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 COVID and pregnancy, self-perceived versus objective assessments of hearing loss, behavioral intervention for obesity in low income people, and how flu vaccine behavior can inform COVID vaccination.
1:43 Vaccination rates, states, age
2:41 Target those unlikely to get vaccinated
3:40 Now have three COVID vaccines in phase III trials
4:35 Pregnancy and COVID
5:35 Same risk factors for non-pregnant people
6:34 Moms with chronic illness four times more likely to need ICU
7:35 Routinely test pregnant women
8:43 Intensive lifestyle change had 5% loss
9:46 Difference between self-perceived and tested hearing loss
10:45 Corrected for multiple factors
11:41 Long term cognitive impairment
12:36 Don’t know if hearing aids correct
Elizabeth Tracey: What are the manifestations of COVID-19 infection in pregnancy?
Rick Lange: Addressing weight loss in underserved patients.
Elizabeth: Is there a disparity between self-perceived and objectively measured hearing loss?
Rick: And can flu vaccination inform us about COVID vaccination?
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 Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, I think the top-of-mind one for me, at least this week, is this analysis of whether flu vaccination can model for us what we might do when it comes to coronavirus vaccinations. This is in the Journal of General Internal Medicine.
Rick: To put it in perspective, everybody is talking about the COVID vaccine being an important part of preventing disease in the future, but there are many individuals that are unlikely to get vaccinated and so we won’t be able to develop that herd immunity.
What these authors attempted to do was to inform us about what type of individuals do or don’t get flu vaccines because the things that influence that are very likely to influence who gets COVID vaccination. In fact, when you look at the demographics regarding flu — and I’m just going to talk about the 2017/2018 season — there were 45 million symptomatic cases in the U.S. and over 61,000 deaths, but under half of U.S. adults and only two-thirds of children are vaccinated, despite the fact the goal is to have 80%.
The authors looked at an annual national survey of over 400,000 adults conducted by the CDC and state health departments, looked at vaccination rates, the state, geography, age, race, sex, annual income, chronic conditions, to determine who was or who wasn’t likely to get vaccinated. They were able to detain over 95% of the data on over 400,000 adults and unfortunately estimated only one-third of them actually were vaccinated.
Vaccination rates were higher among older, white, and Asian, female, higher-income adults, and those with chronic conditions. The ages over 75 had three times higher adjusted rates of getting vaccinated as people in the 18 to 24 [range]. Unfortunately, Black and Native Americans had a 17% lower odds of vaccination than white adults.
You won’t be surprised to know that having health insurance and a personal physician were independently associated with a two-fold higher rate of vaccination. Disappointingly, to me, the state of Texas’s vaccination rate was only 26% versus the highest rate in the District of Columbia, 44%. This information hopefully will allow us to target these individuals that are unlikely to get vaccinated, not only for flu vaccines, but also when the COVID vaccine becomes available.
Elizabeth: I think one of the things that comes instantly to mind when I listen to this is the fact that as we get older we interact more with the healthcare system and it just seems likely to me that in that interaction there is going to be the suggestion or the recommendation that we get vaccinated for the flu.
Rick: You’re right. They’re more likely to see a primary care physician and that’s related. They’re more likely to have insurance because of Medicare as well, and they’re more likely to have chronic conditions so they interact with the healthcare system. Again, our target is 80%. There wasn’t a single group that had a 60% or a higher vaccination rate, so we’ve got a lot of work to do just across the spectrum.
Elizabeth: Of course, the big concerns right now about oncoming COVID-19 vaccine are that we’re worried about, is it going to be approved before it’s really ready, before the data’s really ripe?
Rick: We certainly need to encourage people to get vaccinated for flu; there’s no question about that. As a COVID vaccine becomes available and is proven to be efficacious — and we now have three that are in phase III studies here in the United States and others worldwide — then we’ll be able to adopt them. But if we don’t do a better job disseminating the flu vaccine, we’re not going to do any better with a COVID vaccine when it’s finally available.
