coaches, etc.—been worried? Or are they thinking, what’s the big deal? Has the sense of how serious this is permeated through this sport?
Plumlee: The NBA is one of the groups that has heightened the understanding and awareness of this by shutting down. I think a lot of people were moving forward as is, and then, when the NBA decided to cancel the season, it let the world know, look, this is to be taken seriously.
Henry: A couple of players did test positive early on.
Plumlee: Exactly. A couple of people tested positive. I think at the outset, the unknown is always scarier. As we’ve learned more about the virus, the guys have become more comfortable. You know, I tested positive back in March. At the time, a loss of taste and smell was not a reported symptom.
Henry: And you had that?
Plumlee: I did have that, but I didn’t know what to think. More research has come out and we have a better understanding of that. I think most of the players are comfortable with the virus. We’re at a time in our lives where we’re healthy, we’re active, and we should be able to fight it off. We know the numbers for our age group. Even still, I think nobody wants to get it. Nobody wants to have to go through it. So why chance it?
Henry: Hats off to you and your sport. Other sports such as Major League Baseball haven’t been quite so successful. Of course, they’re wrestling with the players testing positive, and this has stopped games this season.
I was looking over your background prior to the interview and learned that your mother and father have been involved in the medical arena. Can you tell us about that and how it’s rubbed off on you?
Plumlee: Definitely. My mom is a pharmacist, so I spent a lot of time as a kid going to see her at work. And my dad is general counsel for an orthopedic company. My hometown is Warsaw, Ind. Some people refer to it as the “Orthopedic Capital of the World.” Zimmer Biomet is headquartered there. DePuy Synthes is there. Medtronic has offices there, as well as a lot of cottage businesses that support the orthopedic industry. In my hometown, the rock star was Dane Miller, who founded Biomet. I have no formal education in medicine or health care, but I’ve seen the impact of it. From my parents and some cousins, uncles who are doctors and surgeons, it’s been interesting to see their work and learn about what’s the latest and greatest in health care.
Henry: What’s so nice about you in particular is, with that background of interests from your family and your celebrity and accomplishments in professional basketball, you have used that to explore and promote ways to make progress in health care and help others who are less fortunate. For example, you’re involved in a telehealth platform for all-in-one practice management; affordable telehealth for pediatrics; health benefits for small businesses; prior authorization—if you can help with prior authorization, we will be in the stands for you at every game because it’s the bane of our existence; radiotherapy; and probably from mom’s background, pharmacy benefit management. Pick any of those you’d like to talk about, and tell us about your involvement and how it’s going.
Plumlee: My ticket into the arena is investment. Nobody’s calling me, asking for my expertise. But a lot of these visionary founders need financial support, and that’s where I get involved. Then also, with the celebrity angle from being an athlete, sometimes you can open doors for a start-up founder that they may not be able to open themselves.
I’m happy to speak about any of those companies. I am excited about the relaxed regulation that’s come from the pandemic; not that it’s like the Wild West out here, but I think it has allowed companies to implement solutions or think about problems in a way that they couldn’t before the pandemic. Take the prior authorization play, for example, and a company called Banjo Health, with one of my favorite founders, a guy named Saar Mahna. Medicare mandates that you turn around prior authorizations within three days. This company has an artificial intelligence and machine-learning play on prior authorizations that can deliver on that.
So efficiencies, things that increase access or affordability, better outcomes, those are the things that attract me. I lean on other people for the due diligence. The pediatric play that you referenced is a company called Blueberry Pediatrics. You have a monthly subscription for $15 that can be reimbursed by Medicaid. They send two devices to your home—an otoscope and an oximeter. The company is live in Florida right now, and it’s diverting a ton of emergency room (ER) visits. From home, for $15 a month, a mom has an otoscope and an oximeter, and she can chat or video conference with a pediatrician. There’s no additional fee. So that’s saving everyone time and saving the system money. Those are the kinds of things I’m attracted to.
Henry: You’ve touched on a couple of hot button issues for us. In oncology, unfortunately, most of our patients have pain. I am mystified every time I try to get a narcotic or a strong painkiller for a patient on a Friday night and I’m told it requires prior authorization and they’ll open up again on Monday. Well, that’s insane. These patients need something right away. So if you have a special interest in helping all of us with prior authorization, the artificial intelligence is a no brainer. If this kind of computer algorithm could happen overnight, that would be wonderful.
You mentioned the ER. Many people go to the ER as a default. They don’t know what else to do. In the COVID era, we’re trying to dial that down because we want to be able to see the sickest and have the non-sick get care elsewhere. If this particular person or people don’t know what to do, they go to the ER, it costs money, takes a lot of time, and others who may be sick are diverted from care. Families worry terribly about their children, so a device for mom and access to a pediatrician for $15 a month is another wonderful idea. These are both very interesting. Another company is in the pharmacy benefit management (PBM) space. Anything you could say about how that works?
Plumlee: I can give an overview of how I look at this as an investor in the PBM space. Three companies control about 75% of a multibillion dollar market. Several initiatives have been pursued politically to provide transparent pricing between these PBMs and pharmaceutical companies, and a lot of people are pointing fingers, but ultimately, drug prices just keep going up. Everybody knows it.
A couple of start-up founders are really set on bringing a competitive marketplace back to the pharmacy benefit manager. As an investor, when you see three people controlling a market, and you have small or medium PBMs that depend on aggregators to get competitive pricing with those big three, you get interested. It’s an interesting industry. My feeling is that somebody is going to disrupt it and bring competition back to that space. Ultimately, drug prices will come down because it’s not sustainable. The insurance companies just accommodate whatever the drug pricing is. If the drug prices go up, your premiums go up. I think these new companies will be level-setting.
Henry: In my world of oncology, we’re just a little more than halfway through 2020 and we’ve had five, six, seven new drugs approved. They all will be very expensive. One of the nicer things that’s happening and may help to tamp this down involves biosimilars. When you go to CVS or Rite Aid, you go down the aspirin aisle and see the generics, and they’re identical to the brand name aspirin. Well, these very complex molecules we used to treat cancer are antibodies or proteins, and they’re made in nature’s factories called cells. They’re not identical to the brand name drugs, but they’re called biosimilars. They work exactly the same as the branded drugs with exactly the same safety–our U.S. FDA has done a nice job of vetting that, to be sure. X, Y, Z Company has copied the brand drug after the patent expires. They were hoping for about a 30% discount in price but we’re seeing more like 15%. Nothing’s ever easy. So you make a very good point. This is not sustainable and the competition will be wonderful to tamp down these prices.
Plumlee: My hope is that those biosimilars and generics get placement in these formularies because the formularies are what’s valuable to the drug manufacturers. But they have to accommodate what the Big Three want in the PBM space. To me, making things affordable and accessible is what a lot of these startups are trying to do. And hopefully they will win.
Henry: What have you been going through, in terms of COVID? Have you recovered fully? Have your taste and smell returned, and you’re back to normal?
Plumlee: I’m all good. It caught me off guard but the symptoms weren’t too intense. For me, it was less than a flu, but more than a cold. And I’m all good today.
Henry: We’re so glad and wish you the best of luck.
Dr. Henry is a clinical professor of medicine at the University of Pennsylvania and vice chairman of the department of medicine at Pennsylvania Hospital in Philadelphia and the host of the Blood & Cancer podcast. He has no relevant financial conflicts.
Mr. Plumlee is a board advisor to both Formsense and the Prysm Institute and a board observer with Voiceitt.
Editor’s Note: This transcript from the August 20 episode of the Blood & Cancer podcast has been edited for clarity. Click this link to listen to the full episode.
David Henry, MD: Welcome to this Blood & Cancer podcast. I’m your host, Dr. David Henry. This podcast airs on Thursday morning each week. This interview and others are archived with show notes from our residents at Pennsylvania Hospital at this link.
Each week we interview key opinion leaders involved in various aspects of blood and cancer. Mason was a first round pick in the NBA, a gold medalist for the U.S. men’s national team, and NBA All-Rookie first team honoree. He’s one of the top playmaking forwards in the country, if not the world, in my opinion. In his four-year college career at Duke University, he helped lead the Blue Devils to a National Collegiate Athletic Association (NCAA) championship and twice earned All-America first team academic honors at Duke. So he’s not just a basketball star, but an academic star as well. Mason, thanks so much for taking some time out from the bubble in Florida to talk with us today.
Mason Plumlee: Thanks for having me on. I’m happy to be here.
Henry: Beginning in March, the NBA didn’t know what to do about the COVID pandemic but finally decided to put you professional players in a ‘bubble.’ What did you have to go through to get there? You, your teammates, coaches, trainers, etc. And what’s the ongoing plan to be sure you continue to be safe?
Plumlee: Back to when the season shut down in March, the NBA shut down the practice facilities at the same time. Most people went home. I went back to Indiana. And then, as the idea of this bubble came up and the NBA formalized a plan to start the season again, players started to go back to market. I went back to Denver and was working out there.
About two weeks before we were scheduled to arrive in Orlando, they started testing us every other day. They used the deep nasal swab as well as the throat swab. But they were also taking two to three blood tests in that time period. You needed a certain number of consecutive negative tests before they would allow you to fly on the team plane down to Orlando. So there was an incredible amount of testing in the market. Once you got to Orlando, you went into a 48-hour quarantine. You had to have two negative tests with 48 hours between them before you could leave your hotel room.
Since then, it’s been quite strict down here. And although it’s annoying in a lot of ways, I think it’s one of the reasons our league has been able to pull this off. We’ve had no positive tests within the bubble and we are tested every day. A company called BioReference Laboratories has a setup in one of the meeting rooms here, and it’s like clockwork—we go in, we get our tests. One of my teammates missed a test and they made him stay in his room until he could get another test and get the results, so he missed a game because of that.
Henry: During this bubble time, no one has tested positive—players, coaches, staff?
Plumlee: Correct.
Henry: That’s incredible, and it’s allowed those of us who want to watch the NBA and those of you who are in it professionally to continue the sport. It must be a real nuisance for you and your family and friends, because no one can visit you, right?
