H5N1

The next pandemic? More likely a polydemic

Last week The Tyee published my article The Next Pandemic? More Likely a Polydemic. After going through a number of unpleasant problems in global health, I concluded:

These are just some of the threats in the present polydemic, which itself is part of the present hot mess of economic decline, rising prices, war, climate change and political polarization that writers like Adam Tooze are calling a polycrisis. And it’s precisely now that Canadian health spending should be rising to support pandemic preparation and prevention, not levelling off.  

From a political point of view, lower spending makes sense. The system is still trying to catch up with all the knee and hip replacements postponed for the last two years. Inflation makes it impossible to raise taxes, and the deficit spending that kept everyone afloat in 2020 and 2021 is now politically unacceptable.  

Besides, governments have learned that they don’t have to take pandemics as seriously as they once did. Provincial governments that let COVID-19 rip have been re-elected. Public health measures like masks and vaccine mandates have triggered a populist backlash that some politicians are exploiting. Health-care workers are exhausted, underpaid and embittered.

So even if a government wanted to take the polydemic seriously, and to build up the system against future pandemics, it would face serious resistance from many voters, not to mention the business sector. Rebuilding health-care staff numbers and infrastructure would take billions, spent over more years than any government is likely to survive. Short-term emergencies would always take priority over long-term needs.  

And when the next pandemic arrived and became a short-term emergency, neither governments nor the governed would implement or accept even proven measures to protect public health. They’d recycle COVID-19 misinformation as precedent: “It was mostly mild, it only killed old people, we got through it.”  

But if it’s a pandemic as lethal as H5N1 or Ebola, which has an average case fatality rate of 50 per cent, the survivors will think otherwise.

Before 2020, the pandemic anticipators I called Flublogia were certainly worried about the impact of a new influenza or other virus. But we still had a naive faith that while it would be bad, we in North America and western Europe and Japan would have the technology and the experts to deal with it.

The response of the western nations, and especially the US, was and is a disgrace and a revelation: just as the fearsome Russian army turned out to be stupid and incompetent, so have the health systems and politicians of the "advanced" nations. If the next virus turns serious, I really doubt whether the public will listen to the advice of the health experts. Nor will healthcare workers be willing to resist another onslaught. And that, of course, will only make matters much, much worse,

A multinational Delphi consensus to end the COVID-19 public health threat

Via Nature: A multinational Delphi consensus to end the COVID-19 public health threat. The abstract:

Despite notable scientific and medical advances, broader political, socioeconomic and behavioural factors continue to undercut the response to the COVID-19 pandemic. Here we convened, as part of this Delphi study, a diverse, multidisciplinary panel of 386 academic, health, non-governmental organization, government and other experts in COVID-19 response from 112 countries and territories to recommend specific actions to end this persistent global threat to public health.  

The panel developed a set of 41 consensus statements and 57 recommendations to governments, health systems, industry and other key stakeholders across six domains: communication; health systems; vaccination; prevention; treatment and care; and inequities.  

In the wake of nearly three years of fragmented global and national responses, it is instructive to note that three of the highest-ranked recommendations call for the adoption of whole-of-society and whole-of-government approaches, while maintaining proven prevention measures using a vaccines-plus approach that employs a range of public health and financial support measures to complement vaccination.  

Other recommendations with at least 99% combined agreement advise governments and other stakeholders to improve communication, rebuild public trust and engage communities in the management of pandemic responses.  

The findings of the study, which have been further endorsed by 184 organizations globally, include points of unanimous agreement, as well as six recommendations with >5% disagreement, that provide health and social policy actions to address inadequacies in the pandemic response and help to bring this public health threat to an end.

Post-acute health care burden after SARS-CoV-2 infection: A retrospective cohort study

This helps to explain why our healthcare system is under such pressure. Via CMAJ: Post-acute health care burden after SARS-CoV-2 infection: a retrospective cohort study.

Background: The post-acute burden of health care use after SARS-CoV-2 infection is unknown. We sought to quantify the post-acute burden of health care use after SARS-CoV-2 infection among community-dwelling adults in Ontario by comparing those with positive and negative polymerase chain reaction (PCR) test results for SARS-CoV-2 infection.  

