While the strain of COVID-19 has lessened in some countries, the long-term health effects of the disease and the collapse of healthcare systems around the world is a clear reminder that the pandemic’s impact carries on. Simultaneously, Northwestern Medicine investigators continue to assess COVID-19 treatments for mild to severe cases, the widespread adoption of telemedicine, and why a “return to normal” would be a missed opportunity to use knowledge gained from the previous year to improve healthcare.
Evaluating Current Treatments for COVID-19
Compared to the beginning of the pandemic, treating COVID-19 has become less of a trial-and-error effort, thanks in large part to the scientific community’s continuous study of novel therapeutic interventions in reducing mortality for patients hospitalized with mild to severe COVID-19. Further research about these therapies will be essential to best treat patients as the pandemic continues, according to a Northwestern Medicine editorial published in The BMJ.
“It’s been a little over a year since the pandemic was officially declared. A lot of scientific advances have been made since that time and there have been many studies looking for the magic bullet for severe COVID-19. Though there is still no curative agent, we have much more than we started off with. It is important at this time to review the data to re-evaluate how we treat COVID moving forward,” said Khalilah Gates, MD, assistant dean of Medical Education, assistant professor of Medicine in the Division of Pulmonary and Critical Care and a co-author of the editorial.
One effective treatment is glucocorticoids, more commonly known as steroids such as dexamethasone and prednisone. Glucocorticoids shut down the body’s inflammatory response that causes severe illness and is currently the only medication proven to reduce mortality in patients hospitalized with severe COVID-19, according to the authors.
“The very interesting part of use of steroids in SARS-CoV-2 infection, is that it appears to be one of the only viral pneumonias in which steroids are helpful,” Gates said.
Beyond glucocorticoids, previous work has found that the antiviral medication Remdesivir is helpful in shortening recovery time for patients hospitalized with COVID-19. However, because it has not been shown to reduce mortality, the use of the drug currently remains under debate by various health organizations and institutions. Further study of immune modulators used in rheumatologic diseases, such as tocilizumab and baricitinib, is also warranted, according to the authors.
The authors also advised performing thromboprophylaxis within 24 hours of hospital admission and only treating patients with antibiotics until signs of active bacterial infection can be ruled out.
“It is very hard for clinicians to see a patient who is short of breath and has a viral pneumonia and be concerned about a bacterial infection or that the person is going to develop a bacterial superinfection; getting past that anxiety is really hard. It can also be hard for clinicians to stop antibiotics that might have been started by another doctor. Experience has taught us that most patients do not benefit from antibiotics and, in fact, do worse when we give them unnecessary antibiotics,” said Jeffrey Linder, ’97 MD, MPH, the Michael A. Gertz Professor of Medicine, chief of General Internal Medicine and Geriatrics in the Department of Medicine and a co-author of the editorial.
Non-drug management such as conservative fluid management, adequate supplemental oxygen, proning and lung protective ventilation, as well as communication between patients and healthcare professionals and getting vaccinated, are also essential in preventing long-term hospitalization, the authors wrote.
“Thankfully, we have vaccines that are safe and effective at preventing you from getting sick enough to need the hospital. Immunity from natural infection is short-lived compared to the vaccines, so even those who have recovered from COVID-19 infection should get vaccinated,” said Cheryl Lee, MD, assistant professor of Medicine in the Division of Hospital Medicine, of Pediatrics and a co-author of the editorial.
Opioid Overdose During Quarantine
The number of fatal opioid overdoses in Cook County increased to 25.6 percent during Illinois’ first 11-week COVID-19 stay-at-home order last spring, according to a Northwestern Medicine study published in JAMA Insights.
“People could be staying at home and using alone, which limits the possibility that a bystander can call 911 or give naloxone to reverse the overdose. There has been a disruption in the drug market associated with COVID, so if people aren’t able to purchase from their usual supplier, they have to go to new people and possibly take new substances that are too powerful for them,” said Maryann Mason, PhD, associate professor of Emergency Medicine and lead author of the study.
For the current study, investigators analyzed data from the Cook County medical examiner’s office, looking at the number overdoses before, during and after the stay-at-home order was enacted in Cook County. The number of weekly deaths were calculated for the weeks between January 5, 2018 and December 23, 2020. A total of 4,283 opioid overdose-related deaths occurred in Cook County during that time, with weekly deaths ranging from 12 to 53.