Plumlee: Right. There’s no visitation. We had one false positive. It was our media relations person and the actions they took when that positive test came in -- they quarantined him in his room and interviewed everybody he had talked to; they tested anyone who had any interaction with him and those people had to go into quarantine. They’re on top of things down here. In addition to the testing, we each have a pulse oximeter and a thermometer, and we use these to check in everyday on an app. So, they’re getting all the insight they need. After the first round of the playoffs, they’re going to open the bubble to friends and family, but those friends and family will be subject to all the same protocols that we were coming in and once they’re here as well.
Henry: I’m sure you’ve heard about the Broadway star [Nick Cordero] who was healthy and suddenly got sick, lost a leg, and then lost his life. There have been some heart attacks that surprised us. Have your colleagues—players, coaches, etc.—been worried? Or are they thinking, what’s the big deal? Has the sense of how serious this is permeated through this sport?
Plumlee: The NBA is one of the groups that has heightened the understanding and awareness of this by shutting down. I think a lot of people were moving forward as is, and then, when the NBA decided to cancel the season, it let the world know, look, this is to be taken seriously.
Henry: A couple of players did test positive early on.
Plumlee: Exactly. A couple of people tested positive. I think at the outset, the unknown is always scarier. As we’ve learned more about the virus, the guys have become more comfortable. You know, I tested positive back in March. At the time, a loss of taste and smell was not a reported symptom.
Henry: And you had that?
Plumlee: I did have that, but I didn’t know what to think. More research has come out and we have a better understanding of that. I think most of the players are comfortable with the virus. We’re at a time in our lives where we’re healthy, we’re active, and we should be able to fight it off. We know the numbers for our age group. Even still, I think nobody wants to get it. Nobody wants to have to go through it. So why chance it?
Henry: Hats off to you and your sport. Other sports such as Major League Baseball haven’t been quite so successful. Of course, they’re wrestling with the players testing positive, and this has stopped games this season.
I was looking over your background prior to the interview and learned that your mother and father have been involved in the medical arena. Can you tell us about that and how it’s rubbed off on you?
Plumlee: Definitely. My mom is a pharmacist, so I spent a lot of time as a kid going to see her at work. And my dad is general counsel for an orthopedic company. My hometown is Warsaw, Ind. Some people refer to it as the “Orthopedic Capital of the World.” Zimmer Biomet is headquartered there. DePuy Synthes is there. Medtronic has offices there, as well as a lot of cottage businesses that support the orthopedic industry. In my hometown, the rock star was Dane Miller, who founded Biomet. I have no formal education in medicine or health care, but I’ve seen the impact of it. From my parents and some cousins, uncles who are doctors and surgeons, it’s been interesting to see their work and learn about what’s the latest and greatest in health care.
Henry: What’s so nice about you in particular is, with that background of interests from your family and your celebrity and accomplishments in professional basketball, you have used that to explore and promote ways to make progress in health care and help others who are less fortunate. For example, you’re involved in a telehealth platform for all-in-one practice management; affordable telehealth for pediatrics; health benefits for small businesses; prior authorization—if you can help with prior authorization, we will be in the stands for you at every game because it’s the bane of our existence; radiotherapy; and probably from mom’s background, pharmacy benefit management. Pick any of those you’d like to talk about, and tell us about your involvement and how it’s going.
Plumlee: My ticket into the arena is investment. Nobody’s calling me, asking for my expertise. But a lot of these visionary founders need financial support, and that’s where I get involved. Then also, with the celebrity angle from being an athlete, sometimes you can open doors for a start-up founder that they may not be able to open themselves.
I’m happy to speak about any of those companies. I am excited about the relaxed regulation that’s come from the pandemic; not that it’s like the Wild West out here, but I think it has allowed companies to implement solutions or think about problems in a way that they couldn’t before the pandemic. Take the prior authorization play, for example, and a company called Banjo Health, with one of my favorite founders, a guy named Saar Mahna. Medicare mandates that you turn around prior authorizations within three days. This company has an artificial intelligence and machine-learning play on prior authorizations that can deliver on that.
So efficiencies, things that increase access or affordability, better outcomes, those are the things that attract me. I lean on other people for the due diligence. The pediatric play that you referenced is a company called Blueberry Pediatrics. You have a monthly subscription for $15 that can be reimbursed by Medicaid. They send two devices to your home—an otoscope and an oximeter. The company is live in Florida right now, and it’s diverting a ton of emergency room (ER) visits. From home, for $15 a month, a mom has an otoscope and an oximeter, and she can chat or video conference with a pediatrician. There’s no additional fee. So that’s saving everyone time and saving the system money. Those are the kinds of things I’m attracted to.
Henry: You’ve touched on a couple of hot button issues for us. In oncology, unfortunately, most of our patients have pain. I am mystified every time I try to get a narcotic or a strong painkiller for a patient on a Friday night and I’m told it requires prior authorization and they’ll open up again on Monday. Well, that’s insane. These patients need something right away. So if you have a special interest in helping all of us with prior authorization, the artificial intelligence is a no brainer. If this kind of computer algorithm could happen overnight, that would be wonderful.
You mentioned the ER. Many people go to the ER as a default. They don’t know what else to do. In the COVID era, we’re trying to dial that down because we want to be able to see the sickest and have the non-sick get care elsewhere. If this particular person or people don’t know what to do, they go to the ER, it costs money, takes a lot of time, and others who may be sick are diverted from care. Families worry terribly about their children, so a device for mom and access to a pediatrician for $15 a month is another wonderful idea. These are both very interesting. Another company is in the pharmacy benefit management (PBM) space. Anything you could say about how that works?
Plumlee: I can give an overview of how I look at this as an investor in the PBM space. Three companies control about 75% of a multibillion dollar market. Several initiatives have been pursued politically to provide transparent pricing between these PBMs and pharmaceutical companies, and a lot of people are pointing fingers, but ultimately, drug prices just keep going up. Everybody knows it.
A couple of start-up founders are really set on bringing a competitive marketplace back to the pharmacy benefit manager. As an investor, when you see three people controlling a market, and you have small or medium PBMs that depend on aggregators to get competitive pricing with those big three, you get interested. It’s an interesting industry. My feeling is that somebody is going to disrupt it and bring competition back to that space. Ultimately, drug prices will come down because it’s not sustainable. The insurance companies just accommodate whatever the drug pricing is. If the drug prices go up, your premiums go up. I think these new companies will be level-setting.
Henry: In my world of oncology, we’re just a little more than halfway through 2020 and we’ve had five, six, seven new drugs approved. They all will be very expensive. One of the nicer things that’s happening and may help to tamp this down involves biosimilars. When you go to CVS or Rite Aid, you go down the aspirin aisle and see the generics, and they’re identical to the brand name aspirin. Well, these very complex molecules we used to treat cancer are antibodies or proteins, and they’re made in nature’s factories called cells. They’re not identical to the brand name drugs, but they’re called biosimilars. They work exactly the same as the branded drugs with exactly the same safety–our U.S. FDA has done a nice job of vetting that, to be sure. X, Y, Z Company has copied the brand drug after the patent expires. They were hoping for about a 30% discount in price but we’re seeing more like 15%. Nothing’s ever easy. So you make a very good point. This is not sustainable and the competition will be wonderful to tamp down these prices.
Plumlee: My hope is that those biosimilars and generics get placement in these formularies because the formularies are what’s valuable to the drug manufacturers. But they have to accommodate what the Big Three want in the PBM space. To me, making things affordable and accessible is what a lot of these startups are trying to do. And hopefully they will win.
Henry: What have you been going through, in terms of COVID? Have you recovered fully? Have your taste and smell returned, and you’re back to normal?
Plumlee: I’m all good. It caught me off guard but the symptoms weren’t too intense. For me, it was less than a flu, but more than a cold. And I’m all good today.
Henry: We’re so glad and wish you the best of luck.
Dr. Henry is a clinical professor of medicine at the University of Pennsylvania and vice chairman of the department of medicine at Pennsylvania Hospital in Philadelphia and the host of the Blood & Cancer podcast. He has no relevant financial conflicts.
Mr. Plumlee is a board advisor to both Formsense and the Prysm Institute and a board observer with Voiceitt.
Editor’s Note: This transcript from the August 20 episode of the Blood & Cancer podcast has been edited for clarity. Click this link to listen to the full episode.
David Henry, MD: Welcome to this Blood & Cancer podcast. I’m your host, Dr. David Henry. This podcast airs on Thursday morning each week. This interview and others are archived with show notes from our residents at Pennsylvania Hospital at this link.
Each week we interview key opinion leaders involved in various aspects of blood and cancer. Mason was a first round pick in the NBA, a gold medalist for the U.S. men’s national team, and NBA All-Rookie first team honoree. He’s one of the top playmaking forwards in the country, if not the world, in my opinion. In his four-year college career at Duke University, he helped lead the Blue Devils to a National Collegiate Athletic Association (NCAA) championship and twice earned All-America first team academic honors at Duke. So he’s not just a basketball star, but an academic star as well. Mason, thanks so much for taking some time out from the bubble in Florida to talk with us today.
Mason Plumlee: Thanks for having me on. I’m happy to be here.
Henry: Beginning in March, the NBA didn’t know what to do about the COVID pandemic but finally decided to put you professional players in a ‘bubble.’ What did you have to go through to get there? You, your teammates, coaches, trainers, etc. And what’s the ongoing plan to be sure you continue to be safe?
Plumlee: Back to when the season shut down in March, the NBA shut down the practice facilities at the same time. Most people went home. I went back to Indiana. And then, as the idea of this bubble came up and the NBA formalized a plan to start the season again, players started to go back to market. I went back to Denver and was working out there.
About two weeks before we were scheduled to arrive in Orlando, they started testing us every other day. They used the deep nasal swab as well as the throat swab. But they were also taking two to three blood tests in that time period. You needed a certain number of consecutive negative tests before they would allow you to fly on the team plane down to Orlando. So there was an incredible amount of testing in the market. Once you got to Orlando, you went into a 48-hour quarantine. You had to have two negative tests with 48 hours between them before you could leave your hotel room.