Methods: We conducted a retrospective cohort study involving community-dwelling adults in Ontario who had a PCR test between Jan. 1, 2020, and Mar. 31, 2021. Follow-up began 56 days after PCR testing. We matched people 1:1 on a comprehensive propensity score. We compared per-person-year rates for health care encounters at the mean and 99th percentiles, and compared counts using negative binomial models, stratified by sex.  

Results: Among 531 702 matched people, mean age was 44 (standard deviation [SD] 17) years and 51% were female. Females who tested positive for SARS-CoV-2 had a mean of 1.98 (95% CI 1.63 to 2.29) more health care encounters overall per-person-year than those who had a negative test result, with 0.31 (95% CI 0.05 to 0.56) more home care encounters to 0.81 (95% CI 0.69 to 0.93) more long-term care days. At the 99th percentile per-person-year, females who tested positive had 6.48 more days of hospital admission and 28.37 more home care encounters.  

Males who tested positive for SARS-CoV-2 had 0.66 (95% CI 0.34 to 0.99) more overall health care encounters per-person-year than those who tested negative, with 0.14 (95% CI 0.06 to 0.21) more outpatient encounters and 0.48 (95% CI 0.36 to 0.60) long-term care days, and 0.43 (95% CI −0.67 to −0.21) fewer home care encounters. At the 99th percentile, they had 8.69 more days in hospital per-person-year, with fewer home care (−27.31) and outpatient (−0.87) encounters.   

Interpretation: We found significantly higher rates of health care use after a positive SARS-CoV-2 PCR test in an analysis that matched test-positive with test-negative people. Stakeholders can use these findings to prepare for health care demand associated with post-COVID-19 condition (long COVID).

Medical associations confront Canada's healthcare crisis

Via Medscape.com: Medical Associations Confront Canada's Healthcare Crisis. Excerpt:

The Canadian healthcare system has reached a breaking point and requires immediate and long-term changes to prevent a total collapse, according to new recommendations from three of the country’s top medical associations.  

The Canadian Medical Association, Canadian Nurses Association, and College of Family Physicians of Canada developed an action plan to rebuild the healthcare workforce, reduce burnout, and retain healthcare workers who have felt strained for more than 2 years.

“We’ve really seen the challenges in the healthcare system brought much more to the forefront during the pandemic. It’s reaching a level of crisis that we’ve not seen before,” Katharine Smart, MD, president of the Canadian Medical Association, told Medscape Medical News.  

“We’re hearing daily from people across the country about how bad things are,” she said. “From primary care to hospitals to specialists, everything is starting to implode.”  

The organizations presented the policy recommendations to the House of Commons’ Standing Committee on Health and the federal/provincial/territorial Committee on Health Workforce in April. The action plan was published on the organizations’ websites on May 16.  

Collaboration and Support  

The Canadian healthcare system was struggling before the COVID-19 pandemic, the authors wrote. For more than 2 years now, healthcare workers have tried to keep the system from buckling under the strain.  

Now healthcare workers are burning out and leaving the industry, which has pushed the system to a tipping point, they wrote. Healthcare professionals are facing massive patient backlogs and cannot provide the care that is needed.  

“We’ve spent the last several months raising awareness of how dire things are,” Smart said. “Canadians have pride about our healthcare, but it idealizes our system and gets in the way of being realistic about what’s happening.”  

The Canadian Medical Association, Canadian Nurses Association, and College of Family Physicians of Canada developed health human resources solutions to address the healthcare workforce in a “proactive and sustainable way,” she said. The plan offers immediate, medium, and long-term policy recommendations for the federal government to adopt and share with provinces and territories.

Exacerbation of COVID-19 mortality by the fragmented United States healthcare system: A retrospective observational study

Via The Lancet Regional Health - Americas: Exacerbation of COVID-19 mortality by the fragmented United States healthcare system: A retrospective observational study. The summary:

Background  

Before widespread vaccination, the United States was disproportionately affected by COVID-19 with a mortality rate several times that of other affluent societies. Comparing regions with different rates of health insurance, we assess how much of this excess mortality may be due to the relatively large population without health insurance.  