Elizabeth: I would just add one more thing, having listened to quite a lot about this vaccine coming over the transom. With so many activities being curtailed, or frankly closed, points of contact for people to be administered the vaccine — which most people feel is going to be a two-dose kind of a vaccine — are fewer and so there’s all kinds of concerns about that part of it as well.
Rick: You’re right. There’s a lot of obstacles to overcome. The information I just highlighted was when there were no restrictions. A lot of structural things we need to overcome.
Elizabeth: On an upside, I would say that at least recently, pharmacists are now empowered to give vaccinations even to the pediatric population and so pharmacists, I think, are going to be a point of contact for many of us when it comes to this.
Let’s turn to the British Medical Journal. This is a look at that population in whom there was a lot of controversy — gosh, what is the impact of COVID-19 infection in women who are pregnant?
This is a meta-analysis. They included in this 28 studies, over 11,000 women, pregnant, recently pregnant, attending or admitted to hospital for any reason and were diagnosed as having suspected or confirmed COVID-19.
Interestingly, their clinical manifestations did not include fever and cough as they do for so many other people. They were less likely to report either fever or muscle aches and pains. However, they were more likely to need admission to an intensive care unit and invasive ventilation.
In this study, they only see 0.1% deaths among pregnant women and I think there’s still some fuzziness surrounding that number, so I’m not convinced. I want to see a little bit more. But in any case, what were the risk factors? The same risk factors that we see for anybody getting severe COVID-19 disease: high BMI, chronic hypertension, pre-existing diabetes. When women had this, they were more likely to get severe COVID-19 during pregnancy, so the pregnancy seems like it was almost an aside.
Okay. So what about, “What happens with the baby?” A quarter of all these neonates were admitted to the NICU. They were not, though, more likely to die than kids whose moms did not have COVID-19.
Rick: A really interesting study and they are calling it a living systematic review and meta-analysis because here’s what happened. Early on were case reports or small series and then people began to accumulate these, and some reported them in a meta-analysis, and there would be another couple cases or a small study. It would be updated and the ball just kept rolling. It got very difficult to stay up with all the information. So they collected all the information to date and then continue to update their analysis, so this is the most current up-to-date and the largest series reported on the outcomes in pregnant women and with the outcomes of their births as well.
As you mentioned, the mothers that had those chronic illnesses were four times more likely to be in intensive care unit or on a ventilator. Fortunately, the death rate is fairly low. But again, that’s because the mothers are relatively young age, even despite the comorbidities.
Elizabeth: Well, I think that one of the concerns about pregnancy was the anergic condition and if there’s already sort of an immune compromise, is COVID-19 disease going to be worse? I think that in this case I’m kind of buoyed by the data that it’s not showing that it will be worse if you weren’t obese and had hypertension and diabetes.
Rick: Yep. It seems that the way this study was constructed is they looked at pregnant women with or without comorbidities and COVID infection. They didn’t compare it to a similarly-aged group that weren’t pregnant, so it was hard to make that comparison directly. It is somewhat reassuring that the death rate is fairly low.
The interesting thing about this study that we didn’t talk about was that many centers now routinely test pregnant women to see whether they’re COVID-infected or not because the vast majority of women are asymptomatic. And in fact, what they found out is in some of these studies as many as 10% of the women tested positive for COVID and really didn’t demonstrate the normal symptoms.
Elizabeth: Yeah. More coming, I’m sure. Let’s turn to your next one. That’s in the New England Journal of Medicine.
Rick: This is a really well-done study looking at weight loss in underserved patients. Multiple studies have looked intensive coaching in terms of encouraging and sustaining weight loss, but very few of those studies have been done in underserved populations and centered in primary care clinics. The question is, are those particular techniques helpful in this population?
These authors conducted what’s called a cluster-randomized trial to test the effectiveness of a high-intensity, lifestyle-based program for treating obesity and it was centered in primary care clinics. Eighteen clinics — nine received the intensive lifestyle changes and nine just the usual care. The study went on for 24 months.