Since then, it’s been quite strict down here. And although it’s annoying in a lot of ways, I think it’s one of the reasons our league has been able to pull this off. We’ve had no positive tests within the bubble and we are tested every day. A company called BioReference Laboratories has a setup in one of the meeting rooms here, and it’s like clockwork—we go in, we get our tests. One of my teammates missed a test and they made him stay in his room until he could get another test and get the results, so he missed a game because of that.
Henry: During this bubble time, no one has tested positive—players, coaches, staff?
Plumlee: Correct.
Henry: That’s incredible, and it’s allowed those of us who want to watch the NBA and those of you who are in it professionally to continue the sport. It must be a real nuisance for you and your family and friends, because no one can visit you, right?
Plumlee: Right. There’s no visitation. We had one false positive. It was our media relations person and the actions they took when that positive test came in -- they quarantined him in his room and interviewed everybody he had talked to; they tested anyone who had any interaction with him and those people had to go into quarantine. They’re on top of things down here. In addition to the testing, we each have a pulse oximeter and a thermometer, and we use these to check in everyday on an app. So, they’re getting all the insight they need. After the first round of the playoffs, they’re going to open the bubble to friends and family, but those friends and family will be subject to all the same protocols that we were coming in and once they’re here as well.
Henry: I’m sure you’ve heard about the Broadway star [Nick Cordero] who was healthy and suddenly got sick, lost a leg, and then lost his life. There have been some heart attacks that surprised us. Have your colleagues—players, coaches, etc.—been worried? Or are they thinking, what’s the big deal? Has the sense of how serious this is permeated through this sport?
Plumlee: The NBA is one of the groups that has heightened the understanding and awareness of this by shutting down. I think a lot of people were moving forward as is, and then, when the NBA decided to cancel the season, it let the world know, look, this is to be taken seriously.
Henry: A couple of players did test positive early on.
Plumlee: Exactly. A couple of people tested positive. I think at the outset, the unknown is always scarier. As we’ve learned more about the virus, the guys have become more comfortable. You know, I tested positive back in March. At the time, a loss of taste and smell was not a reported symptom.
Henry: And you had that?
Plumlee: I did have that, but I didn’t know what to think. More research has come out and we have a better understanding of that. I think most of the players are comfortable with the virus. We’re at a time in our lives where we’re healthy, we’re active, and we should be able to fight it off. We know the numbers for our age group. Even still, I think nobody wants to get it. Nobody wants to have to go through it. So why chance it?
Henry: Hats off to you and your sport. Other sports such as Major League Baseball haven’t been quite so successful. Of course, they’re wrestling with the players testing positive, and this has stopped games this season.
I was looking over your background prior to the interview and learned that your mother and father have been involved in the medical arena. Can you tell us about that and how it’s rubbed off on you?
Plumlee: Definitely. My mom is a pharmacist, so I spent a lot of time as a kid going to see her at work. And my dad is general counsel for an orthopedic company. My hometown is Warsaw, Ind. Some people refer to it as the “Orthopedic Capital of the World.” Zimmer Biomet is headquartered there. DePuy Synthes is there. Medtronic has offices there, as well as a lot of cottage businesses that support the orthopedic industry. In my hometown, the rock star was Dane Miller, who founded Biomet. I have no formal education in medicine or health care, but I’ve seen the impact of it. From my parents and some cousins, uncles who are doctors and surgeons, it’s been interesting to see their work and learn about what’s the latest and greatest in health care.
Henry: What’s so nice about you in particular is, with that background of interests from your family and your celebrity and accomplishments in professional basketball, you have used that to explore and promote ways to make progress in health care and help others who are less fortunate. For example, you’re involved in a telehealth platform for all-in-one practice management; affordable telehealth for pediatrics; health benefits for small businesses; prior authorization—if you can help with prior authorization, we will be in the stands for you at every game because it’s the bane of our existence; radiotherapy; and probably from mom’s background, pharmacy benefit management. Pick any of those you’d like to talk about, and tell us about your involvement and how it’s going.
Plumlee: My ticket into the arena is investment. Nobody’s calling me, asking for my expertise. But a lot of these visionary founders need financial support, and that’s where I get involved. Then also, with the celebrity angle from being an athlete, sometimes you can open doors for a start-up founder that they may not be able to open themselves.
I’m happy to speak about any of those companies. I am excited about the relaxed regulation that’s come from the pandemic; not that it’s like the Wild West out here, but I think it has allowed companies to implement solutions or think about problems in a way that they couldn’t before the pandemic. Take the prior authorization play, for example, and a company called Banjo Health, with one of my favorite founders, a guy named Saar Mahna. Medicare mandates that you turn around prior authorizations within three days. This company has an artificial intelligence and machine-learning play on prior authorizations that can deliver on that.
So efficiencies, things that increase access or affordability, better outcomes, those are the things that attract me. I lean on other people for the due diligence. The pediatric play that you referenced is a company called Blueberry Pediatrics. You have a monthly subscription for $15 that can be reimbursed by Medicaid. They send two devices to your home—an otoscope and an oximeter. The company is live in Florida right now, and it’s diverting a ton of emergency room (ER) visits. From home, for $15 a month, a mom has an otoscope and an oximeter, and she can chat or video conference with a pediatrician. There’s no additional fee. So that’s saving everyone time and saving the system money. Those are the kinds of things I’m attracted to.
Henry: You’ve touched on a couple of hot button issues for us. In oncology, unfortunately, most of our patients have pain. I am mystified every time I try to get a narcotic or a strong painkiller for a patient on a Friday night and I’m told it requires prior authorization and they’ll open up again on Monday. Well, that’s insane. These patients need something right away. So if you have a special interest in helping all of us with prior authorization, the artificial intelligence is a no brainer. If this kind of computer algorithm could happen overnight, that would be wonderful.
You mentioned the ER. Many people go to the ER as a default. They don’t know what else to do. In the COVID era, we’re trying to dial that down because we want to be able to see the sickest and have the non-sick get care elsewhere. If this particular person or people don’t know what to do, they go to the ER, it costs money, takes a lot of time, and others who may be sick are diverted from care. Families worry terribly about their children, so a device for mom and access to a pediatrician for $15 a month is another wonderful idea. These are both very interesting. Another company is in the pharmacy benefit management (PBM) space. Anything you could say about how that works?
Plumlee: I can give an overview of how I look at this as an investor in the PBM space. Three companies control about 75% of a multibillion dollar market. Several initiatives have been pursued politically to provide transparent pricing between these PBMs and pharmaceutical companies, and a lot of people are pointing fingers, but ultimately, drug prices just keep going up. Everybody knows it.
A couple of start-up founders are really set on bringing a competitive marketplace back to the pharmacy benefit manager. As an investor, when you see three people controlling a market, and you have small or medium PBMs that depend on aggregators to get competitive pricing with those big three, you get interested. It’s an interesting industry. My feeling is that somebody is going to disrupt it and bring competition back to that space. Ultimately, drug prices will come down because it’s not sustainable. The insurance companies just accommodate whatever the drug pricing is. If the drug prices go up, your premiums go up. I think these new companies will be level-setting.
Henry: In my world of oncology, we’re just a little more than halfway through 2020 and we’ve had five, six, seven new drugs approved. They all will be very expensive. One of the nicer things that’s happening and may help to tamp this down involves biosimilars. When you go to CVS or Rite Aid, you go down the aspirin aisle and see the generics, and they’re identical to the brand name aspirin. Well, these very complex molecules we used to treat cancer are antibodies or proteins, and they’re made in nature’s factories called cells. They’re not identical to the brand name drugs, but they’re called biosimilars. They work exactly the same as the branded drugs with exactly the same safety–our U.S. FDA has done a nice job of vetting that, to be sure. X, Y, Z Company has copied the brand drug after the patent expires. They were hoping for about a 30% discount in price but we’re seeing more like 15%. Nothing’s ever easy. So you make a very good point. This is not sustainable and the competition will be wonderful to tamp down these prices.
Plumlee: My hope is that those biosimilars and generics get placement in these formularies because the formularies are what’s valuable to the drug manufacturers. But they have to accommodate what the Big Three want in the PBM space. To me, making things affordable and accessible is what a lot of these startups are trying to do. And hopefully they will win.
Henry: What have you been going through, in terms of COVID? Have you recovered fully? Have your taste and smell returned, and you’re back to normal?
Plumlee: I’m all good. It caught me off guard but the symptoms weren’t too intense. For me, it was less than a flu, but more than a cold. And I’m all good today.
Henry: We’re so glad and wish you the best of luck.
Dr. Henry is a clinical professor of medicine at the University of Pennsylvania and vice chairman of the department of medicine at Pennsylvania Hospital in Philadelphia and the host of the Blood & Cancer podcast. He has no relevant financial conflicts.
Mr. Plumlee is a board advisor to both Formsense and the Prysm Institute and a board observer with Voiceitt.
COVID-19 plans put to test as firefighters crowd camps for peak wildfire season
Jon Paul was leery entering his first wildfire camp of the year late last month to fight three lightning-caused fires scorching parts of a Northern California forest that hadn’t burned in 40 years.
The 54-year-old engine captain from southern Oregon knew from experience that these crowded, grimy camps can be breeding grounds for norovirus and a respiratory illness that firefighters call the “camp crud” in a normal year. He wondered what the coronavirus would do in the tent cities where hundreds of men and women eat, sleep, wash, and spend their downtime between shifts.
Mr. Paul thought about his immunocompromised wife and his 84-year-old mother back home. Then he joined the approximately 1,300 people spread across the Modoc National Forest who would provide a major test for the COVID-prevention measures that had been developed for wildland firefighters.
“We’re still first responders and we have that responsibility to go and deal with these emergencies,” he said in a recent interview. “I don’t scare easy, but I’m very wary and concerned about my surroundings. I’m still going to work and do my job.”
Mr. Paul is one of thousands of firefighters from across the United States battling dozens of wildfires burning throughout the West. It’s an inherently dangerous job that now carries the additional risk of COVID-19 transmission. Any outbreak that ripples through a camp could easily sideline crews and spread the virus across multiple fires – and back to communities across the country – as personnel transfer in and out of “hot zones” and return home.