Methods  

We use daily surveillance data from the US Centers for Disease Control and Prevention (CDC) stratified by region, age group, gender, and race in regression analysis of daily COVID-19 cases, hospitalization, and mortality. COVID-19 data have been matched with structural characteristics of the region including average proportion with health insurance. As checks, we have estimated regressions for different time periods, different groups of states, and by comparing adjacent counties between states with and without Medicaid expansion.  

Findings  

Groups with lower health insurance coverage had significantly higher mortality as well as greater case counts and hospitalization. Early in the pandemic, they were also less likely to be tested for COVID-19. Applying our regression estimates, we estimate that had there been full health insurance coverage of the population, there would have been 60,000 fewer deaths, 26% of the total death toll in the period of this analysis.  

Interpretation  

Our study demonstrates that a significant share of COVID-19 mortality in the United States, and much of the excess mortality in the United States compared with other countries, is due to our reliance on a system of market-driven healthcare. Providing universal insurance coverage should be part of our campaign to reduce COVID-19 mortality. It also suggests that these concerns should not be restricted to COVID-19 but apply across all diseases, contributing to many unnecessary deaths in the United States each year even apart from the COVID-19 pandemic.

COVID-19: It ain’t over ’til it’s over

Via Science, an editorial by Editor in Chief H. Holden Thorp: It ain’t over ’til it’s over. Excerpt:

The Biden administration is sheepishly waving a checkered flag on the pandemic. If you look closely, you can see its members cringing as they do so. 

Chief Medical Advisor Anthony Fauci told the PBS Newshour that the United States was “out of the pandemic phase” and then walked it back, saying he meant that the “acute compo­nent” of the pandemic phase was over. President Biden attended the likely superspreading White House Corre­spondents’ Dinner last weekend but skipped cocktails and the meal, opting to just give his talk. Fauci avoid­ed the whole affair. 

Meanwhile, Vice President Harris continued to isolate after her positive COVID-19 test, and many members of Congress and the administra­tion announced positive test results as well. All of this happened while the White House allowed a renegade federal judge in Florida (where else?) to end the nationwide mask mandate without much of a fight. 

These mixed messages have been emanating from the administration for months now, and although those with resources have tools to manage COVID-19, care needs to be taken that those without such means are not forgotten. 

When Biden pledged to “follow the science,” it was hard to imagine that the country could have ended up here. But the administration made a big bet that vaccines would provide sterilizing immunity and end the pandemic, allowing it to move on to other priorities. 

Leaving behind the insanity of ivermectin, hydroxy­chloroquine, and bleach was certainly a great step forward. However, evolution has had other plans, and variants of severe acute respiratory syndrome corona­virus 2 (SARS-CoV-2, the virus that causes COVID-19) have kept the pandemic going. This left the White House in a very tight spot: There was little political will to keep pushing nonpharmaceutical interven­tions, yet the pandemic was far from over. Add to this mounting inflation worries and concerns about the war in Ukraine, and the response has been a clumsy pivot to a message that politicians always turn to: personal responsibility. 

Get vaccinated, get boosted, wear a mask, get a prescription for the antiviral Pax­lovid—if you want to. This may be fine if you have a healthy immune system, great health insurance, and the ability to navigate the US health care system. But what about everyone else? 

COVID-19 is at a similar place to where the HIV/AIDS global pandemic was when the antiretroviral drugs came along. Yale epidemiologist Gregg Gonsalves told me about important parallels between both pandem­ics. “The HIV epidemic didn’t go away,” he said. “It just went to where people could ignore it. It went into the rural South, it went to communities that were already facing disparities in health.” 

At that time, confusion between medicine and public health was also an im­portant factor. “The discourse shifting to private choice and private adjudication of risk is really not what public health science is,” he said. “We work in populations. And if we’re talking about medicine, it’s about private risk and private choices.”

