TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.
This week’s topics include persistent COVID-19 symptoms, testing for COVID in long term care facilities, the mRNA vaccine for COVID, and perceptions of CPR.
0:37 First COVID vaccine
1:36 Same level of antibody as natural infection
2:37 Novel vaccine
3:12 Long term symptoms of COVID
4:12 Some ventilated some not
5:12 Neurologic and cardiac sequelae
6:16 Testing for COVID in long term care facilities
7:18 900 received testing
8:20 Hotspot testing
9:05 What people think about CPR
10:06 64% had done a CPR course
11:07 Talk about advance directives
12:10 Where to discuss?
Elizabeth Tracey: What symptoms persist after acute COVID-19 infection?
Rick Lange: Preliminary report of a COVID vaccine.
Elizabeth: What do people think are likely outcomes following CPR?
Rick: And detecting COVID in long-term care facilities.
Elizabeth: That’s what we’re talking about this week on TT HealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: And I’m Rick Lange, President of the Texas Tech University Health Sciences Center in El Paso, where I’m also Dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, hot off the press, early results of the first COVID-19 vaccine and it’s all yours. That’s in the New England Journal of Medicine.
Rick: Elizabeth, several weeks ago we alluded to it because there was a preliminary report, but the study had not been published. We told our listeners that when it became available we’d present the information, and so it is.
This is a report of what’s called an mRNA vaccine that encodes the spike protein on the virus and that’s the protein that mediates the attaching to the cell and entry into the cell. They took 45 healthy individuals between the ages of 18 and 55, and provided them one of three doses — either 25, 50, or 100 mcg — at 2 different vaccinations, day 1 and they gave it again at day 28. After the second vaccine, essentially all individuals had detectable neutralizing antibody. Actually when they looked at the level of it and compared it to people that had previously been infected, the antibody in response to the vaccine was the same level as those that had actually had infection previously.
Then they looked at the side effects, and after the first dose there were very few individuals that had any side effects. But after the second dose, a larger number of individuals had side effects, particularly in the higher dose. Most of them were relatively minor. Some people developed fevers, chills, fatigue, kind of in the moderate to severe range.
This is really good news and this is going to spark additional studies. They’re taking it to the phase II trials with 600 individuals, looking at safety, and then finally they’ll bring it to several tens of thousands of individuals as early as this summer.
Elizabeth: Right. That’s what I understand. I think that it’s really novel, of course. This will be — if it becomes licensed and it’s out there for the general public — the first mRNA vaccine that’s out there.
Rick: It is. The reason why they could bring it so quickly to market is because we have previous experience with the coronavirus, with MERS and SARS. The genome was identified early on in January. This is one of, I believe, two mRNA vaccines that will be tested.
Elizabeth: I just think it’s going to be really interesting to see this, since it’s a totally novel kind of a vaccine. The other thing that I’m wondering about is if we’re going to see one of those accelerated responses to actual infection under these circumstances and I don’t think we know the answer to that one.
Rick: No. I mean, it could accelerate the immune response and cause overactivation. In some studies, the vaccines actually accelerated the risk of secondary pneumonias. A lot of things unknown, but again, huge credit to the scientific community for bringing this to studies in such a short period of time.
Elizabeth: Indeed, and we’re watching, of course. Let’s turn to the Journal of the American Medical Association. This is a research letter on a topic that’s getting a lot of attention and that is, “What are the sequelae of acute COVID-19 infection or the persistent symptoms in this case?”
This was a group of patients from Italy. I’m a little jealous because in their methods they say, “In the waning phase of their pandemic beginning on April 21st,” and of course, here in the U.S. we can’t make any kind of a prognostication relative to waning pandemic.
They included all patients who met WHO criteria for discontinuation of quarantine, improvement of other symptoms, and two negative test results for SARS-CoV-2. They had a comprehensive medical assessment and they said, “Well, what is going on with you? What do you still have?” Initially, it looked like they had 179 patients. They included results on 143. They found some things about — their length of stay in the hospital was just shy of 2 weeks, some on non-invasive ventilation, and some on invasive who were intubated.
The patients were assessed a mean of just about 2 months after the onset of their symptoms. At that time, only 12.6% were completely free of any COVID-19-related symptom, while a third of them had one to two symptoms and more than half had three or more.
Okay. Well, what were the major things that they complained of? They were fatigue, shortness of breath, and joint pain, chest pain, and cough that were still persistent. Some of them still had a persistent loss of their sense of smell and then there were a number of other symptoms that kind of followed on down.
Some of these were just things that I would have expected. I mean, when we see people who have acute viral infections, we do see persistent symptoms. I’ve complained of them to you myself a long time after I’ve had a URI.
So I think some of the sequelae that I really am most concerned about are some of the neurologic sequelae and also some of the cardiac sequelae that we’re not reporting on this week but that are starting to emerge in the literature.
Rick: This is the first I am aware of that looked in a large population about the presence of persistent symptoms. This is 5 weeks after discharge, and you’d expect, maybe an occasional person would have some persistent symptoms. But in this particular study, 88% of people that were COVID-infected still had symptoms, an overwhelmingly large percentage with more than one symptom.
Fortunately, the ones that are considered to be most severe — that is the cardiac and neurologic symptoms that you mentioned — weren’t reported in this particular trial, but they appear to be relatively uncommon. But I think what most of our listeners need to realize is there’s especially the younger population feels like, “Oh, I can go out and get COVID infection and I’m not likely to die of it.” Well, you may not die, because you may not have many risk factors, but you may not recover for a long period of time. You may not recover fully, by the way.