Though most firefighters are young and fit, some will inevitably fall ill in these remote makeshift communities of shared showers and portable toilets, where medical care can be limited. The pollutants in the smoke they breathe daily also make them more susceptible to COVID-19 and can worsen the effects of the disease, according to the Centers for Disease Control and Prevention.
Also, one suspected or positive case in a camp will mean many other firefighters will need to be quarantined, unable to work. The worst-case scenario is that multiple outbreaks could hamstring the nation’s ability to respond as wildfire season peaks in August, the hottest and driest month of the year in the western United States.
The number of acres burned so far this year is below the 10-year average, but the fire outlook for August is above average in nine states, according to the National Interagency Fire Center. Twenty-two large fires were ignited on Monday alone after lightning storms passed through the Northwest.
A study published this month by researchers at Colorado State University and the U.S. Forest Service’s Rocky Mountain Research Station concluded that COVID outbreaks “could be a serious threat to the firefighting mission” and urged vigilant social distancing and screening measures in the camps.
“If simultaneous fires incurred outbreaks, the entire wildland response system could be stressed substantially, with a large portion of the workforce quarantined,” the study’s authors wrote.
This spring, the National Wildfire Coordinating Group’s Fire Management Board wrote – and has since been updating – protocols to prevent the spread of COVID-19 in fire camps, based on CDC guidelines. Though they can be adapted by managers at different fires and even by individual team, they center on some key recommendations, including the following:
- Firefighters should be screened for fever and other COVID symptoms when they arrive at camp.
- Every crew should insulate itself as a “module of one” for the fire season and limit interactions with other crews.
- Firefighters should maintain social distancing and wear face coverings when social distancing isn’t possible. Smaller satellite camps, known as spike camps, can be built to ensure enough space.
- Shared areas should be regularly cleaned and disinfected, and sharing tools and radios should be minimized.
The guidance does not include routine testing of newly arrived firefighters – a practice used for athletes at training camps and students returning to college campuses.
The Fire Management Board’s Wildland Fire Medical and Public Health Advisory Team wrote in a July 2 memo that it “does not recommend utilizing universal COVID-19 laboratory testing as a standalone risk mitigation or screening measure among wildland firefighters.” Rather, the group recommends testing an individual and directly exposed coworkers, saying that approach is in line with CDC guidance.
The lack of testing capacity and long turnaround times are factors, according to Forest Service spokesperson Dan Hottle.
The exception is Alaska, where firefighters are tested upon arrival at the airport and are quarantined in a hotel while awaiting results, which come within 24 hours, Mr. Hottle said.
Fire crews responding to early-season fires in the spring had some problems adjusting to the new protocols, according to assessments written by fire leaders and compiled by the Wildland Fire Lessons Learned Center.
Shawn Faiella, superintendent of the interagency “hotshot crew” – so named because they work the most challenging or “hottest” parts of wildfires – based at Montana’s Lolo National Forest, questioned the need to wear masks inside vehicles and the safety of bringing extra vehicles to space out firefighters traveling to a blaze. Parking extra vehicles at the scene of a fire is difficult in tight dirt roads – and would be dangerous if evacuations are necessary, he wrote.
“It’s damn tough to take these practices to the fire line,” Mr. Faiella wrote after his team responded to a 40-acre Montana fire in April.
One recommendation that fire managers say has been particularly effective is the “module of one” concept requiring crews to eat and sleep together in isolation for the entire fire season.
“Whoever came up with it, it is working,” said Mike Goicoechea, the Montana-based incident commander for the Forest Service’s Northern Region Type 1 team, which manages the nation’s largest and most complex wildfires and natural disasters. “Somebody may test positive, and you end up having to take that module out of service for 14 days. But the nice part is you’re not taking out a whole camp. ... It’s just that module.”
The total number of positive COVID cases among wildland firefighters among the various federal, state, local, and tribal agencies is not being tracked. Each fire agency has its own system for tracking and reporting COVID-19, said Jessica Gardetto, a spokesperson for the Bureau of Land Management (BLM) and the National Interagency Fire Center in Idaho.
The largest wildland firefighting agency is the Department of Agriculture’s Forest Service, with 10,000 firefighters. Another major agency is the Department of the Interior, which BLM is part of and which had more than 3,500 full-time fire employees last year. As of the first week of August, 111 Forest Service firefighters and 40 BLM firefighters (who work underneath the broader Interior Department agency) had tested positive for COVID-19, according to officials for the respective agencies.
“Considering we’ve now been experiencing fire activity for several months, this number is surprisingly low if you think about the thousands of fire personnel who’ve been suppressing wildfires this summer,” Ms. Gardetto said.
Mr. Goicoechea and his Montana team traveled north of Tucson, Arizona, on June 22 to manage a rapidly spreading fire in the Santa Catalina Mountains that required 1,200 responders at its peak. Within 2 days of the team’s arrival, his managers were overwhelmed by calls from firefighters worried or with questions about preventing the spread of COVID-19 or carrying the virus home to their families.
In an unusual move, Mr. Goicoechea called upon Montana physician – and former National Park Service ranger with wildfire experience – Harry Sibold, MD, to join the team. Physicians are rarely, if ever, part of a wildfire camp’s medical team, Mr. Goicoechea said.
Dr. Sibold gave regular coronavirus updates during morning briefings, consulted with local health officials, soothed firefighters worried about bringing the virus home to their families, and advised fire managers on how to handle scenarios that might come up.
But Dr. Sibold said he wasn’t optimistic at the beginning about keeping the coronavirus in check in a large camp in Pima County, which has the second-highest number of confirmed cases in Arizona, at the time a national COVID-19 hot spot. “I quite firmly expected that we might have two or three outbreaks,” he said.
There were no positive cases during the team’s 2-week deployment, just three or four cases in which a firefighter showed symptoms but tested negative for the virus. After the Montana team returned home, nine firefighters at the Arizona fire from other units tested positive, Mr. Goicoechea said. Contact tracers notified the Montana team, some of whom were tested. All tests returned negative.
“I can’t say enough about having that doctor to help,” Mr. Goicoechea said, suggesting other teams might consider doing the same. “We’re not the experts in a pandemic. We’re the experts with fire.”
That early success will be tested as the number of fires increases across the West, along with the number of firefighters responding to them. There were more than 15,000 firefighters and support personnel assigned to fires across the nation as of mid-August, and the success of those COVID-19 prevention protocols depend largely on them.
Mr. Paul, the Oregon firefighter, said that the guidelines were followed closely in camp, but less so out on the fire line. It also appeared to him that younger firefighters were less likely to follow the masking and social-distancing rules than the veterans like him. That worried him as he realized it wouldn’t take much to spark an outbreak that could sideline crews and cripple the ability to respond to a fire.
“We’re outside, so it definitely helps with mitigation and makes it simpler to social distance,” Mr. Paul said. “But I think if there’s a mistake made, it could happen.”
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
Jon Paul was leery entering his first wildfire camp of the year late last month to fight three lightning-caused fires scorching parts of a Northern California forest that hadn’t burned in 40 years.
The 54-year-old engine captain from southern Oregon knew from experience that these crowded, grimy camps can be breeding grounds for norovirus and a respiratory illness that firefighters call the “camp crud” in a normal year. He wondered what the coronavirus would do in the tent cities where hundreds of men and women eat, sleep, wash, and spend their downtime between shifts.
Mr. Paul thought about his immunocompromised wife and his 84-year-old mother back home. Then he joined the approximately 1,300 people spread across the Modoc National Forest who would provide a major test for the COVID-prevention measures that had been developed for wildland firefighters.
“We’re still first responders and we have that responsibility to go and deal with these emergencies,” he said in a recent interview. “I don’t scare easy, but I’m very wary and concerned about my surroundings. I’m still going to work and do my job.”
Mr. Paul is one of thousands of firefighters from across the United States battling dozens of wildfires burning throughout the West. It’s an inherently dangerous job that now carries the additional risk of COVID-19 transmission. Any outbreak that ripples through a camp could easily sideline crews and spread the virus across multiple fires – and back to communities across the country – as personnel transfer in and out of “hot zones” and return home.
Though most firefighters are young and fit, some will inevitably fall ill in these remote makeshift communities of shared showers and portable toilets, where medical care can be limited. The pollutants in the smoke they breathe daily also make them more susceptible to COVID-19 and can worsen the effects of the disease, according to the Centers for Disease Control and Prevention.
Also, one suspected or positive case in a camp will mean many other firefighters will need to be quarantined, unable to work. The worst-case scenario is that multiple outbreaks could hamstring the nation’s ability to respond as wildfire season peaks in August, the hottest and driest month of the year in the western United States.
The number of acres burned so far this year is below the 10-year average, but the fire outlook for August is above average in nine states, according to the National Interagency Fire Center. Twenty-two large fires were ignited on Monday alone after lightning storms passed through the Northwest.
A study published this month by researchers at Colorado State University and the U.S. Forest Service’s Rocky Mountain Research Station concluded that COVID outbreaks “could be a serious threat to the firefighting mission” and urged vigilant social distancing and screening measures in the camps.
“If simultaneous fires incurred outbreaks, the entire wildland response system could be stressed substantially, with a large portion of the workforce quarantined,” the study’s authors wrote.
This spring, the National Wildfire Coordinating Group’s Fire Management Board wrote – and has since been updating – protocols to prevent the spread of COVID-19 in fire camps, based on CDC guidelines. Though they can be adapted by managers at different fires and even by individual team, they center on some key recommendations, including the following:
- Firefighters should be screened for fever and other COVID symptoms when they arrive at camp.
- Every crew should insulate itself as a “module of one” for the fire season and limit interactions with other crews.
- Firefighters should maintain social distancing and wear face coverings when social distancing isn’t possible. Smaller satellite camps, known as spike camps, can be built to ensure enough space.
- Shared areas should be regularly cleaned and disinfected, and sharing tools and radios should be minimized.
The guidance does not include routine testing of newly arrived firefighters – a practice used for athletes at training camps and students returning to college campuses.
The Fire Management Board’s Wildland Fire Medical and Public Health Advisory Team wrote in a July 2 memo that it “does not recommend utilizing universal COVID-19 laboratory testing as a standalone risk mitigation or screening measure among wildland firefighters.” Rather, the group recommends testing an individual and directly exposed coworkers, saying that approach is in line with CDC guidance.