WHO: 14.9 million excess deaths associated with the COVID-19 pandemic in 2020 and 2021

A news release from WHO: 14.9 million excess deaths associated with the COVID-19 pandemic in 2020 and 2021.

New estimates from the World Health Organization (WHO) show that the full death toll associated directly or indirectly with the COVID-19 pandemic (described as “excess mortality”) between 1 January 2020 and 31 December 2021 was approximately 14.9 million (range 13.3 million to 16.6 million).    

“These sobering data not only point to the impact of the pandemic but also to the need for all countries to invest in more resilient health systems that can sustain essential health services during crises, including stronger health information systems,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “WHO is committed to working with all countries to strengthen their health information systems to generate better data for better decisions and better outcomes.”  

Excess mortality is calculated as the difference between the number of deaths that have occurred and the number that would be expected in the absence of the pandemic based on data from earlier years.   

Excess mortality includes deaths associated with COVID-19 directly (due to the disease) or indirectly (due to the pandemic’s impact on health systems and society). Deaths linked indirectly to COVID-19 are attributable to other health conditions for which people were unable to access prevention and treatment because health systems were overburdened by the pandemic. The estimated number of excess deaths can be influenced also by deaths averted during the pandemic due to lower risks of certain events, like motor-vehicle accidents or occupational injuries.   

Most of the excess deaths (84%) are concentrated in South-East Asia, Europe, and the Americas. Some 68% of excess deaths are concentrated in just 10 countries globally. Middle-income countries account for 81% of the 14.9 million excess deaths (53% in lower-middle-income countries and 28% in upper-middle-income countries) over the 24-month period, with high-income and low-income countries each accounting for 15% and 4%, respectively.   

The estimates for a 24-month period (2020 and 2021) include a breakdown of excess mortality by age and sex. They confirm that the global death toll was higher for men than for women (57% male, 43% female) and higher among older adults. The absolute count of the excess deaths is affected by the population size. The number of excess deaths per 100,000 gives a more objective picture of the pandemic than reported COVID-19 mortality data.  

“Measurement of excess mortality is an essential component to understand the impact of the pandemic. Shifts in mortality trends provide decision-makers information to guide policies to reduce mortality and effectively prevent future crises. Because of limited investments in data systems in many countries, the true extent of excess mortality often remains hidden,” said Dr Samira Asma, Assistant Director-General for Data, Analytics and Delivery at WHO. “These new estimates use the best available data and have been produced using a robust methodology and a completely transparent approach.”  

“Data is the foundation of our work every day to promote health, keep the world safe, and serve the vulnerable. We know where the data gaps are, and we must collectively intensify our support to countries, so that every country has the capability to track outbreaks in real-time, ensure delivery of essential health services, and safeguard population health,” said Dr Ibrahima Socé Fall, Assistant Director-General for Emergency Response.   

The production of these estimates is a result of a global collaboration supported by the work of the Technical Advisory Group for COVID-19 Mortality Assessment and country consultations.   

This group, convened jointly by the WHO and the United Nations Department of Economic and Social Affairs (UN DESA), consists of many of the world’s leading experts, who developed an innovative methodology to generate comparable mortality estimates even where data are incomplete or unavailable.

This methodology has been invaluable as many countries still lack capacity for reliable mortality surveillance and therefore do not collect and generate the data needed to calculate excess mortality. Using the publicly available methodology, countries can use their own data to generate or update their own estimates.

“The United Nations system is working together to deliver an authoritative assessment of the global toll of lives lost from the pandemic. This work is an important part of UN DESA’s ongoing collaboration with WHO and other partners to improve global mortality estimates,” said Mr Liu Zhenmin, United Nations Under-Secretary-General for Economic and Social Affairs.

Mr Stefan Schweinfest, Director of the Statistics Division of UN DESA, added: “Data deficiencies make it difficult to assess the true scope of a crisis, with serious consequences for people’s lives. The pandemic has been a stark reminder of the need for better coordination of data systems within countries and for increased international support for building better systems, including for the registration of deaths and other vital events.”