During Illinois’ 11-week stay-at-home order (enacted on March 21, 2020 and lifted on May 30, 2020), the investigators found the average number of weekly overdose deaths increased from 35.1 to 44.1 — a total of 25.6 percent. The team also found that opioid overdose deaths following the stay-at-home period also remained elevated above pre-2020 levels.
“The findings help us understand the relatively greater risks of the pandemic for people who use opioids, the need to support people with opioid misuse during these times and the ‘collateral’ damage of a pandemic beyond COVID deaths,” Mason said.
Co-authors of the study included Joseph Feinglass, PhD, research professor of Medicine in the Division of General Internal Medicine and Geriatrics and of Preventive Medicine in the Division of Public Health Practice, and Ponni Arunkumar, MD, adjunct assistant professor of Pathology.
Adopting Telemedicine During COVID-19
When the onset of the COVID-19 pandemic forced the world into quarantine, individuals and groups alike frantically adjusted to a new normal of self-isolation. For healthcare institutions, the use of telemedicine expanded as restrictions were placed on in-person visits, but a recent study published in Frontiers in Pediatrics found that this transition was easier for providers who had already incorporated more telemedicine visits into their practices.
“Telemedicine has long allowed providers and patients and families to overcome the barrier of geographic distance, enabling care connections to occur regardless of patient or provider location. The pandemic necessitated reduced interpersonal contact to prevent infectious spread, catalyzing unprecedented demand for telemedicine. Telemedicine has allowed for improved care coordination, continuity of care and ability to receive care safely during the pandemic,” said Dana Schinasi, MD, assistant professor of Pediatrics in the Division of Emergency Medicine and lead author of the study.
According to Schinasi, telemedicine use in Illinois was limited prior to the pandemic due to poor reimbursement and restrictions related to the provision of telemedicine, such as the state requiring another healthcare provider to be present at the patient site.
For the study, Schinasi and her team surveyed clinicians at Ann & Robert H. Lurie Children’s Hospital of Chicago about expanding their telemedicine practice between March 21, 2020 to June 30, 2020. The survey assessed the providers’ prior experience using telemedicine, their concerns about it and their intentions to continue using telemedicine in the future.
Survey results showed that 54 percent of respondents had conducted more than 20 video patient visits during that time, and more than 75 percent of providers said telemedicine was easy to learn.
Providers who had more video visits in a typical week in June reported greater ease of incorporating telemedicine into their clinical practice and a greater intention to continue telemedicine practice over the next six months. Payer reimbursement was the leading influencer of anticipated future use of telemedicine.
Overall, having healthcare providers use telemedicine post-pandemic will depend on patient acceptance, clinical need, patient reimbursement for the service, improved health outcomes and actively addressing health disparities caused by geographical distance and societal and healthcare structures rooted in racism and discrimination, according to the authors.
“Telemedicine must be held to the same quality standards as in-person care, and so another requirement for providers to sustain their telemedicine practice relates to health outcomes, ensuring that children continue to receive high-quality care. It is also important to recognize that disparities exist in access to care, and we must better understand these disparities to reach our patients equitably – this is a priority,” Schinasi said.
Co-authors of the study included Michelle Macy, MD, MS, associate professor of Pediatrics in the Division of Emergency Medicine and Director of the Mary Ann and J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, and Carolyn Foster, MD, MSHS, assistant professor of Pediatrics in the Division of Advanced General Pediatrics and Primary Care and a member of the Smith Child Health Center.
Study Shows Bamlanivimab Reduces COVID-19 Hospitalization
Non-hospitalized patients with mild to moderate COVID-19 who received the monoclonal antibody drug bamlanivimab had a lower 30-day hospitalization rate than patients who did not receive the drug, according to a Northwestern Medicine study published in the journal Clinical Infectious Diseases.
Previous work has shown monoclonal antibody drugs are effective in preventing hospitalization in persons with COVID-19, especially for those at higher risk of developing severe disease. As new variants of SARS-CoV-2 — the virus that causes COVID-19 — continue to emerge, some monoclonal antibodies have decreased activity against these variants.