The lack of testing capacity and long turnaround times are factors, according to Forest Service spokesperson Dan Hottle.
The exception is Alaska, where firefighters are tested upon arrival at the airport and are quarantined in a hotel while awaiting results, which come within 24 hours, Mr. Hottle said.
Fire crews responding to early-season fires in the spring had some problems adjusting to the new protocols, according to assessments written by fire leaders and compiled by the Wildland Fire Lessons Learned Center.
Shawn Faiella, superintendent of the interagency “hotshot crew” – so named because they work the most challenging or “hottest” parts of wildfires – based at Montana’s Lolo National Forest, questioned the need to wear masks inside vehicles and the safety of bringing extra vehicles to space out firefighters traveling to a blaze. Parking extra vehicles at the scene of a fire is difficult in tight dirt roads – and would be dangerous if evacuations are necessary, he wrote.
“It’s damn tough to take these practices to the fire line,” Mr. Faiella wrote after his team responded to a 40-acre Montana fire in April.
One recommendation that fire managers say has been particularly effective is the “module of one” concept requiring crews to eat and sleep together in isolation for the entire fire season.
“Whoever came up with it, it is working,” said Mike Goicoechea, the Montana-based incident commander for the Forest Service’s Northern Region Type 1 team, which manages the nation’s largest and most complex wildfires and natural disasters. “Somebody may test positive, and you end up having to take that module out of service for 14 days. But the nice part is you’re not taking out a whole camp. ... It’s just that module.”
The total number of positive COVID cases among wildland firefighters among the various federal, state, local, and tribal agencies is not being tracked. Each fire agency has its own system for tracking and reporting COVID-19, said Jessica Gardetto, a spokesperson for the Bureau of Land Management (BLM) and the National Interagency Fire Center in Idaho.
The largest wildland firefighting agency is the Department of Agriculture’s Forest Service, with 10,000 firefighters. Another major agency is the Department of the Interior, which BLM is part of and which had more than 3,500 full-time fire employees last year. As of the first week of August, 111 Forest Service firefighters and 40 BLM firefighters (who work underneath the broader Interior Department agency) had tested positive for COVID-19, according to officials for the respective agencies.
“Considering we’ve now been experiencing fire activity for several months, this number is surprisingly low if you think about the thousands of fire personnel who’ve been suppressing wildfires this summer,” Ms. Gardetto said.
Mr. Goicoechea and his Montana team traveled north of Tucson, Arizona, on June 22 to manage a rapidly spreading fire in the Santa Catalina Mountains that required 1,200 responders at its peak. Within 2 days of the team’s arrival, his managers were overwhelmed by calls from firefighters worried or with questions about preventing the spread of COVID-19 or carrying the virus home to their families.
In an unusual move, Mr. Goicoechea called upon Montana physician – and former National Park Service ranger with wildfire experience – Harry Sibold, MD, to join the team. Physicians are rarely, if ever, part of a wildfire camp’s medical team, Mr. Goicoechea said.
Dr. Sibold gave regular coronavirus updates during morning briefings, consulted with local health officials, soothed firefighters worried about bringing the virus home to their families, and advised fire managers on how to handle scenarios that might come up.
But Dr. Sibold said he wasn’t optimistic at the beginning about keeping the coronavirus in check in a large camp in Pima County, which has the second-highest number of confirmed cases in Arizona, at the time a national COVID-19 hot spot. “I quite firmly expected that we might have two or three outbreaks,” he said.
There were no positive cases during the team’s 2-week deployment, just three or four cases in which a firefighter showed symptoms but tested negative for the virus. After the Montana team returned home, nine firefighters at the Arizona fire from other units tested positive, Mr. Goicoechea said. Contact tracers notified the Montana team, some of whom were tested. All tests returned negative.
“I can’t say enough about having that doctor to help,” Mr. Goicoechea said, suggesting other teams might consider doing the same. “We’re not the experts in a pandemic. We’re the experts with fire.”
That early success will be tested as the number of fires increases across the West, along with the number of firefighters responding to them. There were more than 15,000 firefighters and support personnel assigned to fires across the nation as of mid-August, and the success of those COVID-19 prevention protocols depend largely on them.
Mr. Paul, the Oregon firefighter, said that the guidelines were followed closely in camp, but less so out on the fire line. It also appeared to him that younger firefighters were less likely to follow the masking and social-distancing rules than the veterans like him. That worried him as he realized it wouldn’t take much to spark an outbreak that could sideline crews and cripple the ability to respond to a fire.
“We’re outside, so it definitely helps with mitigation and makes it simpler to social distance,” Mr. Paul said. “But I think if there’s a mistake made, it could happen.”
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
Jon Paul was leery entering his first wildfire camp of the year late last month to fight three lightning-caused fires scorching parts of a Northern California forest that hadn’t burned in 40 years.
The 54-year-old engine captain from southern Oregon knew from experience that these crowded, grimy camps can be breeding grounds for norovirus and a respiratory illness that firefighters call the “camp crud” in a normal year. He wondered what the coronavirus would do in the tent cities where hundreds of men and women eat, sleep, wash, and spend their downtime between shifts.
Mr. Paul thought about his immunocompromised wife and his 84-year-old mother back home. Then he joined the approximately 1,300 people spread across the Modoc National Forest who would provide a major test for the COVID-prevention measures that had been developed for wildland firefighters.
“We’re still first responders and we have that responsibility to go and deal with these emergencies,” he said in a recent interview. “I don’t scare easy, but I’m very wary and concerned about my surroundings. I’m still going to work and do my job.”
Mr. Paul is one of thousands of firefighters from across the United States battling dozens of wildfires burning throughout the West. It’s an inherently dangerous job that now carries the additional risk of COVID-19 transmission. Any outbreak that ripples through a camp could easily sideline crews and spread the virus across multiple fires – and back to communities across the country – as personnel transfer in and out of “hot zones” and return home.
Though most firefighters are young and fit, some will inevitably fall ill in these remote makeshift communities of shared showers and portable toilets, where medical care can be limited. The pollutants in the smoke they breathe daily also make them more susceptible to COVID-19 and can worsen the effects of the disease, according to the Centers for Disease Control and Prevention.
Also, one suspected or positive case in a camp will mean many other firefighters will need to be quarantined, unable to work. The worst-case scenario is that multiple outbreaks could hamstring the nation’s ability to respond as wildfire season peaks in August, the hottest and driest month of the year in the western United States.
The number of acres burned so far this year is below the 10-year average, but the fire outlook for August is above average in nine states, according to the National Interagency Fire Center. Twenty-two large fires were ignited on Monday alone after lightning storms passed through the Northwest.
A study published this month by researchers at Colorado State University and the U.S. Forest Service’s Rocky Mountain Research Station concluded that COVID outbreaks “could be a serious threat to the firefighting mission” and urged vigilant social distancing and screening measures in the camps.
“If simultaneous fires incurred outbreaks, the entire wildland response system could be stressed substantially, with a large portion of the workforce quarantined,” the study’s authors wrote.
This spring, the National Wildfire Coordinating Group’s Fire Management Board wrote – and has since been updating – protocols to prevent the spread of COVID-19 in fire camps, based on CDC guidelines. Though they can be adapted by managers at different fires and even by individual team, they center on some key recommendations, including the following:
- Firefighters should be screened for fever and other COVID symptoms when they arrive at camp.
- Every crew should insulate itself as a “module of one” for the fire season and limit interactions with other crews.
- Firefighters should maintain social distancing and wear face coverings when social distancing isn’t possible. Smaller satellite camps, known as spike camps, can be built to ensure enough space.
- Shared areas should be regularly cleaned and disinfected, and sharing tools and radios should be minimized.
The guidance does not include routine testing of newly arrived firefighters – a practice used for athletes at training camps and students returning to college campuses.
The Fire Management Board’s Wildland Fire Medical and Public Health Advisory Team wrote in a July 2 memo that it “does not recommend utilizing universal COVID-19 laboratory testing as a standalone risk mitigation or screening measure among wildland firefighters.” Rather, the group recommends testing an individual and directly exposed coworkers, saying that approach is in line with CDC guidance.
The lack of testing capacity and long turnaround times are factors, according to Forest Service spokesperson Dan Hottle.
The exception is Alaska, where firefighters are tested upon arrival at the airport and are quarantined in a hotel while awaiting results, which come within 24 hours, Mr. Hottle said.
Fire crews responding to early-season fires in the spring had some problems adjusting to the new protocols, according to assessments written by fire leaders and compiled by the Wildland Fire Lessons Learned Center.
Shawn Faiella, superintendent of the interagency “hotshot crew” – so named because they work the most challenging or “hottest” parts of wildfires – based at Montana’s Lolo National Forest, questioned the need to wear masks inside vehicles and the safety of bringing extra vehicles to space out firefighters traveling to a blaze. Parking extra vehicles at the scene of a fire is difficult in tight dirt roads – and would be dangerous if evacuations are necessary, he wrote.
“It’s damn tough to take these practices to the fire line,” Mr. Faiella wrote after his team responded to a 40-acre Montana fire in April.
One recommendation that fire managers say has been particularly effective is the “module of one” concept requiring crews to eat and sleep together in isolation for the entire fire season.
“Whoever came up with it, it is working,” said Mike Goicoechea, the Montana-based incident commander for the Forest Service’s Northern Region Type 1 team, which manages the nation’s largest and most complex wildfires and natural disasters. “Somebody may test positive, and you end up having to take that module out of service for 14 days. But the nice part is you’re not taking out a whole camp. ... It’s just that module.”
The total number of positive COVID cases among wildland firefighters among the various federal, state, local, and tribal agencies is not being tracked. Each fire agency has its own system for tracking and reporting COVID-19, said Jessica Gardetto, a spokesperson for the Bureau of Land Management (BLM) and the National Interagency Fire Center in Idaho.