Physical, psychological and cognitive profile of post-COVID condition in healthcare workers, Quebec, Canada

Via medRxiv: Physical, psychological and cognitive profile of post-COVID condition in healthcare workers, Quebec, Canada. This could have serious implications for healthcare systems around the world. The abstract:

Importance Most adults with COVID-19 do not require hospitalization, but the subsequent risk of post-COVID condition, including associated psychological and cognitive dysfunction, remains poorly understood among non-hospitalized versus hospitalized cases.  

Objective To assess the prevalence and duration of post-COVID condition, including physical, psychological and cognitive symptoms.  

Design Case series and case-control study between December 2020 and May 2021  

Setting Healthcare workers in Quebec, Canada  

Participants Eligible cases were symptomatic healthcare workers with PCR-confirmed COVID-19 between July 2020 and May 2021. Among 17,717 contacted cases, 6061 (34%) participated. A random sample of symptomatic healthcare workers with negative PCR result between November 2020 and May 2021 served as controls. Among 11,498 contacted controls, 4390 (38%) participated.  

Exposures In multivariable models, sociodemographic and clinical characteristics, as well as vaccine history, were evaluated as potential risk factors. Prevalence ratios compared self-reported cognitive dysfunctions (difficulty concentrating; difficulty organizing oneself; forgetfulness; loss of necessary items) among cases with post-COVID condition to controls, adjusting for psychological distress and fatigue.  

Outcomes Post-COVID condition was defined by symptoms persisting ≥4 weeks or ≥12 weeks after COVID-19 onset.  

Results Four-week and 12-week post-COVID condition prevalences of 46% (2,746/5,943) and 40% (653/1,746), respectively, were observed among non-hospitalized cases and 76% (90/118) and 68% (27/37), respectively, among hospitalized cases. Hospitalization, female sex and age were associated with higher risk.  

A substantial proportion of non-hospitalized cases with 4-week post-COVID condition often or very often reported cognitive dysfunction, including concentration (33%) or organizing (23%) difficulties, forgetfulness (20%) and loss of necessary items (10%), with no decline at 12 weeks. All four aspects of cognitive dysfunction were 2.2 to 3.0 times more prevalent among cases with post-COVID condition than in controls, but also independently associated with psychological distress and fatigue.  

Conclusions and relevance Post-COVID condition may be a frequent sequela of ambulatory COVID-19 in working-age adults, with important effects on cognition. With so many healthcare workers infected since the beginning of the COVID-19 pandemic, the ongoing implications for quality healthcare delivery could be profound should cognitive dysfunction and other severe post-COVID symptoms persist in a professionally-disabling way over the longer term.  

Question How common and long-lasting are the physical, psychological and cognitive effects of post-COVID condition in healthcare workers, both hospitalized and non-hospitalized?  

Findings The prevalence of post-COVID condition was 46% at 4 weeks and 40% at 12 weeks among non-hospitalized cases and 76% and 68% among hospitalized cases. One third of non-hospitalized healthcare workers with post-COVID condition reported cognitive impairment, which was independently associated with persistent physical symptoms, but also psychological distress and fatigue.  

Meaning Persistent cognitive and other professionally-disabling sequelae of COVID-19 in essential workers could have critical implications for quality healthcare delivery during and after the pandemic.

Evaluation of science advice during the COVID-19 pandemic in Sweden

Oh boy. This is devastating. Via Nature.com, an article in Humanities and Social Sciences Communications: Evaluation of science advice during the COVID-19 pandemic in Sweden. The abstract:

Sweden was well equipped to prevent the pandemic of COVID-19 from becoming serious. Over 280 years of collaboration between political bodies, authorities, and the scientific community had yielded many successes in preventive medicine. Sweden’s population is literate and has a high level of trust in authorities and those in power. During 2020, however, Sweden had ten times higher COVID-19 death rates compared with neighbouring Norway. 

In this report, we try to understand why, using a narrative approach to evaluate the Swedish COVID-19 policy and the role of scientific evidence and integrity. We argue that that scientific methodology was not followed by the major figures in the acting authorities—or the responsible politicians—with alternative narratives being considered as valid, resulting in arbitrary policy decisions. 