“Due to these changes in the virus, research continues with developing new monoclonal antibodies, identifying if these antibodies can be used to prevent COVID in people that have been exposed to SARS-CoV-2 and new methods of administration of the antibodies,” said Michael Angarone, DO, associate professor of Medicine in the Division of Infectious Diseases, of Medical Education, and senior author of the study.
For the current study, investigators identified non-hospitalized patients from a single healthcare system in Chicago who were prescribed bamlanivimab, noting who did and who did not receive the medication between November 2020 and January 2021. Patients identified were 52 percent male, had a higher risk of developing severe COVID-19, were average age of 64 years and had an average body mass index of 30.
The 30-day hospitalization rate for patients who received bamlanivimab was 7.3 percent compared to 20 percent of controls. Additionally, patients who identified as white and whose first language was English were more likely to receive bamlanivimab than patients who identified as Black or Hispanic.
“These findings draw attention to the use of monoclonal antibodies as a viable treatment option in the outpatient setting for our high-risk patients. These findings also highlight the need for more streamlined processes of diagnosing COVID-19 and referring patients to monoclonal antibody treatment. Additionally, our study highlighted health disparities involved with the administration of the medication, which is something that can be addressed as we continue to provide monoclonal antibodies to treat COVID-19,” said Rebecca Kumar, MD, an Infectious Diseases fellow and first author of the study.
Co-authors include Valentina Stosor, MD, ’93, ’95 GME, professor of Medicine in the Division of Infectious Diseases and of Surgery in the Division of Organ Transplantation; Chad Achenbach, ’02 MD, ’02 MPH, associate professor of Medicine in the Division of Infectious Diseases and of Preventive Medicine; and Michael Ison, MD, MS, professor of Medicine in the Division of Infectious Diseases and of Surgery in the Division of Organ Transplantation.
Achenbach, Angarone and Ison are members of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University.
This work was supported by the National Institutes of Health (NIH)’s National Center for Advancing Translational Sciences grant UL1TR001422 and NIH grant T32AI095207.
“A Return to Normal is Not Good Enough”
While the U.S.’ COVID-19 vaccine rollout coupled with a downward trend of new COVID-19 cases may appear to be a light at the end of the tunnel, a “return to normal” will be a poorly missed opportunity to improve healthcare, public health and science both in the U.S. and globally, according to a recent editorial published in Circulation.
“Many weaknesses, vulnerabilities and biases of the healthcare and public health systems have been laid bare by the pandemic and we should not go back to pre-pandemic business as usual. We must do better to care for our patients and population,” said Donald Lloyd-Jones, MD, the Eileen M. Foell Professor, chair of Preventive Medicine and a co-author of the editorial.
The authors noted that the long-term health effects of COVID-19, a likelihood that the pandemic will shift to an endemic due to emerging disease variants of the SARS-CoV-2 virus, and the U.S.’s divisive stance on vaccination cannot be ignored. And choosing to forget the pandemic altogether may lead to complacency and unpreparedness for public health crises in the future.
The authors also called for a global distribution of COVID-19 vaccines and for public health officials and agencies to acknowledge their failure in preparing the greater population for the pandemic with poor public health messaging, promoting therapies with poor efficacy and launching clinical trials at the institutional level instead of at the multi-national level.
“We will need to acknowledge our failures and build on the successful strategies that worked to ensure that the scientific enterprise is prepared for future similar catastrophes,” the authors wrote.
Moreover, the pandemic has also shone a light on the longstanding weakness of the U.S. healthcare system and public health systems at large, including unaffordable health insurance, disparities in healthcare access and quality, and the country’s incredibly high healthcare spending, despite being among the lowest-ranked countries for life expectancy, preventable death, maternal mortality and cardiovascular diseases.
Moving forward, the authors reasserted AHA’s previous call for adequate, accessible and affordable health insurance, health equity in the U.S and investing in public health education, health infrastructure, improved social services and supporting future healthcare providers. The authors also recommended that all people 12 and older should get vaccinated, unless there are specific health concerns from doing so.
“For unvaccinated individuals, AHA continues to recommend masking, social distancing and handwashing as before. For vaccinated individuals, AHA endorses CDC guidance given the state of the science given falling infection rates and the demonstrated efficacy of the vaccines in preventing transmission, and very high efficacy in preventing serious complications in the unusual case of infection among vaccinated individuals,” Lloyd-Jones said.