The largest wildland firefighting agency is the Department of Agriculture’s Forest Service, with 10,000 firefighters. Another major agency is the Department of the Interior, which BLM is part of and which had more than 3,500 full-time fire employees last year. As of the first week of August, 111 Forest Service firefighters and 40 BLM firefighters (who work underneath the broader Interior Department agency) had tested positive for COVID-19, according to officials for the respective agencies.
“Considering we’ve now been experiencing fire activity for several months, this number is surprisingly low if you think about the thousands of fire personnel who’ve been suppressing wildfires this summer,” Ms. Gardetto said.
Mr. Goicoechea and his Montana team traveled north of Tucson, Arizona, on June 22 to manage a rapidly spreading fire in the Santa Catalina Mountains that required 1,200 responders at its peak. Within 2 days of the team’s arrival, his managers were overwhelmed by calls from firefighters worried or with questions about preventing the spread of COVID-19 or carrying the virus home to their families.
In an unusual move, Mr. Goicoechea called upon Montana physician – and former National Park Service ranger with wildfire experience – Harry Sibold, MD, to join the team. Physicians are rarely, if ever, part of a wildfire camp’s medical team, Mr. Goicoechea said.
Dr. Sibold gave regular coronavirus updates during morning briefings, consulted with local health officials, soothed firefighters worried about bringing the virus home to their families, and advised fire managers on how to handle scenarios that might come up.
But Dr. Sibold said he wasn’t optimistic at the beginning about keeping the coronavirus in check in a large camp in Pima County, which has the second-highest number of confirmed cases in Arizona, at the time a national COVID-19 hot spot. “I quite firmly expected that we might have two or three outbreaks,” he said.
There were no positive cases during the team’s 2-week deployment, just three or four cases in which a firefighter showed symptoms but tested negative for the virus. After the Montana team returned home, nine firefighters at the Arizona fire from other units tested positive, Mr. Goicoechea said. Contact tracers notified the Montana team, some of whom were tested. All tests returned negative.
“I can’t say enough about having that doctor to help,” Mr. Goicoechea said, suggesting other teams might consider doing the same. “We’re not the experts in a pandemic. We’re the experts with fire.”
That early success will be tested as the number of fires increases across the West, along with the number of firefighters responding to them. There were more than 15,000 firefighters and support personnel assigned to fires across the nation as of mid-August, and the success of those COVID-19 prevention protocols depend largely on them.
Mr. Paul, the Oregon firefighter, said that the guidelines were followed closely in camp, but less so out on the fire line. It also appeared to him that younger firefighters were less likely to follow the masking and social-distancing rules than the veterans like him. That worried him as he realized it wouldn’t take much to spark an outbreak that could sideline crews and cripple the ability to respond to a fire.
“We’re outside, so it definitely helps with mitigation and makes it simpler to social distance,” Mr. Paul said. “But I think if there’s a mistake made, it could happen.”
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
COVID-19: Optimizing therapeutic strategies for children, adolescents with ADHD
Recently, the Yakima Health District (YHD), in collaboration with the Washington State Department of Health, issued dramatic revisions to its educational curriculum, opting for exclusively remote learning as an important next step in COVID-19 containment measures.
The newly implemented “enhanced” distance-learning paradigm has garnered considerable national attention. Even more noteworthy is how YHD addressed those with language barriers and learning differences such as ADHD as a “priority group”; these individuals are exempt from the newly implemented measures, and small instructional groups of no more than five “at-risk” students will be directly supervised by specialized educators.1,2 To overcome these new unprecedented challenges from the coronavirus pandemic, especially from the perspective of distance education and mental health for susceptible groups such as those with ADHD, it is of utmost importance to explore various programs of interest, as well as the targeted therapies being considered during this crisis.
From a therapeutic standpoint, individuals with learning differences are more likely to play catch-up with their age-matched peers. This puts them at significant risk for developmental delays with symptoms manifesting as disruptive behavioral issues. This is why ongoing parental guidance, coupled with a paradoxically stimulating environment, is critical for children and adolescents with ADHD.3 Accumulating evidence, based on a myriad of studies, demonstrates that childhood treatment with ADHD stimulants reduces the incidence of future substance use, as well as that of other negative outcomes.4,5
Therapeutic strategies that work
“The new normal” has forced unique challenges on clinicians for mitigating distress by novel means of health care delivery. Given the paucity of research exploring the interactions of individuals with ADHD within the context of COVID-19, Take for example, the suggested guidelines from the European ADHD Guidelines Group (EAGG) – such as the following:
- Telecommunications in general, and telepsychiatry in particular, should function as the primary mode of health care delivery to fulfill societal standards of physical distancing.
- Children and adolescents with ADHD should be designated as a “priority group” with respect to monitoring initiatives by educators in a school setting, be it virtual or otherwise.
- Implementation of behavioral strategies by parent or guardian to address psychological well-being and reduce the presence of comorbid behavioral conditions (such as oppositional defiant disorder).
In addition to the aforementioned guidance, EAGG maintains that individuals with ADHD may be initiated on medications after the completion of a baseline examination; if the patients in question are already on a treatment regimen, they should proceed with it as indicated. Interruptions to therapy are not ideal because patients are then subjected to health-related stressors of COVID-19. Reasonable regulations concerning access to medications, without unnecessary delays, undoubtedly will facilitate patient needs, allowing for a smooth transition in day-to-day activities. The family, as a cohesive unit, may benefit from reeducation because it contributes toward the therapeutic process. Neurofeedback, coping skills, and cognitive restructuring training are potential modalities that can augment medications.
Although it may seem counterintuitive, parents or caregivers should resist the urge to increase the medication dose during an outbreak with the intended goal of diminishing the psychosocial burden of ADHD symptomatology. Likewise, unless indicated by a specialist, antipsychotics and/or hypnotics should not be introduced for addressing behavioral dysregulation (such as agitation) during the confinement period.
Historically, numerous clinicians have suggested that patients undergo a routine cardiovascular examination and EKG before being prescribed psychostimulants (the rationale for this recommendation is that sympathomimetics unduly affect blood pressure and heart rate).6,7 However, the American Academy of Pediatrics (AAP) and the American Heart Association (AHA) eventually amended their previous stance by releasing a joint statement in which they deemed a baseline EKG necessary only in ADHD patients with preexisting cardiac risk. For all other patients, the use of EKGs was entirely contingent on physician discretion. However, given the nature of safety precautions for COVID-19, it is prudent to discourage or delay in-person cardiovascular examination/monitoring protocols altogether, especially in those patients without known heart conditions.
Another area of concern is sleep dysfunction, which might exist as an untoward effect of ADHD medication intake or because of the presence of COVID-19 psychosocial stressors. However, clinicians advise that unnecessary psychopharmacology (such as hypnotics or melatonin) be avoided. Instead, conservative lifestyle measures should be enacted, emphasizing the role of proper sleep hygiene in maintaining optimal behavioral health. Despite setbacks to in-person appointments, patients are expected to continue their pharmacotherapy with “parent-focused” ADHD interventions taking a primary role in facilitating compliance through remote monitoring.
ADMiRE, a tertiary-level, dedicated ADHD intervention program from South Dublin, Ireland, has identified several roadblocks with respect to streamlining health care for individuals with ADHD during the confinement period. The proposed resolution to these issues, some of which are derived from EAGG guidelines, might have universal applications elsewhere, thereby facilitating the development of therapeutic services of interest. ADMiRE has noted a correspondence between the guidelines established by EAGG and that of the Canadian ADHD Resource Alliance (CADDRA), including minimal in-person interactions (in favor of virtual teleconferencing) and a cardiovascular screen can be performed in lieu of baseline cardiac auscultation. Moreover, in the event that the patient is a low cardiac risk candidate for ADHD treatment, monitoring protocols may be continued from a home setting. However, if a physical examination is indicated, CADDRA recommends the use of precautionary PPE before commencing ADHD pharmacotherapy.
One of the most significant hurdles is that of school closures because teacher feedback for baseline behavior was traditionally instrumental in dictating patient medical management (for example, for titration schedule). It is expected that, for the time being, this role will be supplanted by parental reports. As well as disclosing information on behavioral dysregulation, family members should be trained to relay critical information about the development of stimulant-induced cardiovascular symptoms – namely, dyspnea, chest pain, and/or palpitations. Furthermore, as primary caregivers, parents should harbor a certain degree of emotional sensitivity because their mood state may influence the child’s overall behavioral course in terms of symptom exacerbation.8
Toward adopting an integrated model for care
Developing an effective assessment plan for patients with ADHD often proves to be a challenging task for clinicians, perhaps even more so in environments that enforce social distancing and limited physical contact by default. As a neurodevelopmental disorder from childhood, the symptoms (including inattention, hyperactivity, and/or impulsivity) of ADHD do not arise in a vacuum – comorbid conditions include mood and anxiety disorders, which are complicated further by a background risk for substance use and self-medicating tendencies.9 Unfortunately, the pandemic has limited the breadth of non-COVID doctors visits, which hinders the overall diagnostic and monitoring process for identifiable comorbid conditions, such as autism spectrum disorder, intellectual disability, oppositional defiant and conduct disorders, and so on.10 Since ADHD symptoms cannot be treated by pharmacotherapy or behavioral interventions alone, our team advocates that families provide additional emotional support and continuous encouragement during these uncertain times.
ADHD and the self-medication hypothesis
The Khantzian self-medication hypothesis posits that a drug seeker may subconsciously gravitate toward a particular agent only to discover a sense of relief concerning inner turmoil or restlessness after use. Observations support the notion that individuals with undiagnosed ADHD have sought cocaine or even recreational designer drugs (such as methylenedioxypyrovalerone, or “bath salts”).11 Given the similar mechanism of action between cocaine, methylenedioxypyrovalerone, and prescribed psychostimulants such as methylphenidate, the results are hardly surprising because these agents all work on the brain’s “reward center” (for example, the nucleus accumbens) by invoking dopamine release. Aside from the aforementioned self-medication hypothesis, “downers” such as Xanax recently have experienced a prescription spike during the outbreak. While there isn’t an immediate cause for concern of Xanax abuse in ADHD individuals, the potential for addiction is certainly real, especially when taking into account comorbid anxiety disorder or sleep dysfunction.