In 2014, the Public Health Agency merged with the Institute for Infectious Disease Control; the first decision by its new head (Johan Carlson) was to dismiss and move the authority’s six professors to Karolinska Institute. With this setup, the authority lacked expertise and could disregard scientific facts. 

The Swedish pandemic strategy seemed targeted towards “natural” herd-immunity and avoiding a societal shutdown. The Public Health Agency labelled advice from national scientists and international authorities as extreme positions, resulting in media and political bodies to accept their own policy instead. 

The Swedish people were kept in ignorance of basic facts such as the airborne SARS-CoV-2 transmission, that asymptomatic individuals can be contagious and that face masks protect both the carrier and others. Mandatory legislation was seldom used; recommendations relying upon personal responsibility and without any sanctions were the norm. Many elderly people were administered morphine instead of oxygen despite available supplies, effectively ending their lives. 

If Sweden wants to do better in future pandemics, the scientific method must be re-established, not least within the Public Health Agency. It would likely make a large difference if a separate, independent Institute for Infectious Disease Control is recreated. 

We recommend Sweden begins a self-critical process about its political culture and the lack of accountability of decision-makers to avoid future failures, as occurred with the COVID-19 pandemic.

South Korea reports all-time high of 441,423 daily COVID-19 cases

Via Yonhap: S. Korea reports all-time high of 441,423 daily COVID-19 cases. The authorities seem to be trying to turn COVID into flu, with a tolerably small fatality rate. But many COVID survivors will still experience long COVID, and the South Korean healthcare system is taking punishment it didn't need.

SEOUL, March 15 (Yonhap) -- South Korea reported 441,423 new COVID-19 cases on Tuesday, setting a new daily record as the country battles through the worst wave of the virus sparked by the omicron variant.  

The all-time high was reported as of 9 p.m., with three hours left until the daily tally ends. The total will be announced the following morning.  

Earlier Tuesday, the Korea Disease Control and Prevention Agency (KDCA) said the country added 362,338 new COVID-19 infections the previous day, mostly locally transmitted, putting the total caseload at 7,228,550.  

The previous record was 383,664 cases reported Saturday. The daily counts tend to decline on Mondays due to fewer tests on the weekend before rising sharply toward the end of the week.  

The death toll from COVID-19 hit a record high of 293 on Tuesday, up 93 from Monday, with the total at 10,888. The fatality rate came to 0.15 percent.  

The number of critically ill patients also reached an all-time high of 1,196, up 38 from the previous day.  

South Korea has seen a spike in the COVID-19 caseload since the beginning of this year, with the numbers surging from four digits to six digits in about three weeks last month.  

The focus now in the fight against COVID-19 has been about how to bring back everyday life as much as possible while maintaining steps to rein in the virus surge.  

"Managing the fatality rate is very important," Sohn Young-rae, a senior health ministry official, said in a briefing. "The fatality rate for the past four weeks has been lower than 0.1 percent, so the short-term fatality rate is similar to that of the seasonal flu," Sohn said. The fatality rate of seasonal flu stands at 0.05-0.1 percent.  

Health authorities forecast the current virus wave will enter its peak between later this week and next week. Sohn said the numbers of critically ill cases and deaths are expected to continue to rise until two to three weeks after the peak.  

Health authorities said they would begin to consider readjusting social distancing rules that currently limit business hours till 11 p.m. and private gatherings of up to six people, as those measures are due to end this week.  

The government announced children aged between 5 and 11 will be able to receive vaccine shots starting March 31. It began to allow uninfected students and school staff members to attend school in person even if family members who live with them are virus positive.  

Of the locally transmitted cases reported Tuesday, 66,067 cases came from Seoul and 102,983 from the surrounding Gyeonggi Province. The western port city of Incheon reported 20,444 cases. Fifty-five cases came from overseas, raising the total to 30,358.  

As of Tuesday, 32.15 million people out of the 52 million population, or 62.7 percent, had received booster shots. Fully vaccinated people came to 44.43 million, representing 86.6 percent, the KDCA said.