Elizabeth: Yeah, I know. Some of the lung abnormalities or shortness of breath that people have been reporting has persisted for months afterwards, even in people who were previously extremely healthy.
Let’s turn to your other one, since we’re trying to do all the COVID material first. It’s in JAMA Internal Medicine and this is looking at universal COVID-19 testing in long term care facilities.
Rick: We’ve talked before about the fact that residents in these long-term care facilities are at a particularly high risk of not only getting infected, but having a poor outcome when they do develop a COVID infection.
It’s interesting. Early in the course of the pandemic, the CDC recommended testing residents and staff of these long-term facilities based upon the presence of typical symptoms. Obviously, there was some concern about how many individuals could be asymptomatic. To address that, this was a study that did universal testing of all long term care facility residents at 11 Maryland facilities.
What prompted this testing was there were some residents and staff that had typical symptoms, so they tested those, but then they decided just to test everybody regardless of whether there were symptoms or not. They had almost 900 individuals that received testing.
What they found out was that 40% of those individuals actually tested positive for the COVID virus. When they looked at those individuals, about 80% were asymptomatic. And, by the way, when they followed them for the next 2 weeks, they continued to be asymptomatic.
Elizabeth: Clearly, as the pandemic rages on, and as we keep ramping up more and more and more folks here in the United States who are becoming infected, we are experiencing even more acute issues relative to testing.
One of the questions I have with regard to testing of everyone in a long term care facility is, “Really? We can’t even test people who are coming forward and who are symptomatic.” The other thing is, it’s not free. I mean, it costs some money to be able to do these things and especially to continue to do it as things go on.
Rick: We have to admit that if we have limited testing we’re going to use that testing in what we consider to be “hotspots.” I would submit to you that long term care facilities are definitely a hotspot for COVID infection and a hotspot for mortality as well. I think you look at this as a hotspot and you can’t test in these facilities solely on the basis of symptoms. You’re going to miss the vast number of individuals that are infected.
Elizabeth: I think all of this points to — I saw a development yesterday that I thought was really pretty good — MIT et al. having a paper-based assay that’s really simple, that’s point-of-care, and that looks like it could be both sensitive and specific. That’s something that we really desperately need and it’s frankly surprising to me that we don’t have it after all these months into this whole situation.
Rick: I would agree. Accurate point-of-care testing is really important and I think it will be vital if we’re actually going to do our best to mitigate — that is, to contain viral spread.
Elizabeth: Finally, let’s turn to the British Medical Journal, a favorite topic of mine, which is, “What in the world do people think CPR is going to do for them anyway?” That’s my parenthetical look at this particular study.
This one was unique in that what they did was assess the beliefs of people who presented at an emergency department toward, “What are the likely outcomes of CPR?” This included both the putative patient who was waiting, as well as their family members or their loved ones who were with them.
What they did was conduct a survey in the waiting area in the ED of a tertiary care hospital between June and September of 2016. They developed a really interesting assessment tool themselves in order to be able to look at, “Well, what do you think is going to be the likely outcome of CPR if you have to have it and do you want it?”
What they found in these 500 respondents was that 53% of them had previously performed or witnessed CPR and/or had participated in a CPR course, which was 64% of those folks. They predicted in toto that the success rate of CPR was over 75% in all situations. And 90% of them said they wanted to receive CPR, although interestingly that was stratified according to age, with those older than 70 actually saying fewer of them actually wanted to receive CPR, but it was still the majority.
This is in spite of the fact that only 12% of out-of-hospital cardiac arrest and 24% to 40% of in-hospital arrests are successful in that the patient survives when CPR is administered. Also, I would note that they all revealed that the majority of their information relative to the success rate of CPR was from television.
Rick: You say, “Well, why would you even care about what they think about CPR?” That is because the emergency department is oftentimes where you talk to people about their advance directives. If people have an overestimate of the value of CPR or underestimate the morbidity, of course everybody’s going to want it. These people overestimate the value of CPR, and interestingly enough, even in those individuals that said that they had had training or were part of the healthcare profession.
I think back to the CPR training I’ve had with the American Heart Association or the American Red Cross, and it tells you how to do it, but it never sits down and tells you what the long-term outcomes are. That’s an educational gap.
Now, the next step is, based upon this information, would anybody change their advance directives?
Elizabeth: The other thing that this study does was they asked, “Would you like to discuss this? Have you discussed this with your healthcare provider?” The majority of folks said, “Yeah, you know what? I haven’t. I would welcome that opportunity.”
I think it does point to a clear direction for the need — as we’ve talked about before — for people to really take a look at this in a comprehensive and open fashion before they get into a situation where there’s critical illness, there’s all of the emotions, and all the craziness that surrounds that.
Rick: Elizabeth, where would you suggest that be done? I mean, I see patients in clinic. I’m not going to walk in and say, “Hi, I’m Dr. Lange. I’m going to be your cardiologist. Let’s talk about advanced directives and whether you think CPR is successful or not.” Where do you think it would have the greatest impact?
Elizabeth: I think that all primary care physicians should talk with their patients about advanced directives. I think that we also need to engage other social situations where people would really think about that.
Because bearing witness to what I regard often as futile care that, in my mind, really prolongs suffering, it would be my fervent wish that people would really take a look at this stuff ahead of time when they can think calmly and weigh what their options are.
Rick: You mentioned the fact that most people get their information from television. On television, the article mentions the fact that somewhere between 20% and 75% of the time CPR is performed on television it’s successful. When you see that, you think, “Well, gosh. It is successful,” and that people come back and have a fruitful and meaningful life.
Elizabeth: The other thing that’s not included in this particular data is you might survive, but do you survive neurologically intact? That reduces those numbers quite a bit.
On that note then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.