Because of limited resources and precautionary guidelines, clinicians are at a considerable disadvantage in terms of formulating a comprehensive diagnostic and treatment plan for children and adolescents with ADHD. This situation is further compounded by the recent closure of schools and the lack of feedback with respect to baseline behavior from teachers and specialized educators. This is why it is imperative for primary caregivers to closely monitor children with ADHD for developing changes in behavioral patterns (for example, mood or anxiety issues and drug-seeking or disruptive behavior) and work with health care professionals.
References
1. “Distance learning strongly recommended for all Yakima county schools.” NBC Right Now. 2020 Aug 5.
2. Retka J. “Enhanced” remote learning in Yakima county schools? What that means for students this fall. Yakima Herald-Republic. 2020 Aug 8.
3. Armstrong T. “To empower! Not Control! A holistic approach to ADHD.” American Institute for Learning and Development. 1998.
4. J Child Psychol Psychiatry. 2014 Aug;55(8):878-85.
5. Ir J Psychol Med. 2020 May 21:1-22.
6. Lancet Child Adolesc Health. 2020 Jun;4(6):412-4.
7. O’Keefe L. AAP News. 2008 Jun;29(6):1.
8. Asian J Psychiatr. 2020 Jun;51:102077.
9. Current Psychiatry. 2015 Dec;14(12):e3-4.
10. Encephale. 2020 Jun 7;46(3S):S85-92.
11. Current Psychiatry. 2014 Dec; 3(12): e3-4.
Dr. Islam is a medical adviser for the International Maternal and Child Health Foundation (IMCHF), Montreal, and is based in New York. He also is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Islam disclosed no relevant financial relationships. Zaid Ulhaq Choudhry is a research assistant at the IMCHF. He has no disclosures. Dr. Zia Choudhry is the chief scientific officer and head of the department of mental health and clini-cal research at the IMCHF and is Mr. Choudhry’s father. He has no disclosures.
Recently, the Yakima Health District (YHD), in collaboration with the Washington State Department of Health, issued dramatic revisions to its educational curriculum, opting for exclusively remote learning as an important next step in COVID-19 containment measures.
The newly implemented “enhanced” distance-learning paradigm has garnered considerable national attention. Even more noteworthy is how YHD addressed those with language barriers and learning differences such as ADHD as a “priority group”; these individuals are exempt from the newly implemented measures, and small instructional groups of no more than five “at-risk” students will be directly supervised by specialized educators.1,2 To overcome these new unprecedented challenges from the coronavirus pandemic, especially from the perspective of distance education and mental health for susceptible groups such as those with ADHD, it is of utmost importance to explore various programs of interest, as well as the targeted therapies being considered during this crisis.
From a therapeutic standpoint, individuals with learning differences are more likely to play catch-up with their age-matched peers. This puts them at significant risk for developmental delays with symptoms manifesting as disruptive behavioral issues. This is why ongoing parental guidance, coupled with a paradoxically stimulating environment, is critical for children and adolescents with ADHD.3 Accumulating evidence, based on a myriad of studies, demonstrates that childhood treatment with ADHD stimulants reduces the incidence of future substance use, as well as that of other negative outcomes.4,5
Therapeutic strategies that work
“The new normal” has forced unique challenges on clinicians for mitigating distress by novel means of health care delivery. Given the paucity of research exploring the interactions of individuals with ADHD within the context of COVID-19, Take for example, the suggested guidelines from the European ADHD Guidelines Group (EAGG) – such as the following:
- Telecommunications in general, and telepsychiatry in particular, should function as the primary mode of health care delivery to fulfill societal standards of physical distancing.
- Children and adolescents with ADHD should be designated as a “priority group” with respect to monitoring initiatives by educators in a school setting, be it virtual or otherwise.
- Implementation of behavioral strategies by parent or guardian to address psychological well-being and reduce the presence of comorbid behavioral conditions (such as oppositional defiant disorder).
In addition to the aforementioned guidance, EAGG maintains that individuals with ADHD may be initiated on medications after the completion of a baseline examination; if the patients in question are already on a treatment regimen, they should proceed with it as indicated. Interruptions to therapy are not ideal because patients are then subjected to health-related stressors of COVID-19. Reasonable regulations concerning access to medications, without unnecessary delays, undoubtedly will facilitate patient needs, allowing for a smooth transition in day-to-day activities. The family, as a cohesive unit, may benefit from reeducation because it contributes toward the therapeutic process. Neurofeedback, coping skills, and cognitive restructuring training are potential modalities that can augment medications.
Although it may seem counterintuitive, parents or caregivers should resist the urge to increase the medication dose during an outbreak with the intended goal of diminishing the psychosocial burden of ADHD symptomatology. Likewise, unless indicated by a specialist, antipsychotics and/or hypnotics should not be introduced for addressing behavioral dysregulation (such as agitation) during the confinement period.
Historically, numerous clinicians have suggested that patients undergo a routine cardiovascular examination and EKG before being prescribed psychostimulants (the rationale for this recommendation is that sympathomimetics unduly affect blood pressure and heart rate).6,7 However, the American Academy of Pediatrics (AAP) and the American Heart Association (AHA) eventually amended their previous stance by releasing a joint statement in which they deemed a baseline EKG necessary only in ADHD patients with preexisting cardiac risk. For all other patients, the use of EKGs was entirely contingent on physician discretion. However, given the nature of safety precautions for COVID-19, it is prudent to discourage or delay in-person cardiovascular examination/monitoring protocols altogether, especially in those patients without known heart conditions.
Another area of concern is sleep dysfunction, which might exist as an untoward effect of ADHD medication intake or because of the presence of COVID-19 psychosocial stressors. However, clinicians advise that unnecessary psychopharmacology (such as hypnotics or melatonin) be avoided. Instead, conservative lifestyle measures should be enacted, emphasizing the role of proper sleep hygiene in maintaining optimal behavioral health. Despite setbacks to in-person appointments, patients are expected to continue their pharmacotherapy with “parent-focused” ADHD interventions taking a primary role in facilitating compliance through remote monitoring.
ADMiRE, a tertiary-level, dedicated ADHD intervention program from South Dublin, Ireland, has identified several roadblocks with respect to streamlining health care for individuals with ADHD during the confinement period. The proposed resolution to these issues, some of which are derived from EAGG guidelines, might have universal applications elsewhere, thereby facilitating the development of therapeutic services of interest. ADMiRE has noted a correspondence between the guidelines established by EAGG and that of the Canadian ADHD Resource Alliance (CADDRA), including minimal in-person interactions (in favor of virtual teleconferencing) and a cardiovascular screen can be performed in lieu of baseline cardiac auscultation. Moreover, in the event that the patient is a low cardiac risk candidate for ADHD treatment, monitoring protocols may be continued from a home setting. However, if a physical examination is indicated, CADDRA recommends the use of precautionary PPE before commencing ADHD pharmacotherapy.
One of the most significant hurdles is that of school closures because teacher feedback for baseline behavior was traditionally instrumental in dictating patient medical management (for example, for titration schedule). It is expected that, for the time being, this role will be supplanted by parental reports. As well as disclosing information on behavioral dysregulation, family members should be trained to relay critical information about the development of stimulant-induced cardiovascular symptoms – namely, dyspnea, chest pain, and/or palpitations. Furthermore, as primary caregivers, parents should harbor a certain degree of emotional sensitivity because their mood state may influence the child’s overall behavioral course in terms of symptom exacerbation.8
Toward adopting an integrated model for care
Developing an effective assessment plan for patients with ADHD often proves to be a challenging task for clinicians, perhaps even more so in environments that enforce social distancing and limited physical contact by default. As a neurodevelopmental disorder from childhood, the symptoms (including inattention, hyperactivity, and/or impulsivity) of ADHD do not arise in a vacuum – comorbid conditions include mood and anxiety disorders, which are complicated further by a background risk for substance use and self-medicating tendencies.9 Unfortunately, the pandemic has limited the breadth of non-COVID doctors visits, which hinders the overall diagnostic and monitoring process for identifiable comorbid conditions, such as autism spectrum disorder, intellectual disability, oppositional defiant and conduct disorders, and so on.10 Since ADHD symptoms cannot be treated by pharmacotherapy or behavioral interventions alone, our team advocates that families provide additional emotional support and continuous encouragement during these uncertain times.
ADHD and the self-medication hypothesis
The Khantzian self-medication hypothesis posits that a drug seeker may subconsciously gravitate toward a particular agent only to discover a sense of relief concerning inner turmoil or restlessness after use. Observations support the notion that individuals with undiagnosed ADHD have sought cocaine or even recreational designer drugs (such as methylenedioxypyrovalerone, or “bath salts”).11 Given the similar mechanism of action between cocaine, methylenedioxypyrovalerone, and prescribed psychostimulants such as methylphenidate, the results are hardly surprising because these agents all work on the brain’s “reward center” (for example, the nucleus accumbens) by invoking dopamine release. Aside from the aforementioned self-medication hypothesis, “downers” such as Xanax recently have experienced a prescription spike during the outbreak. While there isn’t an immediate cause for concern of Xanax abuse in ADHD individuals, the potential for addiction is certainly real, especially when taking into account comorbid anxiety disorder or sleep dysfunction.
Because of limited resources and precautionary guidelines, clinicians are at a considerable disadvantage in terms of formulating a comprehensive diagnostic and treatment plan for children and adolescents with ADHD. This situation is further compounded by the recent closure of schools and the lack of feedback with respect to baseline behavior from teachers and specialized educators. This is why it is imperative for primary caregivers to closely monitor children with ADHD for developing changes in behavioral patterns (for example, mood or anxiety issues and drug-seeking or disruptive behavior) and work with health care professionals.
References
1. “Distance learning strongly recommended for all Yakima county schools.” NBC Right Now. 2020 Aug 5.
2. Retka J. “Enhanced” remote learning in Yakima county schools? What that means for students this fall. Yakima Herald-Republic. 2020 Aug 8.
3. Armstrong T. “To empower! Not Control! A holistic approach to ADHD.” American Institute for Learning and Development. 1998.