With the intensive lifestyle, what they did was they embedded health coaches in the clinics and they had weekly sessions for the first 6 months followed by monthly sessions for the remaining 18 months, and they followed the individuals for 24 [months].
I’m happy to report that in this 800-patient study, the individuals that were in the intensive lifestyle change had a 5% reduction in weight versus the usual care [at 2 years], where essentially there was no change. It was 0.5%. The major weight loss was done at 1 year. The average weight [loss] was 7% [at 1 year], so they gained a little bit between 1 and 2 years, but it was still sustained at 2 years. 67% of the individuals in the study were Black and had an annual income less than $40,000. 83% completed the study — so it’s doable — and most of these individuals were women, so a really great study.
Elizabeth: I like this, of course, because what we have been seeing in abundance with the COVID-19 pandemic has been this disproportionate impact on people who are overweight and of other ethnicities. And so if we can establish this intervention — low-cost and right where they live — and actually have a positive impact, I think that’s a win-win.
Rick: Right. It didn’t involve any pharmacy or medication, no side effects, and I think it’s a terrific study. I’m glad you picked it. This makes a significant difference. Then by the way, it improved their quality of life as well. I know that you’re not surprised by that.
Elizabeth: Finally, let’s turn to JAMA Network Open. I like this one because it’s something that I think we’re seeing in abundance, that a man hears what he wants to hear and disregards the rest in so many venues relative to health. In this case, this is a look at an aging population and their self-assessment of their hearing loss compared to an objective assessment of their hearing loss.
This is part of the English Longitudinal Study of Ageing. This is a population-based prospective cohort study that’s been looking at aging folks in England for a while now. This cohort had 9,600-plus individuals — it’s called their Wave 7 — and they asked these people, “Hey, do you have any hearing loss?” Then they compared that to a screening test that was done by a qualified nurse to see whether or not they really did have it.
They also corrected for other things: age, marital status, retirement status, indicators of socio-economic position, lifestyle factors — including BMI, physical activity, and tobacco and alcohol consumption — and then they said, “Hey, how does this impact on our self-reported hearing problems or our objective measures?”
Basically, a third of them said, “I really don’t have a problem,” and they did have a problem. Interestingly, I thought this was fascinating because normally I think it’s men who tell themselves stories about things, but it turns out that female sex was more highly associated with this dissociation, this discordance between objective and self measures of hearing loss.
Rick: Elizabeth, this is kind of the rule of thirds. If you just take a look across older Americans, a third of them have significant hearing loss, and as you mentioned, a third of those individuals didn’t even know it. They thought, “Oh, my hearing’s fine.” But then when you test it, it’s not. We’ve talked before about that’s not only a quality of life issue, but long-term cognitive impairment is associated with hearing loss as well.
What you want to do is you want to recognize it, and it’s easily treatable with hearing aids, but it’s only treatable if people know that it’s going on. This suggests we need to be doing routine hearing tests in older individuals. As you noted, women were twice as likely as men to not know they had a hearing loss.
True story: this week I’m on the phone, my wife says, “Can you talk?” I said, “I am on hold.” She thought I said, “I am old.” Perhaps I need to have my wife’s hearing tested.
But there are other things that were associated with the lack of recognition. That is, people that had manual jobs, people that had no educational qualifications, and people that had poor lifestyle choices that either smoked tobacco, or had a high alcohol intake, or didn’t perform much physical activity. All of those things were associated with the lack of recognition that people had a hearing loss.
Elizabeth: As you said, certainly we have hearing aids that are available to help rectify this particular problem. I do not think we have data yet that establish whether or not the use of hearing aids ameliorates many of the other problems that are associated with hearing loss.
Rick: I would grant the fact that, again, hearing losses have been associated with cognitive impairment and an increased cognitive decline. I think it’s pretty clear that hearing aids can improve quality of life — even if for that, or to communicate better with your marital partner or spouse, I think, is important as well.
Elizabeth: 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.
Last Updated September 04, 2020