4. J Child Psychol Psychiatry. 2014 Aug;55(8):878-85.
5. Ir J Psychol Med. 2020 May 21:1-22.
6. Lancet Child Adolesc Health. 2020 Jun;4(6):412-4.
7. O’Keefe L. AAP News. 2008 Jun;29(6):1.
8. Asian J Psychiatr. 2020 Jun;51:102077.
9. Current Psychiatry. 2015 Dec;14(12):e3-4.
10. Encephale. 2020 Jun 7;46(3S):S85-92.
11. Current Psychiatry. 2014 Dec; 3(12): e3-4.
Dr. Islam is a medical adviser for the International Maternal and Child Health Foundation (IMCHF), Montreal, and is based in New York. He also is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Islam disclosed no relevant financial relationships. Zaid Ulhaq Choudhry is a research assistant at the IMCHF. He has no disclosures. Dr. Zia Choudhry is the chief scientific officer and head of the department of mental health and clini-cal research at the IMCHF and is Mr. Choudhry’s father. He has no disclosures.
Recently, the Yakima Health District (YHD), in collaboration with the Washington State Department of Health, issued dramatic revisions to its educational curriculum, opting for exclusively remote learning as an important next step in COVID-19 containment measures.
The newly implemented “enhanced” distance-learning paradigm has garnered considerable national attention. Even more noteworthy is how YHD addressed those with language barriers and learning differences such as ADHD as a “priority group”; these individuals are exempt from the newly implemented measures, and small instructional groups of no more than five “at-risk” students will be directly supervised by specialized educators.1,2 To overcome these new unprecedented challenges from the coronavirus pandemic, especially from the perspective of distance education and mental health for susceptible groups such as those with ADHD, it is of utmost importance to explore various programs of interest, as well as the targeted therapies being considered during this crisis.
From a therapeutic standpoint, individuals with learning differences are more likely to play catch-up with their age-matched peers. This puts them at significant risk for developmental delays with symptoms manifesting as disruptive behavioral issues. This is why ongoing parental guidance, coupled with a paradoxically stimulating environment, is critical for children and adolescents with ADHD.3 Accumulating evidence, based on a myriad of studies, demonstrates that childhood treatment with ADHD stimulants reduces the incidence of future substance use, as well as that of other negative outcomes.4,5
Therapeutic strategies that work
“The new normal” has forced unique challenges on clinicians for mitigating distress by novel means of health care delivery. Given the paucity of research exploring the interactions of individuals with ADHD within the context of COVID-19, Take for example, the suggested guidelines from the European ADHD Guidelines Group (EAGG) – such as the following:
- Telecommunications in general, and telepsychiatry in particular, should function as the primary mode of health care delivery to fulfill societal standards of physical distancing.
- Children and adolescents with ADHD should be designated as a “priority group” with respect to monitoring initiatives by educators in a school setting, be it virtual or otherwise.
- Implementation of behavioral strategies by parent or guardian to address psychological well-being and reduce the presence of comorbid behavioral conditions (such as oppositional defiant disorder).
In addition to the aforementioned guidance, EAGG maintains that individuals with ADHD may be initiated on medications after the completion of a baseline examination; if the patients in question are already on a treatment regimen, they should proceed with it as indicated. Interruptions to therapy are not ideal because patients are then subjected to health-related stressors of COVID-19. Reasonable regulations concerning access to medications, without unnecessary delays, undoubtedly will facilitate patient needs, allowing for a smooth transition in day-to-day activities. The family, as a cohesive unit, may benefit from reeducation because it contributes toward the therapeutic process. Neurofeedback, coping skills, and cognitive restructuring training are potential modalities that can augment medications.
Although it may seem counterintuitive, parents or caregivers should resist the urge to increase the medication dose during an outbreak with the intended goal of diminishing the psychosocial burden of ADHD symptomatology. Likewise, unless indicated by a specialist, antipsychotics and/or hypnotics should not be introduced for addressing behavioral dysregulation (such as agitation) during the confinement period.
Historically, numerous clinicians have suggested that patients undergo a routine cardiovascular examination and EKG before being prescribed psychostimulants (the rationale for this recommendation is that sympathomimetics unduly affect blood pressure and heart rate).6,7 However, the American Academy of Pediatrics (AAP) and the American Heart Association (AHA) eventually amended their previous stance by releasing a joint statement in which they deemed a baseline EKG necessary only in ADHD patients with preexisting cardiac risk. For all other patients, the use of EKGs was entirely contingent on physician discretion. However, given the nature of safety precautions for COVID-19, it is prudent to discourage or delay in-person cardiovascular examination/monitoring protocols altogether, especially in those patients without known heart conditions.
Another area of concern is sleep dysfunction, which might exist as an untoward effect of ADHD medication intake or because of the presence of COVID-19 psychosocial stressors. However, clinicians advise that unnecessary psychopharmacology (such as hypnotics or melatonin) be avoided. Instead, conservative lifestyle measures should be enacted, emphasizing the role of proper sleep hygiene in maintaining optimal behavioral health. Despite setbacks to in-person appointments, patients are expected to continue their pharmacotherapy with “parent-focused” ADHD interventions taking a primary role in facilitating compliance through remote monitoring.
ADMiRE, a tertiary-level, dedicated ADHD intervention program from South Dublin, Ireland, has identified several roadblocks with respect to streamlining health care for individuals with ADHD during the confinement period. The proposed resolution to these issues, some of which are derived from EAGG guidelines, might have universal applications elsewhere, thereby facilitating the development of therapeutic services of interest. ADMiRE has noted a correspondence between the guidelines established by EAGG and that of the Canadian ADHD Resource Alliance (CADDRA), including minimal in-person interactions (in favor of virtual teleconferencing) and a cardiovascular screen can be performed in lieu of baseline cardiac auscultation. Moreover, in the event that the patient is a low cardiac risk candidate for ADHD treatment, monitoring protocols may be continued from a home setting. However, if a physical examination is indicated, CADDRA recommends the use of precautionary PPE before commencing ADHD pharmacotherapy.
One of the most significant hurdles is that of school closures because teacher feedback for baseline behavior was traditionally instrumental in dictating patient medical management (for example, for titration schedule). It is expected that, for the time being, this role will be supplanted by parental reports. As well as disclosing information on behavioral dysregulation, family members should be trained to relay critical information about the development of stimulant-induced cardiovascular symptoms – namely, dyspnea, chest pain, and/or palpitations. Furthermore, as primary caregivers, parents should harbor a certain degree of emotional sensitivity because their mood state may influence the child’s overall behavioral course in terms of symptom exacerbation.8
Toward adopting an integrated model for care
Developing an effective assessment plan for patients with ADHD often proves to be a challenging task for clinicians, perhaps even more so in environments that enforce social distancing and limited physical contact by default. As a neurodevelopmental disorder from childhood, the symptoms (including inattention, hyperactivity, and/or impulsivity) of ADHD do not arise in a vacuum – comorbid conditions include mood and anxiety disorders, which are complicated further by a background risk for substance use and self-medicating tendencies.9 Unfortunately, the pandemic has limited the breadth of non-COVID doctors visits, which hinders the overall diagnostic and monitoring process for identifiable comorbid conditions, such as autism spectrum disorder, intellectual disability, oppositional defiant and conduct disorders, and so on.10 Since ADHD symptoms cannot be treated by pharmacotherapy or behavioral interventions alone, our team advocates that families provide additional emotional support and continuous encouragement during these uncertain times.
ADHD and the self-medication hypothesis
The Khantzian self-medication hypothesis posits that a drug seeker may subconsciously gravitate toward a particular agent only to discover a sense of relief concerning inner turmoil or restlessness after use. Observations support the notion that individuals with undiagnosed ADHD have sought cocaine or even recreational designer drugs (such as methylenedioxypyrovalerone, or “bath salts”).11 Given the similar mechanism of action between cocaine, methylenedioxypyrovalerone, and prescribed psychostimulants such as methylphenidate, the results are hardly surprising because these agents all work on the brain’s “reward center” (for example, the nucleus accumbens) by invoking dopamine release. Aside from the aforementioned self-medication hypothesis, “downers” such as Xanax recently have experienced a prescription spike during the outbreak. While there isn’t an immediate cause for concern of Xanax abuse in ADHD individuals, the potential for addiction is certainly real, especially when taking into account comorbid anxiety disorder or sleep dysfunction.
Because of limited resources and precautionary guidelines, clinicians are at a considerable disadvantage in terms of formulating a comprehensive diagnostic and treatment plan for children and adolescents with ADHD. This situation is further compounded by the recent closure of schools and the lack of feedback with respect to baseline behavior from teachers and specialized educators. This is why it is imperative for primary caregivers to closely monitor children with ADHD for developing changes in behavioral patterns (for example, mood or anxiety issues and drug-seeking or disruptive behavior) and work with health care professionals.
References
1. “Distance learning strongly recommended for all Yakima county schools.” NBC Right Now. 2020 Aug 5.
2. Retka J. “Enhanced” remote learning in Yakima county schools? What that means for students this fall. Yakima Herald-Republic. 2020 Aug 8.
3. Armstrong T. “To empower! Not Control! A holistic approach to ADHD.” American Institute for Learning and Development. 1998.
4. J Child Psychol Psychiatry. 2014 Aug;55(8):878-85.
5. Ir J Psychol Med. 2020 May 21:1-22.
6. Lancet Child Adolesc Health. 2020 Jun;4(6):412-4.
7. O’Keefe L. AAP News. 2008 Jun;29(6):1.
8. Asian J Psychiatr. 2020 Jun;51:102077.
9. Current Psychiatry. 2015 Dec;14(12):e3-4.
10. Encephale. 2020 Jun 7;46(3S):S85-92.
11. Current Psychiatry. 2014 Dec; 3(12): e3-4.
Dr. Islam is a medical adviser for the International Maternal and Child Health Foundation (IMCHF), Montreal, and is based in New York. He also is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Islam disclosed no relevant financial relationships. Zaid Ulhaq Choudhry is a research assistant at the IMCHF. He has no disclosures. Dr. Zia Choudhry is the chief scientific officer and head of the department of mental health and clini-cal research at the IMCHF and is Mr. Choudhry’s father. He has no disclosures.